SPECT-CT: Τι πρέπει να γνωρίζει ο Καρδιολόγος

Transcription

1 SPECT-CT: Τι πρέπει να γνωρίζει ο Καρδιολόγος Δρ Αναστασία Κίτσιου Διευθύντρια, Καρδιολογική Κλινική, Σισμανόγλειο ΓΝΑ Chair, Education Committee, Section on Nuclear Cardiology & Cardiac CT, EACVI, ESC

2 Disclosures No conflict of interest regarding the topics of this talk

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4 Non-invasive imaging in general To select the appropriate imaging modalities according to the clinical condition: non-invasive imaging in general echocardiography of heart and vessels cardiac magnetic resonance (CMR) cardiac X-ray computed tomography (CT) nuclear techniques To interpret and integrate the results into individual patient care To perform most TTE and routine TOE echocardiographic examinations independently

5 ESC core curriculum for the General Cardiologist Technique Nuclear studies Cardiac CT Description of competence Able to interpret the data independently Able to interpret the data independently Level II: the trainee should acquire practical experience but not as an independent operator. They should have assisted in or performed a particular technique or procedure under the guidance of a trainer.

6 Nuclear techniques Knowledge Techniques (a) basic principles of radionuclide imaging as applied to the cardiovascular system, including radio-isotopes, radiopharmaceuticals, gamma cameras, image acquisition, reconstruction, display, and interpretation (b) single-photon emission computed tomography perfusion scintigraphy (SPECT) (c) gated SPECT (perfusion and LV function) (i) tracers: 201Tl, 99mTc-sestamibi, or 99mTc-tetrofosmin (ii) modalities rest imaging stress imaging (exercise and pharmacological stress with vasodilators and sympathomimetic agents) 2-day and 1-day protocols (d) positron emission tomography (PET): myocardial perfusion, glucose metabolism, and inflammation imaging

7 Nuclear techniques Knowledge Techniques (e) hybrid techniques (PET-CT and SPECT-CT) for attenuation-corrected imaging and for combined anatomical and functional imaging (f) radionuclide ventriculography using equilibrium planar and SPECT imaging, and first-pass planar, phase, and amplitude imaging of regional function (g) imaging of sympathetic innervation (h) imaging of pulmonary embolism, quantification of pulmonary perfusion and right-to-left shunting (i) labelled leucocyte imaging for myocardial abscesses and infection; ( j) imaging of myocardial sarcoidosis

8 Nuclear techniques Knowledge Indications (a) diagnosis of chest pain syndromes (b) management of known and suspected coronary artery disease including detection, localization, and quantification of myocardial ischaemia and scar (c) assessment of prognosis in stable coronary artery disease, in ACS and before noncardiac surgery (d) assessment of LV dysfunction and heart failure, including global and regional LV function, abnormalities of myocardial motion and thickening, viability, stunning, hibernation, and innervation (e) monitoring of LV function before and during cardiotoxic chemotherapy (f) detection and quantification of left-to-right and right-to-left shunting (g) detection of cardiac infection and inflammation

9 Nuclear techniques Skills The ability to: select appropriate indications for and avoid contraindications to nuclear cardiology techniques supervise cardiovascular stress testing using dynamic exercise and pharmacological techniques handle unsealed radiopharmaceutical sources in a manner that is safe for oneself, patients and staff display and interpret nuclear cardiology images (Level II competence)

10 Cardiac CT Knowledge Techniques (a) test bolus acquisition and bolus chasing (b) prospective ECG-triggered axial, and retrospectively ECG-gated spiral scan modes (c) cardiac X-ray CT without contrast enhancement (i) coronary calcium score (d) cardiac X-ray CT with contrast enhancement (i) coronary artery disease (ii) cardiac morphology (e) angiography of the great arteries and veins

11 Cardiac CT Knowledge Indications (a) coronary artery disease (i) coronary calcium score (ii) CT angiography of the coronary arteries to assess degree of coronary stenosis (iii) bypass graft disease (iv) visualization of plaque characteristics (b) coronary anomalies (c) cardiac (non-coronary) pathology: congenital, traumatic, degenerative, atherosclerotic (infarcts/lv aneurysms, etc.), masses (d) interventional guidance: e.g. transcatheter valve implantation, pulmonary vein isolation (e) ventricular function

12 Cardiac CT Knowledge Indications (f) prosthetic heart valve dysfunction (i) quantification of opening and closing angles (ii) visualization of thrombus and pannus (g) endocarditis of native heart valves and prosthetic heart valves (i) visualization of valvular vegetations (ii) assessment of annular abscesses and mycotic aneurysms and relationship to coronary arteries (h) congenital heart disease (i) anatomy; (ii) quantification of ventricular volumes and function; (i) pericardial diseases ( j) diseases of the great arteries and great veins (congenital anomalies, aortic aneurysms, false aneurysms, aortic dissection, periaortic abscesses, aortic arch abnormalities) (k) diseases of the cervical arteries and of the peripheral arteries

13 Cardiac CT Skills The ability to: select appropriate indications for and avoid contraindications to cardiac X- ray CT display and interpret cardiac X-ray CT images in the clinical context

14 Attention! Awareness of the side-effects of contrast media Recognition of the risks of ionizing agents and radiation to patient and personnel

15 Noninvasive imaging for CAD detection Echocardiography Nuclear techniques (SPECT, PET) Cardiac CT CMR

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17 Image Interpretation Stress Rest Normal Reversible defect Irreversible defect Short-Axis Images

18 Ποσοτική περιμετρική ανάλυση Bull s eye

19 Two day rest-stress Tc-99m sestamibi SPECT This study indicates underlying viability and severe ischemia prognostically high risk study N K Sabharwal, A Lahiri. Heart 2003;89:

20 Normal stress-only Tc-tetrofosmin study associated with excellent prognosis

21 56 year-old woman with atypical chest pain and abnormal stress ECG Achenbach S, SCCT

22 Coronary CT angiography LM & LAD Achenbach S, SCCT

23 Coronary CT angiography LM & LCx Achenbach S, SCCT

24 Coronary CT angiography RCA Achenbach S, SCCT

25 Accuracy for stenosis detection High negative predictive value NPV 96-99% Achenbach S, SCCT

26 64-MDCT adenosine perfusion chronic MI SPECT - MPI Fixed perfusion deficit in the inferior and inferolateral territories (chronically occluded distal RCA) George RT, et al. J Am Col Cardiol 2006

27 CT perfusion Fixed myocardial perfusion defect in the anterior wall and the septum Left panel: CT MPI Middle panel: Radionuclide MPI Right panel: Invasive coronary angiogram showing occlusion of the LAD

28 Hybrid imaging Acquisition of coregistered anatomic and functional images in a single examination SPECT/CT PET/CT

29 Low-dose CTCA and MPI Cardiac hybrid imaging below 3mSv CTCA: excellent image quality (1.46 msv) MPI: adenosine stress SPECT with 173 MBq 99mTc-tetrofosmin (1.16 msv) Fused SPECT-CT: stress perfusion defect in the anterior wall, corresponding to the total occlusion in the proximal LAD, confirmed by invasive coronary angiography Herzog BA, et al. Eur Heart J 2008

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