syngo® MI Applications Introduction to Nuclear Cardiology Online Training

Welcome to the syngo® MI Applications Introduction to Nuclear Cardiology online training. This online training will take you through the basics of Nuclear Cardiology for SPECT using the syngo MI Applications software. Cardiovascular disease is the number one cause of death worldwide.1 Coronary artery disease is the most common type of heart disease in the United States.2 During the last two decades, there have been major strides in the diagnosis and treatment of heart disease. Nuclear Cardiology has played a major role in these strides. This imaging modality offers non-invasive evaluation of the myocardial blood flow to the heart. Nuclear cardiology plays a pivotal role in diagnosing, evaluating, and predicting outcomes of coronary artery disease in patients. 1 Cardiovascular Diseases (CVDs). https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) 2 Coronary Artery Disease (CAD). https://www.cdc.gov/heartdisease/coronary_ad.htm Upon successful completion of this course, you will be able to: Evaluate the different cardiac procedures Assess the different isotopes used in Cardiology Imaging Apply workflow customization and setup Correctly demonstrate patient positioning Perform cardiac reconstruction Organize and interpret cardiac images Congratulations. You have completed the syngo MI Applications Introduction to Nuclear Cardiology Online Training course. Listed below are the key points that have been presented. Take time to review the material before you proceed to the final quiz. Evaluate the different cardiac procedures Myocardial Perfusion Imaging Multi-Gated Bloodpool (MUGA) Assess the different isotopes used in Cardiology Imaging Tc99m – Sestamibi Tc99m – Tetrofosmin Thallium201 – chloride  Apply workflow customization and setup The first acquisition should be a single phase with a frame rate of the range 20-50ms and should start just before injection and stop after the transit of the bolus through the heart. If the left anterior oblique (LAO) projection is used there is a significant overlap of the RV by the right atrium, and therefore is considered superior for RV EF calculation. Correctly demonstrate Patient Positioning The patient should be positioned supine on the table and connected to an EKG The SPECT headrest can be used and arms placed above the head for SPECT and non-anterior view statics For anterior static and gated dynamic the patient's arms should be by the side Perform Cardiac reconstruction Images are reconstructed on the computer Technologist reviews the quality of the images Radiologist, Cardiologist, or Nuclear Medicine Physician will interpret images and EKG results Organize and interpret Cardiac images The gated bloodpool activity is used in the cardiac first pass workflow us used to convert a first pass image, synchronized with the R-wave, to calculate the cardiac ejection fraction.   Please note that the learning material is for training purposes only! For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator's Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Note: Some functions shown in this material are optional and might not be part of your system. Certain products, product related claims or functionalities (hereinafter collectively “Functionality”) may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages. All names, images and data of patients, parameters and configuration dependent designations are fictional and examples only. All rights, including rights created by patent grant or registration of a utility model or design, are reserved. Copyright © Siemens Healthcare GmbH, 2019 Customer authorized use of images. CRF on file. Please proceed to the Assessment. Coronary artery disease is the narrowing or blocking of blood vessels that feed the heart. Myocardial Ischemia occurs when blood vessels have been narrowed and the blood supply to the heart is decreased. Myocardial Infarction occurs when one or more blood vessels supplying blood to the heart become completely blocked. Major Indications for MPI Coronary artery disease Risk stratification in patients with known CAD Assessment of therapy and intervention Myocardial viability before percutaneous intervention or bypass surgery Type of Imaging in Nuclear Cardiology Myocardial Perfusion Imaging MUGA Patient is stressed, either by exercise or a pharmaceutical. Then the radioactive tracer is injected at the peak of stress. After the patient recovers, the heart is imaged. Images can be acquired at both stress and rest stages EKG can be used to acquire gated images Patient Preparation Patient Preparation The patient’s ability to exercise and current medications are reviewed prior to the exam. In preparation for an MPI, the patient should be NPO (or nothing to eat or drink) after midnight, the night before the test. The patient may be asked to discontinue certain medications, such as beta blockers, to ensure a good study. The referring physician should also review all indications and contraindications for the procedure prior to performing the study.   Radiopharmaceuticals Radiopharmaceuticals Element HTML To image the heart, a radiopharmaceutical needs to be injected into the patient.  The injected radiopharmaceuticals are delivered to the myocardium in proportion to blood flow. There is reduced uptake of the tracer in regions with reduced blood flow.  These tracers cause no side effects to the patient.    Common tracers used for MPI Studies: •Tl201 – Chloride •Tc99m – Sestamibi •Tc99m – Tetrofosmin Sound File Audio ScriptIn order for the heart to be imaged on a nuclear medicine camera, a radiopharmaceutical (pronounced radio-pharma-suit-i-cal) needs to be injected into the patient.  