PET myocard perfusion & viability Riemer Slart

Transcription

1 PET myocard perfusion & viability Riemer Slart Nuclear Medicine Physician Dept. of Nuclear Medicine and Molecular Imaging University Medical Center Groningen, the Netherlands Professor in Molecular Imaging, University of Twente, the Netherlands EANM Cardiovascular committee

2 Global burden of cardiovascular disease Cardiovascular disease is the leading cause of death worldwide Nature, 493, S2 S3, 2013

3 Global Coronary & Cardiovascular Risk Scores Greenland. J Am Coll Cardiol. 2010;56:e50-e103.

4 What cardiologists want to know: Does the patient have a CAD? CAD with a significant stenosis? What is the extend of the CAD? Of prognostic impact? What is the best therapy? Slide 4

5 The general gatekeeper principle Coronary artery disease Low risk (<1%) Risk factors Clinics Noninvasive imaging Intermediate risk (1-3%) High risk (>3%)

6 Ischemic cascade CAD

7 Coronary stenosis & ischemia Diameter stenosis 50% Dilemma: no perfect match Patient with ischemia Patient with angiographic lesion

8 Coronary stenosis & ischemia Diameter stenosis 90% Dilemma: no perfect match Patient with ischemia Patient with angiographic lesion

9 Diagnosis of CAD: CVI techniques Non-invasive ECG Echocardiogram Dobu MRI MPS SPECT MPS PET Adenosine MRI CT angiography Calcium scoring Invasive Intracoronary echo Coronary angiogram

10 Indications of different imaging tests for the diagnosis of obstructive CAD and for the assessment of prognosis in subjects without known CAD Guidelines on myocardial perfusion, Task Force ESC and EACTS, Eur H J 2010

11 PET(/CT) myocardial perfusion PET-CT scanner PET vs SPECT Pro s: Better resolution Absolute quantification Real time imaging Con s : Costs Availability

12 PET tracers for myocardial perfusion

13 Sogbein et al Biomed Res Int. 2014

14 Absolute quantification 13 N-ammonia: Hutchins model 3-compartments model (K1, K2, K3) 13 N-ammonia free diffusible 13 N-ammonia: glutamate into glutamin (synthetasis) equilibrium Absolute quantification: ml/gr/min

15 Myocardial Blood Flow (absolute values, ml/g/min) Time-activity curves

16 Normal values 13 N-ammonia Rest: ml/min/100g Stress: ml/min/100g In general: MPR > 2.0 Depending on age and gender & technique Blanksma et al., J Nucl Med 1995 Chilian WM, Circulation 1997 DeGrado et al, J Nucl Cardiol 1996 Muzik et al, J Am Coll Cardiol 1998

17 DIFFERENT SOFTWARE PACKAGES -PMOD, SYNGO, FLOWQUANT- Sunderland et al, J Nucl Cardiol 2014

18 Dynamic 13 N-ammonia PET: quantification (Syngo) ml/gr/min

19 Principle MPI/FDG PET scan -Visual analysis- Uptake flowtracer Rest Stress NORMAL tissue normal normal INFARCTED tissue reduced reduced ISCHEMIC tissue normal reduced

20 Preparation patient: Glucose load, low fat? Euglycaemic insulin clamp infusion system Acipimox: fatty acid lowering agent (aspirin needed)

21 PET protocol: ischemia & viability UMC Groningen Viability Viability & ischemia rest 13 NH 3 rest 13 NH 3 (gated) FDG adeno 13 NH 3 (gated) FDG

22 Shorter scan protocol? Residual activity correction (RAC) Lazarenko SV et al, Med Center Alkmaar, NL

23 PET Imaging Flow/FDG Patterns Normal DCM Hibernating Scar Match Mismatch Match

24 Viability testing rest 99m Tc-tetrofosmin IQ SPECT and FDG cpet 99m Tc-tetrofosmin IQ SPECT FDG cpet CABG MVP/ring

25 Case 67 yr male RF: hypertension, DM Dyspnoe, no angina Obese Previous MPS SPECT (MIBI) inconclusive Nevertheless ischemia? rest, stress 13 N-ammonia and (gated) FDG

26 Rest, stress 13 N-ammonia and (gated) FDG

27 Polarmap and quantification

28 Results Rest: 52 ml/min/100g Stress: 68 ml/min/100g MPR: 1.27 (normal > 2) Regions: 5 regions ratio < 1

29 Coronary angiography 3 vessel disease: revascularisation

30 Prognostic value of MPR without intervention -Absolute quantification- Tio, Slart et al., J Nuc Med 2010

31 Prognostic value of MPR after intervention -Absolute quantification- Cardiac death MACE Slart et al, J Nucl Med 2011

32 Absolute flow or myocardial flow reserve for the detection of significant coronary artery disease? 15 O-water PET study 104 patients with moderate pre-test likelihood of CAD without previous myocardial infarction. Reference: CAG Joutsiniemi et al, Eur Heart J Cardiovasc Imag 2015

33 PERFUSION DEFECT SIZE ON MPI PET MULTICENTER TRIAL N = 7000 Dorbola et al, J Am Coll Cardiol, 2013

34 Diagnostic Performance of MPI Using SPECT, cmri, and PET Imaging for the Detection of Obstructive CAD: A Meta-Analysis 166 articles (n = 17,901) : 114 SPECT, 37 CMR, and 15 PET articles. Jaarsma et al., J Am Coll Cardiol, 2012

35 PET vs MRI MPI Morton et al, J Am Coll Cardiol 2012

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37 New developments

38 Flurpiridaz PET phase 3 study PET vs SPECT for overall CAD detection (n=755) Screened 920 Dosed 795 Discontinued 31 PET evaluable 782 SPECT evaluable 778 Angio evaluable 762 Total 755 SPECT+PET+ angio CAD+= 327 CAD-= 428 (CAD prev 43%) Courtesy of J. Knuuti

39 Flurpiridaz PET phase 3 study PET vs SPECT for overall CAD detection (n=755) Original read Re-read Courtesy of J. Knuuti

40 Courtesy of J. Knuuti

41 Sr/Rb generator Ammonia mini cyclotron

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43 Hybrid cardiac imaging: SPECT/CT and PET/CT. A joint position statement by the European Association of Nuclear Medicine (EANM), the European Society of Cardiac Radiology (ESCR) and the European Council of Nuclear Cardiology (ECNC) Eur J Nucl Med & Mol Imag 2011