pet/ct vs spectnucleus.iaea.org/hhw/...2012/...2012/1._vitola_j.pdf · disclosures - honorarium –...
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DISCLOSURES -
Honorarium – Research / Advisor, Expert Services and Conferences in Nuclear Cardiology
BMS, CVT, Astellas, Lantheus, PGx Health, International Atomic Energy Agency
Royalties – Publications in Nuclear Cardiology
Springer-Verlag-Nuclear Cardiology and Correlative Imaging: a teaching file, NY, 2004
Lippincott Williams & Wilkins, - Nuclear Medicine teaching File, 2009
João V. Vitola
Quanta Diagnostico Nuclear
Brazil
PET/CT vs SPECT
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65 yo male
Atypical chest pain
No history of CAD/MI
HTN, hypercholesterolemia
Vitola and Delbeke: Nuclear Cardiology and Correlative Imaging, Springer 2004, NY, Chapter 3
Case
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SAV – EXERCISE
SAV - REST
VLA – EXERCISE
VLA - REST
HLA – EXERCISE
HLA - REST
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1- Does the ECG change represents a silent MI in the
past ?
2- Does he need any additional viability study ?
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Myocardial Viability: 99mTc-perfusion agents
• Retention of MIBI and tetrofosmin depends on cell membrane integrity and mitochondrial function.
• 99mTc-perfusion agents do not redistribute and may underestimate viability compared to 201Tl or FDG
• Improvement for detection of viability with quantitative SPECT criteria and nitrate administration
Cuocolo A et al. J Nucl Med 1992;33:505-511. Soufer R et al. Am J Cardiol 1995;75:1214-1219. Altehoefer C et al. J Nucl Med 1994;35:569-574.
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Conclusions • TMT was less sensitive than MPI for LCX
ischemia detection
• CAD and prior MI detected in a patient with no history
• MIBI was consistent with rest ECG, confirming the suspicion of a prior silent MI
• MIBI detected a large area of viable tissue at risk, not requiring any other test to decide management
• MIBI can be used as a viability agent, however underestimation of viable tissue may occur in some cases and further testing may be needed
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Case
• 68 year-old woman with a history of silent inferior MI who presented with episodes of atrial fibrillation and ventricular tachycardia
• ECG:
– Q waves in II, III, AVF
• Coronary angiography:
– Occluded RCA with collaterals to the distal inferior wall from the left circulation
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Rest only - 15 min Rest- 4h redistribution 201Tl
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Membrane Integrity: Thallium-201
• Analog of potassium
– Myocardial extraction by active and passive transport
– High first pass uptake – 89%
– Myocardial localization: 4% injected dose
• Does redistribute according to perfusion
• Allows evaluation of perfusion and cell membrane integrity (a requirement for viability)
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Vitola and Delbeke: Nuclear Cardiology and Correlative Imaging, Springer 2004, NY, Chapters 3 and 8
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Membrane Integrity: 201Thallium SPECT Rest-4h redistribution - Semiquantitation
• Patterns of uptake in dysfunctional myocardium:
– Fixed defect: <50% of normal: transmural scar
– Fixed defect: 50-80% of normal: non-transmural scar
– Redistribution – Myocardium at risk - viable
Bax JJ et al. Eur J Nucl Med 1997;24:516-522.
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Membrane Integrity: 201Thallium SPECT • Stress/Rest imaging
– 4-hour redistribution imaging:
• fixed defect frequently viable: 45% of fixed defects improve after revascularization.
– Resting imaging after reinjection of 201Tl improves viability assessment : 30-50% fixed defects at 4h redistribution show reversibility.
– 24-h redistribution imaging (in average additional 6%)
Kiat H et al. JACC 1988;12:1456-1463. Yang LD et al. JACC 1990;15:334-340. Dilsizian V et al. NEJM 1990;323:141-146.
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Value of 24h imaging:
Small number of patients:
– Up to 30% of patients with fixed defects (rest-4 hrs) will show improved uptake at 24h
– But only 3% of patients with fixed defects of <50% uptake of normal
Membrane Integrity: 201Thallium SPECT
Wagdy HM et al. Nucl Med Commun 2002;23:629-637.
Matsunari I et al. J Nucl Med 1997;38:1073-1078.
