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Cardiac PET Procedure: Perfusion, Coronary Flow, Viability, Inflammation, and PET/MR

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Nuclear Cardiology

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Abstract

Cardiovascular diseases remain the leading cause of morbidity and mortality in Western societies. Integrated positron emission tomography (PET) with computed tomography (CT) in a single unit—PET/CT—has become an established and valued imaging modality in clinical routine. Cardiac PET allows a noninvasive evaluation of myocardial perfusion, blood flow, function, and metabolism, using physiological substrates labeled with positron-emitting radionuclides, such as oxygen-15, nitrogen-13, carbon-11, fluorine-18, and rubidium-82. This chapter aims to present the most commonly used PET procedures in cardiology. It is schematically divided into perfusion, coronary flow, myocardial viability, and infection/inflammation. The improved PET diagnostic accuracy is due to instrumentation and radiotracer advantages over single photon emission computed tomography (SPECT). PET allows for data acquisition in dynamic sequences to delineate radiotracer kinetics for absolute quantification of myocardial blood flow (MBF) in mL/min/g during the stress and the rest, providing the assessment of coronary flow reserve (ratio of the hyperemic and resting myocardial blood flow), which offers important in vivo insight into the complex nature of the mechanisms underlying functional alteration of the coronary circulation, suggesting a paradigm shift in the evaluation and management of patients with coronary artery disease (CAD). In high-risk patients with CAD and left ventricular dysfunction, PET myocardial viability is an important tool used to identify patients with hibernating and/or stunned myocardium that may benefit from undergoing cardiac revascularization. Areas with reduced perfusion but preserved or increased glucose metabolism (mismatch) represent hibernating myocardium, which implies potential to improve function after revascularization. Inflammation forms an important core of the pathogenic process involved in many diseases affecting the heart and the blood vessels. These diseases include infectious as well as inflammatory noninfectious cardiovascular conditions. In vivo fluorine-18 fluorodeoxyglucose (18F-FDG) is accumulated in activated inflammatory cells such as lymphocytes and macrophages, at the inflammation/infection site. Cardiac infection and inflammation remain a diagnostic challenge, and PET is gaining use in this scenario. 18F-FDG-PET is an important newer tool for the identification of active inflammation in cardiac sarcoidosis. The procedure has a well-established role in the setting of infective endocarditis, mainly in cases of diagnostic uncertainty, and has recently been introduced as a major criterion for the diagnosis of prosthetic valve infections in international guidelines. Cardiac PET offers a wide diagnostic spectrum and utility with proven reduced downstream testing as well as reduced radiation exposure, making this test very appealing as a first line for the assessment of ischemic heart disease and other conditions. The new hybrid PET/MR system certainly will result in interesting new clinical applications.

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  1. Nuclear Medicine Department, The Heart Institute (InCor) -University of Sao Paulo Medical School (FMUSP), São Paulo, SP, Brazil

    José Soares Junior

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    Cláudio Tinoco Mesquita

  2. Hospital Vitória, Rio de Janeiro, Rio de Janeiro, Brazil

    Maria Fernanda Rezende

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Soares Junior, J. (2021). Cardiac PET Procedure: Perfusion, Coronary Flow, Viability, Inflammation, and PET/MR. In: Mesquita, C.T., Rezende, M.F. (eds) Nuclear Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-030-62195-7_1

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