Nuclear Cardiology Introduction

State the importance and purpose of Nuclear Cardiology Imaging. List the types of SPECT Cardiology Imaging procedures commonly used. By the end of this web based training, the attendee will be able to: Describe the purpose and procedure of SPECT myocardial perfusion imaging. Describe the purpose and procedure for SPECT nuclear ventriculography. List the types of PET Cardiology Imaging procedures commonly used. Describe the purpose and procedure for PET myocardial perfusion imaging. Describe the purpose and procedure for PET myocardial blood flow imaging. Describe the purpose and procedure for PET myocardial viability imaging.   Heart disease is the leading cause of death in the western world.   Nuclear Cardiology provides non-invasive techniques in the diagnosis and evaluation of extent of disease. Narrowing or blocking of blood vessels that feed the heart muscle.   Arteries become closed with fatty deposits, or plaque, over time.   Bloodflow to the heart muscle is compromised   Heart attack occurs   X-ray, MRI and CT show anatomy but not much function.   Nuclear imaging shows function but little anatomy. Image courtesy of Siemens Healthcare Single Photon Emission Computed Tomography   Injection of a radioactive tracer.   A disintegration from the tracer releases a single photon.   Attenuated   Scattered   Detected by camera (True Photons)   Many different tracers with different energies Gamma Camera Characteristics   1, 2 or 3 detectors   Scintillation crystal   NaI   Collimators   Planar   Tomographic The most common test in Nuclear Cardiology.    Exercise Pharmacologic   Imaging agent is injected at the peak of exercise   Images are acquired on a gamma camera as a tomo and gated tomo study. Stress Rest   Also known as a “planar gated” or MUGA study   Provides information about the contraction of the heart   Known MI – EF is decreased Evaluate the heart effects of chemotherapy Can be performed with or without a stress test Tomo acquisition to provide slices   More information about filling and contraction One of the first tests done for chest pain   Patient’s exercise ability is evaluated   The patient may need to discontinue certain medications, such as beta blockers   Patient will need to be NPO after midnight   Preferred method of stress testing   EKG leads attached   Blood Pressure cuff   IV for imaging agent and required medications   Baseline EKG and BP are taken before test begins   Alternative for patients unable to exercise   Patient is prepared basically the same fashion as exercise stress test   Patient is give a vasodilator drug to mimic the effects of the exercise The types of vasodilator medications used depend on the institution and the patient’s condition.   Examples of current medications now used are:   Adenosine Dipyridamole Dobutamine Regadenoson (Lexiscan) Imaging agents are radioactive tracers. Radiotracers that target specific organs. Cardiac radiotracers include: Thallium201   Tc99m Sestamibi   Tc99m Tetrofosmin After the patient has been stressed, images are acquired   The delay time after stress to imaging time depends on imaging agent   Nuclear medicine cardiac images usually take 15-30 minutes to acquire           2 day stress/rest   1 day rest/stress   1 day stress/rest   Dual Isotope 1 day stress/rest   IQ•SPECT Ultra-fast cardiac imaging with general purpose camera   Unique collimator design   Cardio-centric image acquisition   Advanced reconstruction technology   4x more counts Measures “ejection fraction”   Get results from both ventricles   Also referred to as a “gated” or MUGA study   Gated Perfusion   Gated Bloodpool Can be acquired in stress or resting states   The patient is connected to EKG   Imaging agent injected   If stress study, patient will exercise on a recumbent bicycle Multi Gated Acquisition   Each EKG QRS wave is divided into segments and images are acquired during each segment   The images of each segment are summed together to form the entire image   The result is a movie of the beating heart   Images are reviewed by physician   Ejection Fraction is a percentage of the contraction of the heart    50% and above is considered normal Positron Emission Tomography   Positron emitted   Annihilation with electron   Two 511 keV photons emitted at opposite angles   Ring scintillation crystal Emission Scan Images acquired from radioactivity coming from the patient Transmission Scan Radioactive sources CT PET Myocardial Perfusion   PET Myocardial Viabilit   IV line established   12 lead EKG   Blood