Hybrid cardiac imaging Advantages, limitations, clinical scenarios and perspectives for the future

Transcription

1 Hybrid cardiac imaging Advantages, limitations, clinical scenarios and perspectives for the future Prof. Juhani Knuuti, MD, FESC Turku, Finland

2 Disclosure: Juhani Knuuti, M.D. Juhani Knuuti, M.D. has financial interests to disclose. Potential conflicts of interest have been resolved. Research Support / Grants Stock/Equity (any amount) Consulting Employment Speakers Bureau / Honoraria None None Lantheus None Philips Research contracts (institutional): Orion Pharma, Turku Imanet Ltd, GE Healthcare, GSK, Merck, Bayer-Schering, Novartis, Lundbeck, Roche; Lantheus 2

3 Detection of CAD Noninvasive imaging vs obstructive CAD in ICA % Patient based analysis Sensitivity 98 Specificity Ex ECG Stress Echo SPECT CMR PET MSCT Adapted from Beller GA PET

4 Paradigm shift 1: From diagnosis to guidance of therapy Anatomy (Obstructive CAD) Flow-Limiting (Perfusion, FFR) Optimal Medical Treatment Complete Functional Revascularization and optimal medical treatment Noninvasive function: Perfusion, WMA Hachamovitch Circulation 2003;107:2900 COURAGE NEJM 2007;356:1503 COURAGE Circulation 2008;117:1283 Invasive function: FFR DEFER JACC 2007;49:2105 FAME NEJM 2009;360:213 FAME JACC 2010;56:177

5 Anatomical and functional imaging of coronary artery disease Anatomical imaging Invasive coronary angiography (+IVUS, OCT) Coronary Calcium Coronary CT angiography Functional imaging Nuclear imaging (SPECT, PET) Stress echocardiography CMR (FFR, invasive pressure gradient)

6 Pressure-derived FFR Invasive Hybrid Imaging N = Angiographic Diameter Stenosis (%) Wijns, de Bruyne, Vanhoenacker, JNC 2007;93:856-61

7 , Finland Functional consequences of stenoses by PET/CT LAD D1 LAD D1

8 Multivessel disease: What is the culprit lesion? Case: stenoses in all major vessels; RCA is culprit RCA LCX LAD

9 Multivessel disease: What is the culprit lesion? LAD RCA C E FFR=0.94 FFR=0.54 D F 3.5 FFR= ml/g/min D1

10 Challenges and solutions of ischemia imaging Challenge LM disease Balanced 3 vessel disease Multivessel disease Anatomical location Non-ischemic CAD Solution Hybrid Hybrid Hybrid Microvascular disease / Hybrid

11 Hybrid noninvasive (PET/CT) vs. Hybrid invasive (ICA + FFR) Sensitivity Specificity PPV (%) NPV (%) Accuracy (%) MDCT PET MDCT-PET hybrid Vessel analysis in patients Figure 3: Vessel with Analysis intermediate against ICA likelihood +FFR of CAD, N=107 percentage MDCT 50 PET 40 MDCT-PET hybrid PPV (%) NPV (%) Accuracy (%) MDCT PET MDCT-PET hybrid Kajander et al Circulation 2010

12 Prognosis and combined MDCT and perfusion imaging van Werkhoven JM, et al J Am Coll Cardiol Feb 17;53(7):

13 Survival Free of MACE Prognostic value of hybrid imaging 1.0 Normal Unmatched Matched Log-rank p< Follow-up (Years) Eur Heart J 2011;32:

14 Revascularisations Impact of hybrid imaging on downstream resource utilization 100% p< % 86% 80% 60% 45% 40% 39% 36% 20% NEJM 2010 USA N= GER N= % CATH rate CAD yield Per CATH REVASC Per CATH Eur Heart J 2011 Jul 30.

15 Myocardial perfusion Paradigm shift 2: From ischemic to CAD cascade Preclinical atherosclerosis Non-obstructive CAD hypoperfusion metabolic alterations diastolic dysfunction systolic dysfunction ECG-Changes Signs of ischaemia angina

16 MDCT findings in patients with normal SPECT perfusion imaging result Werkhoven JM, et al Am J Cardiol Jan 1;101(1):40-5.

17 Concerns on sequential / hybrid imaging for CAD Sequential: Complicated for patients Hybrid: Logistic challenges Higher work load Non-standardized image analysis Higher radiation burden Less evidence Cost-effectiveness

18 Challenges and solutions of ishchemia imaging Challenge LM disease Balanced 3 vessel disease Multivessel disease Anatomical location Non-ischemic CAD Microvascular disease Solution Hybrid Quantification Quantification Hybrid Hybrid Quantification/ Hybrid

19 Absolute quantification vs relative analysis in patients with multi-vessel disease 100 % 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0 % PPV NPV acc absolute relative 106 patients with 30-70% pretest likelihood of CAD Quantitative hybrid PET/CT imaging vs. invasive angiography with FFR Kajander S, et al 2008

20 Absolute flow is as good as flow reserve! Joutsiniemi et al (Circ Imaging)

21 Limitations If no anatomical information is available Patients with heart failure Patients with advanced atherosclerosis but no epicardial obstructive disease Microvascular disease

22 CTA helps in identifying potential stenoses that can be then visualised using coronary TTE CTA (62% diam. stenosis) Color-Doppler view Flow velocity profiles Maximal (2.1 m/s) Ao Ao Pre-stenotic (0.3 m/s) Case 0046 Joutsiniemi et al EHJ Cardiovascular Imaging 2012

23 CTA + CMR PERFUSION

24 Quantification of regional (LAD) myocardial perfusion by stress dynamic perfusion CT Rest Maximal vasodilatation 25% CBF reduction CT MBF: 104 ml/100ml/s FFR: 1.0 CT MBF: 236 ml/100ml/s FFR: 1.0 CT MBF: 173 ml/100ml/s FFR: % CBF reduction 75% CBF reduction CT MBF: 128 ml/100ml/s FFR: 0.55 CT MBF: 101 ml/100ml/s FFR: 0.50

25 Cardiac PET/MRI Extended transmural uptake in the late enhancement image in MR Fused FDG PET shows preserved viability in this area Courtesy: O Ratib, R Nkoulou and T Schindler, University Hospital Geneva

26 Dual gated 18 F-FDG PET/CT of coronary arteries in ACS patients 39 year old man Risk factors of CAD: Smoking Family history + 5 days of UAP ECG: lateral T-inversion LCX subtotal occlusion stented Preliminary results 20 ACS (non-stemi or UAP) patients Dual-gated FDG PET/CT 80% of patients visual coronary FDG uptake TBR 3.2±1.3 (range ) TBR ratio 4.2 Lankinen EHJ 2011 (abstract), Finland, Finland

27 Cardiac hybrid imaging Combination of anatomical and functional imaging Leads more accurate diagnosis of CAD Allows better guidance of CAD therapy Allows detection of non-obstructive CAD Multiple options for combinations CT + SPECT CT + PET CT + CMR CT+ CT perfusion PET + MRI Quantification of perfusion have additional value More evidence warranted especially in different diseases and patient subgroups