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• 61 yo man with exercise induced chest pain (typical angina)
• AMI 2 1/2 y ago, followed by CABG: LIMA to LAD and SVG to the LCX
• Last cath 6 mo ago: 99% native LAD, occluded LIMA, antero-apical akinesia
•Meds: Carvedilol, ACEI, nitrate, ASA, Statin and Aldactone
Referred for a SESTAMIBI study
•MPI: Bruce, 10 METS, ECG positive – new ST depression 1 mm, denied chest pain
Case
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Stress/Rest MIBI • Hx of exercise induced chest pain + new ST depression 1 mm om TMT
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Stress/Rest MIBI
•exercise induced chest pain, new ST depression
Next Step ?
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Nitrate administration
Venodilation
Preload reduction
Decrease of LV volume and wall stress
Reduction of myocardial oxygen demand
Coronary blood flow redistribution towards ischemic
regions by reduction of LV end-diastolic pressure
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Nitrate Myocardial Perfusion Imaging
0 5 10 15 20 25 30 50 70
SPECT imaging
Nitrateadministration
Tracerinjection
Resting conditions
Time (min)
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MIBI with nitroglycerin (NTG)
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Scar > Ischemia
MIBI without NTG
Ischemia > Scar
MIBI with NTG
STRESS
STRESS
REST
STRESS
REST
STRESS
REST
•exercise induced chest pain, new ST depression
Next Step : nitrate MIBI = good choice
REST
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Rest without NTG Rest with NTG
STRESS STRESS
REST REST
Akinetic antero - apical region
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Case
• 52 year-old man with CHF and global LV dysfunction on echocardiography
• Coronary angiography: severe 3-vessel CAD
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• Nitrate: How does it work?
– Preload reduction, some dilatation of stenotic epicardial vessel and improvement of collateral circulation
• How to administer?
– 0.4-0.8 mg sublingually 5 -10 min before the radiopharmaceutical
• Can be used with 201Tl or 99mTc-perfusion agents
• Performance?
Myocardial Viability Resting and nitrate-enhanced SPECT
Bisi G et al. JACC 1994;24:1282-1289.
Batista JF et al. J Nucl Cardiol 1999;6:480-486.
Oudiz RJ et al. Am Heart J 1999;138:206-209.
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FD
G
Viable Necrotic
Via
ble 75
(57%)
34
(26%)
3
(2%)
Necro
tic
19
(15%)
Baseline Tetrofosmin
Agreement: 94/131 (72%)
Kappa = 0.35
Nitrate Tetrofosmin
FD
G
Viable Necrotic
Via
ble 89
(68%)
20
(15%)
3
(2%)
Necro
tic
19
(15%)
Agreement: 109/131 (82%)
Kappa = 0.53
Cardiac Tomography After Nitrate Administration in Patients With
Ischemic LV Dysfunction: Relation to Metabolic Imaging by PET
He W, et al. J Nucl Cardiol 2003
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Cardiac Tomography After Nitrate Administration in Patients
With Ischemic LV Dysfunction: Relation to Metabolic Imaging
by PET
He W, et al. J Nucl Cardiol 2003
Patient 1 Patient 2
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69
8681
86
0
20
40
60
80
100
Sensitivity Specificity
He W, et al. J Nucl Cardiol 2003
Perc
ent
Baseline
Nitrate
Sensitivity and Specificity of Baseline and Nitrate Tetrofosmin
SPECT for Detecting Preserved Metabolic Activity in Patients With
Ischemic LV Dysfunction
p < 0.01 p = NS
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Detection of Myocardial Viability by Radionuclide Imaging
Gold Standard: Recovery of LV Function
9086
81
91 92
54
6760
88
73
0
20
40
60
80
100
Tl-201 Red Tl-201 Rein Mibi Mibi-Nitrate FDG-PET
Bax et al. J Am Coll Cardiol 1997
%
Sensitivity Specificity
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Stunning
Scar from prior MI
Hibernation
Subendocardium
20-30 % = akinesia
May have lots
of viable tissue
Chronic cases =
Mixed pattern
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Lieberman AN et al, Circulation 1981;63:739-746
Contribution of the subendocardium to contractility
Akinetic anterior wall
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Pooled Data from Studies Focusing on Prediction of Recovery of Function Post-revascularization
Technique #Studies/
patients
Sensitivity Specificity NPV PPV
FDG PET 20/598 93% 58% 86% 71%
201Tl 33/858 87% 55% 81% 64%
99mTc-tracers 20/488 81% 66% 77% 71%
Dobutamine
Echo/MRI
32/1090 81% 80% 85% 77%
Pooled data 105/3034 84% 69%
Bax JJ et al. Curr Probl Cardiol 2001;26:142-186
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Why is nuclear less specific compared to echo for Fx improvement ?