pressure   Heart Rate *13NH3 Ammonia Cyclotron produced 10 minute half life Rb82 Generator produced 70 second half life *For indications & important safety information, see slides 62 - 69 at the end of this course. CT Topogram CT Rest Scan for AC Injection of *13NH3 20-25 mCi. Wait 3-5 minutes PET Resting list mode image for 10-15 minutes Wait 20-25 minutes between injections Stress drug injection Wait 3 minutes Injection of *13NH3 20-25 mCi. Wait 3-5 minutes PET Stress list mode image for 10-15 minutes CT Stress Scan for AC *For indications & important safety information, see slides 62 - 69 at the end of this course. Severe AnteroSeptal ischemia with partial reversibility - Rb82 Stress/Rest Myocardial Perfusion PET•CT study 61-year-old man with history of previous MI with occasional exertional dyspnea. Rb82 PET•CT myocardial perfusion study performed at rest and following adenosine stress. Study shows large perfusion defect in Anterior wall and Septum during stress with partial reversibility in Septum and part of anterior wall. Apex and adjacent anterior wall show severe ischemia even at rest. Study suggests infarction in Apex and adjacent anterior wall with revesible ischemia in peri-infarct zone suggesting revascularization of LAD territory to be clinically appropriate. Data courtesy of University of Michigan Ann Arbor Images courtesy of  the University of West Virginia, Morgantown, WV, Dr. G. Morano Data courtesy of Emory Crawford Long Hospital, Atlanta GA USA   Systole: Subendocardial vessels are compressed Epicardial coronary vessels remain patent Blood flow in subendocardium stops Diastole: Most myocardial perfusion occurs during heart relaxation Subendocardial vessels patent under low pressure Myocardial Blood Flow: Increase blood flow in response to exercise Ratio at peak stress (max vasodilitation) to flow at rest. Normal adult ratio is 2.0 or higher Data courtesy of Cardiovascular Imaging Technologies, St. Luke’s Hospital, Kansas City, Missouri, U.S. Data courtesy of the University of Geneva, Geneva, Switzerland Data courtesy of the University of Geneva, Geneva, Switzerland Data Courtesy: University of Eastern Piedmont, Novara General Hospital, Novara, Italy, Prof. E. Inglese   *F18 FDG - imaging agent Derivative of sugar Cardiac muscle uptakes sugar during glucose metabolism *For indications & important safety information, see slides 62 - 69 at the end of this course. Patient has to be in glucose metabolism   Low fat meal evening prior to exam   Technologist checks glucose levels   Glucose level may need to be raised using oral or IV methods   Technologist injects imaging agent at the height of glucose level   Patient waits approximately 45 minutes before scan Combination myocardial perfusion/viability possible   Patient scanned arms up   Scan can take 10-15 minutes to acquire Introduction to Nuclear Cardiology Data courtesy: Bundeswehrzentralkrankenhaus Koblenz, Germany , Nuclear Medicine, Dr. K. P. Kaiser, Prof. Dr. H. Wieler Data Courtesy: University of Eastern Piedmont, Novara General Hospital, Novara, Italy, Prof. E. Inglese Normal Myocardial Perfusion 76-year-old female patient with suspicion of coronary atery disease. Indication Method c.cam, Two-day protocol Stress: exercise, 275 MBq Tc-99m MIBI, 64 projections, 25s projection, Filtered Backprojection Gated Rest: 282 MBq Tc-99 MIBI, 64 projections, 25s/projection, Filtered Backprojection Findings Normal tracer distribution in stress and rest images. Left ventricular ejection fraction in rest 58% Data curtersy of Kardiologische Praxis, Erlangen, Dr. K Bergmann, Dr. U. Sattelbergerund, and Dr. Th. Schmidt Reversible Ischemia - Reduced acquisition time with IQ SPECT Patient Information: 67-year-ol male patient with suspiciaon of CAD with pathological finding in the ST segment of the ECG. Clinical FIndings: Reversible ischemia in the apex and in the antero-septal wall in the apex area. Scan protocol: SPECT; IQ SPECT, One-day scan protocol; Rest: 245 MBq 99mTc-Sestamibi, approx. 7 min acquisition time, Stress: 753 MBq 99mTc-Sestmibi, approx. 