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PET myocard perfusion & viability
Riemer Slart
Nuclear Medicine Physician
Dept. of Nuclear Medicine and Molecular Imaging
University Medical Center Groningen, the Netherlands
Professor in Molecular Imaging, University of Twente, the Netherlands
EANM Cardiovascular committee
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Global burden of cardiovascular disease
Cardiovascular disease is the leading cause of death worldwide
Nature, 493, S2–S3, 2013
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Global Coronary & Cardiovascular Risk Scores
Greenland. J Am Coll Cardiol. 2010;56:e50-e103.
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Slide 4
What cardiologists want to know:
• Does the patient have a CAD?
• CAD with a significant stenosis?
• What is the extend of the CAD?
• Of prognostic impact?
• What is the best therapy?
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“The general gatekeeper principle” Coronary artery disease
Risk factors Clinics
Intermediate risk
(1-3%)
Noninvasive imaging
Low risk (<1%)
High risk (>3%)
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Ischemic cascade CAD
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Coronary stenosis & ischemia
Diameter stenosis 50%
Patient with ischemia
Patient with angiographic lesion
Dilemma: no perfect match
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•Diameter stenosis 90%
•Dilemma: no perfect match
Patient with ischemia
Patient with angiographic lesion
Coronary stenosis & ischemia
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Diagnosis of CAD: CVI techniques
Echocardiogram
MPS SPECT
MPS PET
CT angiography
Calcium scoring
Intracoronary echo
Coronary angiogram
Adenosine MRI
Non-invasive
Invasive
Dobu MRI
ECG
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Indications of different imaging tests for the diagnosis of
obstructive CAD and for the assessment of prognosis in subjects without known CAD
•Guidelines on myocardial perfusion, Task Force ESC and EACTS, Eur H J 2010
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PET(/CT) myocardial perfusion
PET-CT scanner
PET vs SPECT Pro’s:
•Better resolution
•Absolute quantification
•Real time imaging
Con’s :
•Costs
•Availability
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PET tracers for myocardial perfusion
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Sogbein et al Biomed Res Int. 2014
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Absolute quantification 13N-ammonia: Hutchins model
• 3-compartments model (K1, K2, K3)
13N-ammonia free diffusible
13N-ammonia: glutamate into glutamin (synthetasis)
equilibrium
Absolute quantification: mL/gr/min
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Time-activity curves
Myocardial Blood Flow (absolute values, ml/g/min)
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Normal values 13N-ammonia
• Rest: 60-95 mL/min/100g
• Stress: 190-300 mL/min/100g
• In general: MPR > 2.0
• Depending on age and gender & technique
Blanksma et al., J Nucl Med 1995
Chilian WM, Circulation 1997
DeGrado et al, J Nucl Cardiol 1996
Muzik et al, J Am Coll Cardiol 1998
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Sunderland et al, J Nucl Cardiol 2014
DIFFERENT SOFTWARE PACKAGES -PMOD, SYNGO, FLOWQUANT-
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Dynamic 13N-ammonia PET: quantification (Syngo) mL/gr/min
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Principle MPI/FDG PET scan -Visual analysis-
• NORMAL tissue normal normal
• INFARCTED tissue reduced reduced
• ISCHEMIC tissue normal reduced
Rest Stress
Uptake flowtracer
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Preparation patient:
Glucose load, low fat?
Euglycaemic insulin clamp infusion system
Acipimox: fatty acid lowering agent
(aspirin needed)
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PET protocol: ischemia & viability UMC Groningen
rest 13NH3
(gated) FDG
Viability
rest 13NH3
(gated) FDG
Viability & ischemia
adeno 13NH3
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Shorter scan protocol?
Lazarenko SV et al, Med Center Alkmaar, NL
Residual activity correction (RAC)
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Normal Hibernating Scar
PET Imaging
Flow/FDG Patterns
Match Mismatch Match
DCM
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Viability testing rest 99mTc-tetrofosmin IQ SPECT and FDG cPET
99mTc-tetrofosmin IQ SPECT
FDG cPET
CABG MVP/ring
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Case
• 67 yr male
• RF: hypertension, DM
• Dyspnoe, no angina
• Obese
• Previous MPS SPECT (MIBI) inconclusive
• Nevertheless ischemia?
rest, stress 13N-ammonia and (gated) FDG
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Rest, stress 13N-ammonia and (gated) FDG
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Polarmap and quantification
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Results
• Rest: 52 mL/min/100g
• Stress: 68 mL/min/100g
• MPR: 1.27 (normal > 2)
• Regions: 5 regions ratio < 1
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Coronary angiography
3 vessel disease: revascularisation
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Prognostic value of MPR without intervention -Absolute quantification-
Tio, Slart et al., J Nuc Med 2010
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Prognostic value of MPR after intervention -Absolute quantification-
Cardiac death MACE
Slart et al, J Nucl Med 2011
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Joutsiniemi et al, Eur Heart J Cardiovasc Imag 2015
Absolute flow or myocardial flow reserve for
the detection of significant coronary artery disease?
15O-water PET study
104 patients with moderate pre-test likelihood of CAD
without previous myocardial infarction.
Reference: CAG
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Dorbola et al, J Am Coll Cardiol, 2013
PERFUSION DEFECT SIZE ON MPI PET MULTICENTER TRIAL
N = 7000
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Diagnostic Performance of MPI Using SPECT, cMRI, and PET Imaging for the Detection of Obstructive CAD: A Meta-Analysis
Jaarsma et al., J Am Coll Cardiol, 2012
•166 articles (n = 17,901) : 114 SPECT, 37 CMR, and 15 PET articles.
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Morton et al, J Am Coll Cardiol 2012
PET vs MRI MPI
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Screened 920
PET evaluable
782
Discontinued
31
SPECT evaluable
778
Angio evaluable
762
Total 755
SPECT+PET+ angio
Dosed
795
CAD+= 327
CAD-= 428
(CAD prev 43%)
Flurpiridaz PET phase 3 study
PET vs SPECT for overall CAD detection
(n=755)
Courtesy of J. Knuuti
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Flurpiridaz PET phase 3 study
PET vs SPECT for overall CAD detection
(n=755)
Original read Re-read
Courtesy of J. Knuuti
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Courtesy of J. Knuuti
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Ammonia mini cyclotron
Sr/Rb generator
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Hybrid cardiac imaging: SPECT/CT and PET/CT. A joint position statement by the European Association of Nuclear Medicine (EANM), the European Society of Cardiac Radiology (ESCR) and the European Council of Nuclear Cardiology (ECNC)
Eur J Nucl Med & Mol Imag 2011