Qureshi U et al. Circulation 1997;95:626-635
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Subendocardium MI may lead to akinesia
Akinetic segments may have lots of viable tissue detected by Nuclear
Scar may prevent improvement of function and detection by echo
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Conclusions
• MIBI can be used as a viability agent, however underestimation of viable tissue may occur and further testing may be needed in special cases
• Nitrates are easy and safe to use and increase the sensitivity of rest MIBI to detect viable tissue
• There are data in the literature supporting the use of Nitrate MPI with similar accuracy to other protocols including thallium and FDG (LV Fx dependent)
• Akinetic areas may be present after a subendocardium MI
• Viability studies may show large quantities of viable tissue at risk in akinetic areas
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PET CT
Integrated PET-CT Imaging
System
PET
CT
PET - CT
Hybrid Technology - PET/CT Widespread due to oncology
Availability may push for more cardiac utilization
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Cardiac PET/CT
PET/CT
Viability
Systolic/
Diastolic
function
First
Pass
Image
Fusion
CAC
Perfusion
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COMPLETE STATE OF THE ART EVALUATION IN 30 MINUTES ANATOMY, PERFUSION AND FUNCTION
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Differences SPECT vs. PET Radiotracers
Characteristic SPECT PET
Radiotracer Generator Generator/Cyclotron
Energy 80-140 KeV 511KeV
Resolution 20 mm FWHM 10 mm FWHM
Attenuation More Less
Half-life 6 hrs-72 hrs 1.5 to 13 min
Radiation Greater Less
Study duration 3-4 hrs 35-45 min
Stress Exercise > pharm
Pharm > exercise
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Estimated radiation dose to patients: PET vs. SPECT
Adapted from: Gerber et al.
Circulation, Feb 2009; 119: 1056 -
1065.
Einstein et al Circulation.
2007;116:1290-1305
Senthamizhchelvan J. Nucl. Med.
2011 52: 485-491
Stabin, Health Physics: December
2010 - Volume 99 - Issue 6 - pp 811-
813
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SPECT
• Flow heterogeneity to see the defect
• Homogenous decrease: • Three vessel disease, Left main
• Microvascular disease
Beanlands et al. J Am Coll Cardiol 2009 54: 157-159
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PET - Myocardial blood flow absolute quantification: Clinical applications
Diagnosis
Multivascular disease (Diffuse disease)
Microvascular disease
Evaluation of endothelial function
Patient’s treatment follow-up
Myocardial Viability
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Advantages of Cardiac PET
• High image resolution
– Spatial, contrast and temporal
• Superior efficiency
– Time
– Radiation
• Superior ability to delineate extent of CAD
– Quantitative imaging capabilities
– Peak stress LVEF
– Hybrid PET/CT applications
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Variable Soft Tissue Attenuation: SPECT
Stress
Rest
Stress
Rest
Stress
Rest
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Variable Soft Tissue Attenuation on SPECT:
Normal 82 Rb PET
Stress
Rest
Stress
Rest
Stress
Rest
Stress
Rest
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Limited Rest SPECT
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Rb-82 Rest-Stress PET
Stress
Rest
Stress
Rest
Stress
Rest
Stress
Rest
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Equivocal Tc 99m SPECT
5’6”, 190 lbs, F
Stress Tc 99m
Rest Tc 99m
Mildly Abnormal 82Rb PET
Stress Rb-82
Rest Rb-82
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Overall Diagnostic Accuracy
PET vs. SPECT
0
20
40
60
80
100
120
Sensitivity Specificity Accuracy
%
SPECT
PET
P<0.05
P<0.05
Bateman et al, J Nucl Cardiol; 2006:
Jan
86%
100%
ACC/ASNC Radionuclide guidelines
SPECT: Sensitivity 89%, Specificity:75%
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• FDG is taken up by viable myocardial regions
even when flow is significantly reduced.
• Effectively differentiates nontransmural MI
from hibernating condition.
• Soft tissue attenuation correction is routinely
performed.
PET FDG for Viability Assessment
Advantages over SPECT
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>50% uptake
Post-revascularization
Wall motion recovery
Not likely
Nontransmural MI Nontransmural MI
+
Hibernating myocardium
Post-revascularization
Wall motion recovery
likely
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• PET FDG is the preferred imaging method for
assessment of myocardial viability.
• If SPECT is done first, PET should be
considered in those with non- or partially
reversible defects.
PET vs. SPECT for Viability Assessment