Cardiac Imaging. Kimberly Delcour, DO, FACC. Mahi Ashwath, MD, FACC, FASE. Director, Cardiac CT. Director, Cardiac MRI
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1 Cardiac Imaging Kimberly Delcour, DO, FACC Director, Cardiac CT Mahi Ashwath, MD, FACC, FASE Director, Cardiac MRI
2 Cardiac Imaging Discuss the clinical applications of and indications for: Cardiac CT Nuclear Myocardial Perfusion Imaging PET Cardiac MRI Compare/Contrast the imaging modalities including benefits & limitations of each
3 Indications: Cardiac CT Risk predictions calcium scoring Agaston <100, >400 Assess native coronary arteries, anomalies, bypass graft anatomy Evaluation of heart & vascular structures : function, valves, masses, clots, aneurysms, implants, etc Pre-procedural planning: TAVR, TMVR, EP Ablations, etc
4 Coronary Calcium Scoring
5 CT Coronary Angiography - Normal
6 CT Coronary Angiography - Stent
7 CT Coronary Angiography-Variant, Anomaly
8 Cardiac Function
9 Cardiac Function- Normal, Abnormal
10 Valve Assessment
11 Cardiac CT - ED
12 Nuclear Cardiology : SPECT Background Principles & Instrumentation Radiotracers Thalium vstechnetium99m (preferred) SPECT Myocardial Perfusion Imaging Exercise vs Pharmacologic (LBBB, PPM, CI s/ limitations) Isotope Ventriculography PET Myocardial Perfusion Imaging Viability Assessment
13 Radiotracers
14 Myocardial Perfusion Imaging Clinical Applications Detection of coronary artery disease Determination of prognosis Assessment of myocardial viability Preoperative risk assessment Evaluation of the efficacy of revascularization Assessment of functional significance of coronary lesions/stenosis
15 Nuclear SPECT/MPI
16 SPECT Normal Study
17 SPECT Abnormal Study
18 Nuclear Cardiology Common Artifacts
19 Nuclear SPECT- Advantages/Limitations Advantages Relatively simple to perform Provides information regarding perfusion and function Can localize disease Pharmacologic stress can be performed Higher sensitivity than stress echo (flow heterogeneity) Limitations: Radiation Exposure Relatively expensive Decreased specificity due to attenuation artifact (breast, obesity)
20 Cardiac MRI and PET imaging Mahi L Ashwath MD, FACC, FASE
21 Positron emission tomography (PET) Noninvasive method - myocardial perfusion and viability Assesses both perfusion and metabolism Can get PET stress Assessment of ischemia in patients with moderate or severe obesity Attenuation correction can limit artifacts, compared to SPECT stress PET viability Assessment of viable myocardium in patients with occlusive coronary artery disease prior to revascularization
22 Positron emission tomography (PET) Requires the use of positron-emitting isotopes FDA-approved PET perfusion tracers Rubidium-82 produced from a strontium-82 generator and is widely used in centers without on-site cyclotrons 13N-ammonia restricted to centers with an available on-site or nearby cyclotron
23 Radiation exposure: PET stress Rest-stress PET rmpi using 13N - ammonia approximately 2 millisieverts Rest-stress PET rmpi using rubidium-82 approximately 3 millisieverts Pharmacological stressor is preferred Can be combined with exercise stress but has significant technical challenges and not usually performed
24 PET viability Ischemia shifts myocyte metabolism preferentially to glucose from fatty acids Uptake of a glucose analog, fluorine-18 labeled deoxyglucose (FDG) by myocytes in an area of dysfunctional myocardium indicates metabolic activity and thus, viability
25 PET stress
26 PET Stress
27 PET viability
28 PET viability
29 Positron emission tomography (PET) Advantages of PET include: High spatial, temporal, and contrast resolution (advantage over SPECT). High energy tracers with short radiopharmaceutical half-lives, Enhanced overall image quality, Lower radiation, and Efficient protocols Robust built-in attention correction (advantage over SPECT). Quantitative assessment of absolute myocardial blood flow and myocardial flow reserve (advantage over SPECT). Acquisition of left ventricular systolic function during peak stress myocardial flow reserve
30 Positron emission tomography (PET) Limitations Contraindications to vasodilator stress: Hypotension Active wheezing High grade AV block Methylxanthines, such as Aminophylline, theophylline, Caffeine held for 12 hour at least prior to testing Radiation contraindicated during pregnancy
31 Cardiac MRI Noninvasive imaging of the heart No radiation involved Takes about 45 minutes Basic test: Cine images for chambers, wall motion, valves, pericardium and structural abnormalities Inject Gadolinium Post contrast imaging/ delayed enhancement imaging Detection of scar, assess viability, infiltration
32 Cardiac MRI: Additional Sequences as needed T1 and T2 sequences T2* Myocardial edema Myocardial iron content/ hemosiderosis Resting myocardial perfusion Stress myocardial perfusion Ischemia Flow sequences Velocities/ gradients Shunt quantification MRA of the aorta MRV of the pulmonary veins
33 Cardiac MRI: Normal Study
34 Cardiac MRI: Normal Study
35 Cardiac MRI: LAD Infarct
36
37 Hypertrophic Cardiomyopathy
38 Hypertrophic Cardiomyopathy
39 Hypertrophic Cardiomyopathy
40 Hypertrophic Cardiomyopathy
41 Apical Hypertrophic Cardiomyopathy
42
43 Restrictive Cardiomyopathy
44
45 Non-compaction Cardiomyopathy
46 Arrhythmogenic Right Ventricular Cardiomyopathy
47 Myocarditis
48
49 Tricuspid Valve Endocarditis
50 Cardiac Mass
51
52
53
54
55
56
57 Cardiac MRI: Indications Cardiomyopathy Ischemic Cardiomyopathy Evaluation of ischemia Evaluation of scar and viability Evaluation of thrombi Ischemic vs Non-ischemic cardiomyopathy Nonischemic Cardiomyopathy Amyloidosis Sarcoidosis Hemachromatosis ARVC Hypertrophic Cardiomyopathy Myocarditis
58 Arrhythmias: Cardiac MRI: Indications Ventricular arrhythmia for scar detection Heart block for evaluation for scar Pericardial abnormalities: Thickening Constriction Pericarditis Others: Masses ASD, VSD Amonalous vessels- pulmonary veins, coronary arteries Other congenital anomalies
59 Claustrophobia Cardiac MRI: Limitations Pateint can be given anxiolytics Transportation (needs driver after anxiolytics) Pregnancy Can do without contrast GFR <30 or dialysis Absolute contraindiction Reason for concern Nephrogenic systemic fibrosis
60 Cardiac MRI: Limitations Ferromagnetic metals Prosthetic hips, knees, sternal wires, surgical clips, coronary stents OKAY Aneurysm coils NOT OKAY ICD s, Pacemakers depending if they are MR conditional
61 Anatomic Imaging Functional Imaging Modality Comparison Cardiac CTA Nuclear SPECT PET /- +, only EF currently +, hemodynamic significance of stenosis +, hemodynamic significance of stenosis Cardiac MRI +, hemodynamic significance of stenosis, EF, shunt Radiation Contrast +, ~ ml - - +, gadolinium Availability +/- + +/- +/- Cost
62
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