Use of Nuclear Cardiology in Myocardial Viability Assessment and Introduction to PET and PET/CT for Advanced Users
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1 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
2 Panel discussion & open forum: Myocardial Viability: which tests to do? 2D-Echo Coronary angiography Cardiac MRI CT angiography Nuclear (SPECT/PET)
3 Case: A 64-year old male Non-diabetic, non-hypertensive Untreated dyslipidemia Smoker 1 year ago, equivocal stress test Atypical chest pain
4 Calcium Scoring
5 CT angiography
6 CT angiography
7 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)
8 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
9 CT angiography Hard plaque in the coronary artery
10 Case 58 year old businessman with no prior history of CAD Previous smoker Hypertension, diabetes, dyslipidemia TET: abnormal No history of chest pain
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13 CT angiography Soft plaque in the coronary artery
14 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.
15 CT angiography Plaque before the stent
16 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
17 Coronary Stenosis: CA and CTA
18 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.)
19 Does CTA have a role in determining myocardial viability?
20 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
21 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
22 Myocardial Perfusion Imaging Cardiac Determinants of Prognosis LEFT VENTRICULAR FUNCTION LVEF Wall Motion Abnormalities MYOCARDIAL PERFUSION Reversible Perfusion Defects (Myocardium at risk)
23 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
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27 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%
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35 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
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37 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
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41 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
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48 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
49 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
50 PET and CT
51 PET and CT
52 PET AND CT
53 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%
54 CMR Non-transmural infarct/scar with late-enhancement gadolinium
55 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
56 CMR ADVANTAGE: Excellent soft tissue contrast No radiation No need for nephrotoxic contrast
57 CMR Other APPLICATIONS: Rest and stress myocardial perfusion Coronary angiogram
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Match the following using the word bank. 1. A form of arteriosclerosis in which the thickening and hardening of the vessels walls are caused by an accumulation of fatty deposits in the innermost lining