5 min acquisition time, CT base attenuation correction. Data courtesy: Bundeswehrzentralkrankenhaus Koblenz, Germany, Nuclear Medicine, Dr. K. P. Kaiser, Prof. Dr. H. Wieler Lateral Myocardial Infarction Indication 72-year-old patient with coronary artery disease post lateral wall infarction. Bypass operation 2003. PTCA und stent implantation of a proximal LAD stenosis 09/05 Method c.cam, 2 day protocol Physical stress: 230 MBq Tc-99m MIBI, 64 steps, 25s per step, Filtered Backprojection Rest: 190 MBq Tc-99m MIBI, 64 steps, 25s per step, FIltered Backprojection Findings Lateral myocardial infarction with large scar extending in the the apex Data Courtesy: Kardiologische Praxis, Erlangen, Germany, Dr. K. Bermann, Dr. U. Sattelberger und Dr. Th. Schmidt NPO for 4 – 6 hours   No caffeine for 24 hours   No nicotine for 6 hours   No beta blockers   No calcium channel blockers   No theophylline derivatives for 48 hours Cardiac History Documentation   Symptoms Cardiac Events NPO for 6 hours Caffeine and Nicotine   Can affect pharmacological stress medication and should be discontinued 24 hours prior to exam. Smoking can affect CBF reserve and should be discontinued 6 hours prior to exam Medications that can affect pharmacological stress agents: Nitroglycerine compounds Theophylline Beta Blockers Calcium channel blockers Breast Feeding: Stop before injection of tracer *13NH3 Ammonia – Wait 5 hours before resuming 82Rb – Can resume when patient returns home *For indications & important safety information, see slides 62 - 69 at the end of this course. CT Topogram CT Rest Scan for AC Injection of Rb82 20-60 mCi. Wait 60-90 seconds PET Resting list mode image for 8 minutes Stress drug injection Injection of Rb82 20-60 mCi. Wait 60-90 seconds PET Stress list mode image for 8 minutes CT Stress Scan for AC Myocardial Infarction - SPECT Perfusion and PET Viability Indication: 61-year-old male patient after two known myocardial infarction. Possible revascularization through bypass surgery?  Method: e.cam/Biograph 16 Gated SPECT: Stress and Rest, 2-day protocol, 555 MBq Tc-99m Tetrofosmin, 32 views, 25s / view Gated PET: 352 MBq *F-18 FDG, 60 min p.i., 20 min acquisition, attenuation corrected, iterative reconstruction Findings: SPECT stress and rest study reveal a stress induce hypoperfusion in the apex (lateral portion), the lateral and inferior wall. PET shows largely viable tissue in these areas, suggesting that this patient would benefit from a revascularization. Data courtesy of University of Eastern Piedmont, Novara General Hospital, Novara, Italy, Professor E. Inglese *For indications & important safety information, see slides 62 - 69 at the end of this course. Case Study Example 2 – MI Infarction SPECT Perfusion/PET Viability Indication: 57-year-old male patient after myocardial infarction in the anterior wall. Possible revascularization through bypass surgery? Method: e.cam / Biograph 16 Gated SPECT: Stress and rest, 2-day protocol, 555 MBq TC-99m Tetrofosmin, 32 views, 25s / view Gated PET: 352 MBq *F-18 FDG, 60 min p.i., 20 min acquisition, attenuation corrected, iterative resonstruction Findings: SPECT stress and rest perfusion study reveal hyperfusion in the apical half of the antero-septal wall. No FDG uptake in this area, matching the perfusion defect. Hence suggestive of scar tissue. No sign of hibernating myocardium. LV dilation and dyskinesia Data courtesy of University of Eastern Piedmont, Novara General hospital, Novara, Italy, Professor E. Inglese *For indications & important safety information, see slides 62 - 69 at the end of this course. You have completed the course Introduction to Nuclear Cardiology. You should now be able to:   State the importance and purpose of Nuclear Cardiology Imaging.   List the types of SPECT Cardiology Imaging procedures commonly used.   Describe the purpose and procedure of SPECT myocardial perfusion imaging.   Describe the purpose and procedure for SPECT nuclear ventriculography.   List the types of PET Cardiology Imaging procedures commonly used.   Describe the purpose and procedure for PET myocardial perfusion imaging.   Describe the purpose and procedure for PET myocardial blood flow imaging.   Describe the purpose and procedure for PET myocardial viability imaging. Myocardial ischemia Occurs when the blood vessels have been narrowed and the blood supply to the heart is decreased below it’s needs. Myocardial infarction Occurs when the one or more of the blood vessels become completely blocked.   Images are reconstructed on a computer system   Technologist reviews the quality of the images   Radiologist, Cardiologist or Nuclear Medicine physician interpret images and EKG results   Report is sent to referring physician to decide further treatment SMARTZoom Collimators for Cardiocentric Acquisition Center of FOV magnifies the heart Edges sample entire body to avoid truncation artifacts Acquisition is 4 times faster than standard cardiac acquisition Produces similar clinical results IQ·SPECT Iterative Reconstruction Different reconstruction algorithm is used Low count data handling   Indications, Important Safety Information, Dosage Forms and Strenths for *Fludeoxyglucose F18 Injection and *Ammonia N13 Injection   *Important safety information is available on the next few slides. Please see accompanying full prescribing information.   