The Role of SPECT/ PET

Transcription

1 Session 15: Imaging Heart Failure The Role of SPECT/ PET Albert Flotats, MD, FEBNM Hospital de la Santa Creu i Sant Pau, Barcelona Universitat Autònoma de Barcelona

2 HF - Clinical Questions 1. Etiology? (IHD?) 2. If IHD: will LV function improve with revascularization? (hibernation?) 3. Identification of candidates to device treatment (CRT / ICD)

3 Etiology

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5 Accuracy of Gated SPECT 99m Tc-Sestamibi for CAD diagnosis in Patients with new-onset HF (IMAGING study) 201 pts Soman P, et al. JNC 2009;16:82 91

6 LV Function Improvement with Revascularization Imaging Parameters of Myocardial Viability Residual Perfusion / Reserve Contractile Reserve Oxidative Metabolism Glucose Utilization Membrane Integrity Gd-DTPA Enhancement Viable Nonviable

7 FFA 11 C palmitate, 123 I-BMIPP 18 F-FTHA, 18 F-FTP, 18 F-FCPHA 18 F-FDG glucose 11 C lactate 18 F-FDG 18 F-FDG-6-P Glycogen glucose HK glucose-6-p PFK (2) (2) (2) lactate (2) PDH 11 C acetate PPARα CTP I/II citrate TCA cycle FADH Tl 99m Tc-sestamibi (3) 15 O 2 ETC & OP 99m Tc-tetrofosmin (35)

8 Perfusion / Metabolism Patterns Normal / Myopathy Acute Stunning Chronic Stunning / Artifact Hibernation Nontransmural scar Transmural scar NH 3 FDG Contractile Reserve Functional Recovery

9 Accuracy of Noninvasive Tests for Prediction of Functional Recovery after Revascularization Schinkel AF, et al. Curr Prob Cardiol 2007;32:

10 Identification of Candidates to Device Treatment (CRT) Gated MPI with Phase Analysis One stop-shop: LV ischemia + viability + function + mechanical synchronicity + site of latest mechanical activation Courtesy of EV Garcia, PhD

11 Gated MPI with Phase Analysis Technical Development and Clinical Evaluation ChenJ, et al. JNC 2011;18:685 94

12 Innervation (HF) NET downregulation results from increased exposure to NE Shannon JR, et al. NEJM 2000;342:541-9

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14 Potential value of MIBG imaging for predicting response to CRT 45 pts Cha YM, et al. Circ Heart Fail. 2011;4:339-44

15 Identification of Candidates to Device Treatment (ICD) HF Derive largely from 4 large randomized trials (MADIT-2, DINAMIT, DEFINITE and SCD-HeFT) from which LVEF 30-35% became a principal variable for deciding who should receive a device ICD cost ~ 20,000 (not including ICD follow-up costs) >50% of HF pts who die suddenly have a LVEF>30%, thus better individual risk assessment is needed McMurray JJV, et al. EHJ 2012;33:

16 ADMIRE-HF study n= 961 pts HF NYHA II III LVEF 35% median follow-up 17 months HMR l : independent predictor of cardiac and all-cause deaths Jacobson AF, et al. JACC 2010;55:

17 86 pts (9%) experienced arrhythmia or SCD Jacobson AF, et al. JACC 2010;55:

18 Comparison of MIBG cardiac imaging with inducibility of sustained ventricular tachyarrhythmia on EP testing Multicenter study, 50 pts with prior MI and LVEF<40% 30 pts (60%) EP+ 20 pts (40%) EP- Only the late MIBG defect score resulted predictor of inducible ventricular tachyarrhythmias during EP testing on uni/multivariable analysis Late MIBG SPECT Defect Score Bax JJ, et al. Circ Cardiovasc Imaging 2008;1:131-40

19 Combined predictive value of MIBG together with BNP or LVEF for identifying lethal arrhythmia in 54 pts with ICD followed-up 15 months Nagahara D, et al. JNM 2008;49:225 33

20 SCD rates Normal WR 27% Predictive value for SCD MIBG vs. LVEF, signalaveraged ECG, HRV, and QT n=106 pts with chronic stable HF (LVEF<40%) Follow-up: 65 ± 31 m Only WR & LVEF were significantly and independently associated with SCD LVEF >35% LVEF 35% Tamaki S, et al. JACC 2009;53:426-35

21 n= 116 Follow-up of 23±15 months Cumulative event rate (%) * Appropriate ICD therapy Appropriate ICD therapy /cardiac death *, p< I-MIBG SPECT summed defect score I-MIBG SPECT summed defect score > 26 Boogers MJ, et al. JACC 2010;55:

22 Conclusions Gated SPECT and PET MPI (with Phase Analysis) and PET FDG Provide an integrated assessment of LV myocardial ischemia, viability, function, mechanical synchronicity and site of latest mechanical activation Cardiac innervation imaging Has high prognostic value in pts with HF (better predictor of lethal arrhythmias/cardiac death risk than the currently accepted standards) and identifies a low risk subgroup of pts perhaps not requiring an ICD (there is concern about this since not placing an ICD in a pt who meets GL may have medical-legal implications if the pt subsequently suffers a SCD)

23 Thank you for your attention Hospital Sant Pau Barcelona