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Hybridbildgebung in Diagnostik und Therapie der chronischen Myokardischämie

Klinischer Stellenwert

Hybrid imaging in diagnostics and therapy of chronic myocardial ischemia

Clinical value

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Zusammenfassung

In klinischen Untersuchungen konnte übereinstimmend gezeigt werden, dass es nur eine sehr schwache Korrelation zwischen dem angiographisch bestimmten Schweregrad einer koronaren Herzerkrankung (KHK) und der Störung der regionalen Koronarperfusion gibt. Die Ergebnisse randomisierter Studien mit einer FFR („fractional flow reserve“)-gesteuerten koronaren Intervention (DEFER, FAME I, FAME II) konnten andererseits zeigen, dass nicht der angiographisch bestimmte morphologische Schweregrad einer KHK, sondern der mittels FFR bestimmte funktionelle Schweregrad prognostisch und für die Indikation zur Revaskularisation entscheidend ist. Ein nichtinvasives Verfahren, welches eine gleichzeitige anatomische Darstellung der Koronararterien mit einer funktionellen Ischämiediagnostik kombiniert, ist somit besonders wünschenswert. Aus diesem Grund war die Kombination einer Koronarcomputertomographieangiographie (CCTA) mit einem funktionellen Verfahren wie der Perfusions-PET (Positronenemissionstomographie), der Perfusions-SPECT („single photon emission computed tomography“) oder auch der Perfusions-MRT (Magnetresonztomograhie) naheliegend. Dies kann in Form einer Software-gestützten Fusion von Bilddatensets, gewonnen mit unterschiedlichen Geräten („fusion imaging“), oder in einem Kombinationsgerät („hybrid imaging“), einem PET-CT oder einem SPECT-CT erfolgen. Erste Ergebnisse von Studien mit der PET-CCTA und SPECT-CCTA, die als kardiale Hybridbildgebung an einem 64-Zeilen-CT durchgeführt wurden, zeigen, dass dadurch vor allem die Zahl der falsch-positiven Befunde verringert und damit die Spezifität von CCTA und SPECT jeweils signifikant erhöht werden kann. Aufgrund der bisher hohen Kosten, der geringen Verfügbarkeit und der zusätzlichen Strahlenexposition ist die Datenlage trotz der vielversprechenden Ergebnisse bisher nicht ausreichend, um aktuell eindeutige Empfehlungen für den Einsatz der Hybridbildgebung bei Patienten mit niedrigem bis intermediärem Risiko für das Vorliegen einer KHK abgeben zu können. Laufende prospektive Studien wie die SPARC- oder die EVINCI-Studie werden hier weitere Klärung bringen.

Abstract

Clinical studies have consistently shown that there is only a very weak correlation between the angiographically determined severity of coronary artery disease (CAD) and disturbance of regional coronary perfusion. On the other hand, the results of randomized trials with a fractional flow reserve (FFR)-guided coronary intervention (DEFER, FAME I, FAME II) showed that it is not the angiographically determined morphological severity of coronary artery disease but the functional severity determined by FFR that is critical for prognosis and the indications for revascularization. A non-invasive method combining the morphological image of the coronary anatomy with functional imaging of myocardial ischemia is therefore particularly desirable. An obvious solution is the combination of coronary computed tomography angiography (CCTA) with a functional procedure, such as perfusion positron emission tomography (PET), perfusion single photon emission computed tomography (SPECT) or perfusion magnetic resonance imaging (MRI). This can be performed with fusion imaging or with hybrid imaging using PET-CT or SPECT-CT. First trial results with PET CCTA and SPECT CCTA carried out as cardiac hybrid imaging on a 64 slice CT showed a major effect to be a decrease in the number of false positive results, significantly increasing the specificity of CCTA and SPECT. Although the results are promising, due to the previously high costs, low availability and the additional radiation exposure, current data is not yet sufficient to give clear recommendations for the use of hybrid imaging in patients with a low to intermediate risk of CAD. Ongoing prospective studies such as the SPARC or EVINCI trials will bring further clarification here.

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Danksagung

Herrn Michael Tietz, Mitarbeiter der Abteilung Nuklearkardiologie der Praxisklinik Herz und Gefäße Dresden, danken wir vielmals für die zuverlässige und engagierte Assistenz bei der rechnergestützten Fusion der hier vorgestellten SPECT-CCTA-Hybridbilder.

Interessenkonflikt

Der korrespondierende Autor gibt für sich und seine Koautoren an, dass kein Interessenkonflikt besteht.

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Authors and Affiliations

  1. Praxisklinik Herz und Gefäße,AkademischeLehrpraxisklinik der TU Dresden, Forststr. 3, 01099, Dresden, Deutschland

    R. Dörr, C.T. Kadalie & W.G. Franke

  2. Abteilung für Diagnostische und Interventionelle Radiologie, Herzzentrum Leipzig, Leipzig, Deutschland

    M. Gutberlet

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  1. R. Dörr
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  2. C.T. Kadalie
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  3. W.G. Franke
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  4. M. Gutberlet
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Correspondence to R. Dörr.

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Dörr, R., Kadalie, C., Franke, W. et al. Hybridbildgebung in Diagnostik und Therapie der chronischen Myokardischämie. Herz 38, 367–375 (2013). https://doi.org/10.1007/s00059-013-3785-3

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