Myocardial blood flow PET evaluation and quantification. Dr. Erick Alexánderson. Rosas

Transcription

1 Myocardial blood flow PET evaluation and quantification Dr. Erick Alexánderson Rosas

2 Clinical case 62 year old female patient with a history of DM2 and chronic systemic hypertension She complains of progressive shortness of breath associated with diaforesis and a feeling of chest pressure She went to the ER of the ICNICH due to the presence of typical chest pain

3 ER EKG

4 Clinical case With these findings she was sent for an invasive angiography

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8 Clinical case A PCI was performed and a stent was placed in the LAD artery (responsible vessel) The result was succesful with a final TIMI flow III, TMP III

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10 Clinical case A Nuclear Medicine Myocardial perfusion test was performed to evaluate the remaining territories (RCA and Cx)

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12 Vascular territory Rest Stress CFR LAD 0.78 ml/min/gr 1.93 ml/min/gr 2.48 RCA 1.08 ml/min/gr 1.93 ml/min/gr 1.78 Cx 1.14 ml/min/gr 2.16 ml/min/gr 1.98

13 SPECT Flow heterogeneity to see the defect Homogenous decrease: Three vessel disease, Left main Microvascular disease Beanlands et al. J Am Coll Cardiol :

14 SPECT Author, year (reference) Number of pts Tracer Stress Sensitivity% Specificity% Iskandrian, 1989 (4) 193 Thalium 201 Physical Maddahi, 1989 (5) 110 Thalium 201 Physical Mahmarian, 1990 (6) 296 Thalium 201 Physical Cramer, 1994 (11) 38 Thalium 201 Dipiridamol Kapur, 2002 (14) 2560 MIBI Adenosine SENSITIVITY: 90 % SPECIFICITY: 73%

15 SIMULTANEOUS RECOGNITION OF CORONARY DISEASE IN 2 OR MORE TERRITORIES 100% n = % Sensitivity 60% 40% 46,64% 54,05% 34,11% 46% 20% 0% AD + RC+ Cx AD + RC AD + Cx RC + Cx Alexánderson Arch Inst Cardiol Mex :234-40

16 PET Referenc e Number of pts Women History of CAD Tracer Sensitivit y Specificit y PPV NPV Accuracy Sampson et al Rb Go et al 202 NR Rb Tamaki et al 51 NR NH Gould et al 31 NR NR 82 Rb/ 13 NH Sensitivity 95% Specificity 89% PPV (94%) NPV (84%) Modified from Di Carli et al. J Nucl Med 2007

17 SPECT V.S. PET SPECT PET

18 Coronary circulation Smooth muscle cell Arteriole Capilar

19 Coronary Circulation Ohm s Law: F = ΔP R Poiseuille s Law: F = ΔP r4 8nL = ΔP + Diameter R

20 Methods: PET Radiotracers Ammonia Oxygen Rubidium Acetate Unidad PET/CT Ciclotrón UNAM Courtesy of Turku PET Centre Courtesy of B&WH Harvard Unidad PET/CT Ciclotrón UNAM

21 Radiotracers used in myocardial blood flow evaluation 5 Myocardial tracer uptake O-15-water N-13-ammonia Rb MBF (ml/min/g)

22 Dynamic study 11 C - Acetate

23 Coronary blood flow quantification with PET 35 sec

24 Time-Activity Curves

25 13N-Ammonia Myocardial perfusion Protocol PET protocol + Gating + MBF quantification Dynamic study 13N-ammonia 30 mci 13N-ammonia 30 mci Tx Rest Perfusion Adenosine Stress Perfusion minutes Total time: <1 hr

26 Two compartments model for 13N-Ammonia CF (ml/min/g) Freely diffused 13N-Ammonia V(ml/g) CF (ml/min/g) K1 (ml/min/g) K2 (1/min) Metabolically trapped 13N-Amonnia Smith et al, J Nucl Med 1988;29:

27 Validation of coronary blood flow quantification with PET Kuhle et al, Circulation 1992;86:

28 Schelbert Cardiol Clin 2009; 27:277

29 Coronary blood flow [ 13 N]-amonnia PET Rest RCF CPT CF Stress SFR EDVI EDVI 1.5 CFR CFR 3.0 Alexánderson E. Arch Cardiol Mex. 2005

30 Myocardial blood flow absolute quantification: Clinical applications Diagnosis Multivascular disease Microvascular disease Evaluation of the cardiovascular risk Evaluation of endothelial function Patient s treatment and follow-up

31 Myocardial blood flow absolute quantification: Clinical applications Diagnosis Multivascular disease Microvascular disease Evaluation of the cardiovascular risk Evaluation of endothelial function Patient s treatment and follow-up

32 Coronary flow quantification Improves the diagnosis of myocardial ischemia. ml/m in/g 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 0 0,54 0,5 BCF 1,74 1,1 SCF ,55 CFR 2,38 Healthy Ischemic Healthy Ischemic Unidad PET-Ciclotrón, UNAM, México

33 Diagnosis of Multivascular Coronary Disease Myocardial flow relative distribution imaging Trivascular coronary disease Left main disease or equivalents Balanced ischemia

34 Clinical case Stress Rest Stress Rest Stress Rest

35 Clinical case Stress Rest Stress Rest CFR

36 Mean percentage of abnormal sectors in patients with trivascular disease Parkash R, et al. J Nucl Cardiol 2004;11:440

37 Myocardial blood flow absolute quantification: Clinical applications Diagnosis Multivascular disease Microvascular disease Evaluation of the cardiovascular risk Evaluation of endothelial function Patient s treatment and follow-up

38 Diagnosis of microvascular disease Heart transplant Dilated myocardiopathy

39 CFR in patients with a heart transplant CFR> 2.3 MACE-free survival CFR< 2.3 Months Rodrigues et al. Int J Cardiol 2005;201:103

40 Diagnosis of microvascular disease Heart transplant Dilated cardiomyopathy

41 Coronary flow reserve in patients with Idiopathic dilated cardiomyopathy p < 0.05 p < CFR Control IDM NYHA II IDM NYHA III Van den Heuvel et al. JACC 2000;19:35

42 Myocardial blood flow absolute quantification: Clinical applications Diagnosis Multivascular disease Microvascular disease Evaluation of the cardiovascular risk Evaluation of endothelial function Patient s treatment and follow-up

43 Added value of CFR as a predictor of adverse events in patients with a normal perfusion study Herzog et al. JACC 2009;2:150-6

44 Coronary flow in the evaluation of cardiovascular risk Herzog et al. JACC 2009;2:150-6

45 CFR as a risk marker for future CAD Dorbala et al. J Nucl Cardiol 2006:13

46 Myocardial blood flow absolute quantification: Clinical applications Diagnosis Multivascular disease Microvascular disease Evaluation of the cardiovascular risk Evaluation of endothelial function Patient s treatment and follow-up

47 CONCLUSIONS Coronary flow quantification: A relative distribution myocardial flow image has limited diagnostic value. Non-coronary cardiovascular disease with microvascular dysfunction. Coronary risk evaluation Monitoring of the efficacy of risk reduction strategies New F-18-bound perfusion agent