Indications & Usage Fludeoxyglucose F 18 injection (18F FDG) is indicated for positron emission tomography (PET) imaging in the following settings: Oncology: For assessment of abnormal glucose metabolism to assist in the evaluation of malignancy in patients with known or suspected abnormalities found by other testing modalities, or in patients with an existing diagnosis of cancer. Cardiology: For the identification of left ventricular myocardium with residual glucose metabolism and reversible loss of systolic function in patients with coronary artery disease and left ventricular dysfunction, when used together with myocardial perfusion imaging. Neurology: For the identification of regions of abnormal glucose metabolism associated with foci of epileptic seizures. *Please see accompanying prescribing information.   Important Safety Information Radiation Risk: Radiation-emitting products, including Fludeoxyglucose F 18 Injection, may increase the risk for cancer, especially in pediatric patients. Use the smallest dose necessary for imaging and ensure safe handling to protect the patient and health care worker. Blood Glucose Abnormalities: In the oncology and neurology setting, suboptimal imaging may occur in patients with inadequately regulated blood glucose levels. In these patients, consider medical therapy and laboratory testing to assure at least two days of normoglycemia prior to Fludeoxyglucose F 18 Injection administration. Adverse Reactions: Hypersensitivity reactions with pruritus, edema and rash have been reported; have emergency resuscitation equipment and personnel immediately available. *Please see accompanying prescribing information.   Dosage Forms and Strengths Multiple-dose 30 mL and 50 mL glass vial containing 0.74 to 7.40 GBq/mL (20 to 200 mCi/mL) of Fludeoxyglucose F 18 injection and 4.5 mg of sodium chloride with 0.1 to 0.5% w/w ethanol as a stabilizer (approximately 15 to 50 mL volume) for intravenous administration.   Fludeoxyglucose F 18 injection is manufactured by Siemens’ PETNET Solutions, 810 Innovation Drive, Knoxville, TN 39732   *Please see accompanying prescribing information.   Indications & Usage Ammonia N 13 injection is a radioactive diagnostic agent for positron emission tomography (PET) indicated for diagnostic PET imaging of the myocardium under rest or pharmacologic stress conditions to evaluate myocardial perfusion in patients with suspected or existing coronary artery disease. *Please see accompanying prescribing information.   Important Safety Information Radiation Risks Ammonia N 13 injection may increase the risk of cancer. Use the smallest dose necessary for imaging and ensure safe handling to protect the patient and the health care worker.   Adverse Reactions No adverse reactions have been reported for ammonia N 13 injection based on a review of the published literature, publicly available reference sources and adverse drug reaction reporting systems. The completeness of the sources is not known. *Please see accompanying full prescribing information.   Dosage Forms and Strengths Glass vial (30 mL) containing 0.138-1.387 GBq (3.75-37.5 mCi/mL) of Ammonia N 13 Injection in aqueous 0.9 % sodium chloride solution (the total volume in the vial will vary) that is suitable for intravenous administration. Ammonia N13 injection is manufactured by Siemens’ PETNET Solutions, 810 Innovation Drive, Knoxville, TN 39732 *Please see accompanying full prescribing information.   Isotopes: N*13NH3 T1/2: 10 minutes   Rb82 T1/2: 75 seconds   O15H2O T1/2: 2 minutes CT scout scan CT AC scan Radionuclide injection Rest PET LM scan Stress agent injection Delay Radionuclide injection Stress PET LM scan Optional CT AC scan Optional CAC and/or CTA List-mode PET Acquisition PET Image Formation List-mode Replay Static Dynamic Gated Quality assurance PET/CT alignment Image Quality Reconstruction syngo MBF Data Loading Localization Reorientation Segmentation Motion correction TAC generation MBF kinetic modeling CFR computation Perfusion image Polar Plots Quantitative analysis Qualitative review Interpretation 333 Reporting Analysis and Interpretation *For indications & important safety information, see slides 62 - 69 at the end of this course.