The injected radiopharmaceuticals are delivered to the myocardium (pronounced myo-car-Dee-um) in proportion to blood flow. There is reduced tracer uptake in the regions with reduced blood flow and increased tracer uptake in the region with increased blood flow. These tracers cause no side effects to the patient.  The most commonly used radiopharmaceuticals in M.P.I. studies are Thallium  (pronounced thall-lee-um) 201 - chloride, Tc99m-sestamibi (all pronounced as tech-knee-she-um sest-a-mibi) and Tc99m - tetrofosmin (all pronounced as tech-knee-she-um tetro-foz-min).  It is dependent upon the physician and institution preference as to which radiopharmaceutical is used. After the patient is stressed, images are acquired. Nuclear medicine cardiac images usually take 15-30 minutes to acquire. Images can be acquired multiple ways.  The following options need to be determined based on institution specific protocol: Detector configuration: 90 or 76 degrees Gated or ungated SPECT only or SPECT/CT Patient position: supine or prone Reconstruction Reconstruction Element HTML After the images are acquired: Images are reconstructed on the computer so data can be displayed as slices Technologist reviews the quality of the images Radiologist, Cardiologist, or Nuclear Medicine Physician will interpret images and EKG results Sound File Audio ScriptAfter the images are acquired, they need to be reconstructed, or processed.  The original images are in a raw data format that is not able to be displayed in different slices or planes.  After the reconstruction is complete, the images are displayed as slices from 3 different positions.  At this time, the reviewer will check the images for motion or any other quality issues.  The images along with the E.K.G. results will then be sent to the physician to be interpreted.  The physician will review both the raw and reconstructed images.  In addition, the option of quantitative software can be used to aid in the interpretation. Imaging Protocol Imaging Protocol Element HTML Imaging protocols for Myocardial Perfusion Imaging: 2 day stress/rest 1 day rest/stress 1 day stress/rest Dual isotope 1 day stress/rest Sound File Audio ScriptIn addition to the various options available for scanning a myocardial perfusion study, there are also four different imaging protocols.  The two day stress and rest protocol requires that patients are stressed and imaged one day and then come back the next day for the rest images to be acquired.  This protocol is not commonly used due to the inconvenience to the patient.  The other protocols only take one day to complete.  The one day rest-stress and stress-rest involve a waiting period of 2 to 4 hours in-between the scans.  The dual isotopes option uses two imaging agents and does not involve a long wait time between scans. A MUGA is used to assess left ventricular ejection fraction and wall motion. Images are acquired during the QRS segment of the EKG wave. Images are then added together to create a cine of the hearting heart. MUGA - Radiopharmaceuticals MUGA - Radiopharmaceuticals Element HTML MUGA scans are performed using Tc99m-labeled erythrocytes or RBCs. The cells are separated by centrifugation, the plasma is removed and the RBCs are incubated with Tc99m pertechnetate for 5 to 20 minutes with occasional mixing. After incubation, unbound activity is washed away by addition of a few milliliters of saline and centrifugation. The supernatant is removed and the red cells resuspended in saline before re-injection. The usual administered activity range is 500 – 1,050 MBq for adult patients. Sound File Audio ScriptMUGA (pronounced MUG-ah) scans are performed using 99mTc-labelled erythrocytes (pronounced e-ryth-ro-cytes) or red blood cells.  The cells are separated by centrifugation, the plasma is removed and the RBCs are incubated with Tc99m pertechnetate (all pronounced as: tech-knee-she-um per-tech-ni-tate) for 5 to 20 minutes with occasional mixing. After incubation, unbound activity is washed away by the addition of a few milli-liters of saline followed by centrifugation. The supernatant (pronounced super-nay-tent) is removed and the red cells resuspended in saline before re-injection. In vitro (pronounced vee-tro) labelling gives by far the highest labelling efficiency. The usual administered activity range is 500 to 1,050 MBq (pronounced mega-beck-er-alls) for adult patients. Patient Setup and Preparation Patient Setup and Preparation Element HTML The patient should be positioned supine on the table and connected to an EKG. The EKG signal quality needs to be checked in the Beat Histogram section of the acquisition activity by using the play function. The SPECT headrest can be used and arms placed above the head for SPECT and non-anterior view statics.  For anterior static and gated dynamic the patient's arms should be by the side. Sound File Audio ScriptThe patient is connected to an E.K.G. with an I.V. setup for the injection of the imaging agent. The patient should be positioned supine on the table and connected to an E.K.G. The E.K.G. signal quality needs to be checked in the Beat Histogram section of the acquisition activity by using the play function.  If the beats are being collected outside the histogram window you may need to widen the window to a maximum of 40 percent to acquire enough gated data. The Spect headrest can be used and arms placed above the head for SPECT and non-anterior view statics. For anterior (pronounced an-te-ri-or) static and gated dynamic, the patients' arms should be by the side so that the detectors can be closer to the patient.