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Organised in conjunction with American Society of Nuclear Cardiology Cardiovascular Committee of the European Association of Nuclear Medicine and the Working Group on Nuclear Cardiology and Cardiac CT of the European Society of Cardiology
Abstracts of original contributions
ICNC11 – 5–8 May 2013
Nuclear Cardiology and Cardiac CT Berlin, Germany
Table of Contents
Welcome address S1
Acknowledgements Graders S2
Statistics S3
Committees S4
Abstracts Presented on Monday 6 May 2013
Oral Abstract Session 1: Young Investigator Award Competition S5
Oral Abstract Session 2: SPECT MPI: New approaches and applications S8
Moderated Posters 1 Morning: Advances in instrumentation S11
Poster Session 1 – Morning: Advances in instrumentation S14
Moderated Posters 2 Afternoon: New pharmaceuticals: regandenosin and MIBG S27
Poster Session 2 – Afternoon: New pharmaceuticals: PET, regandenosin and MIBG S31
Abstracts Presented on Tuesday 7 May 2013
Oral Abstract Session 3: Advances in PET S44
Oral Abstract Session 4: Refining cardiac risk assessment with imaging S47
Moderated Posters 3 Morning: Imaging cardiovascular disease mechanisms S50
Poster Session 3 – Morning: Imaging cardiovascular disease mechanisms S53
Moderated Posters 4 Afternoon: Left ventricular function and new insights S66
Poster Session 4 – Afternoon: Left ventricular function and new insights S70
Abstracts Presented on Wednesday 8 May 2013
Oral Abstract Session 5: Novel cardiovascular molecular imaging probes S83
Oral Abstract Session 6: Cardiac CT: New approaches and applications S85
Poster Session 5 – Morning: Clinical General and Outcome: Cardiac CT Posters S87
Author Index S102
Index of Topics S108
This supplement was not sponsored by outside commercial interests. It was funded entirely by the International Conference on Nuclear Cardiology.
Welcome Address
Dear Colleagues and Friends,
It is our great pleasure to welcome you to ICNC11, the International Conference on Nuclear Cardiology and Cardiac CT. The ICNC meeting has been a key international scientific event for nuclear cardiology and cardiac CT imaging for more than 20 years. It provides the opportunity for practitioners from all over the world to gather to learn about new advances and to exchange scientific ideas and experiences in a distinctive environment.
Over the next few days the meeting will provide an exciting and diversified scientific programme which offers a full spectrum of educational opportunities ranging from continuing education to cutting-edge presentations of new and original scientific research. A core curriculum, as well as advanced and research tracks will be available. As in the past, submitted abstracts will come from a wide geographical area which reinforces the message that ICNC is an important international scientific event. Many “Read with the Experts” case review sessions will allow participants to improve their interpretative skills for cardiac CT and SPECT and PET examinations.
Unique to this meeting will be an even greater emphasis on presentations by young investigators. In addition to the awards and grants we already offer such as the ESC Working Group Travel Grants and the free registration for presenters in the Young Investigator Awards session, this year we will be offering two new categories of grants, the ICNC Grants and the ICNC Young Scientist Award. These 25 grants attributed to abstract presenters and young cardiologists will be generously provided by the ICNC Organising Committee and will carry a stipend of €1 500 per person. The Young Scientist Award will carry a stipend of €5 000. The winner will be announced at the gala dinner on Tuesday, 6 May.
The beautiful city of Berlin is the venue for ICNC11. Germany’s capital city combines all the things necessary for a successful congress, including a robust medical science community, a rich history, lively entertainment and affordability. Indeed, the ICNC organisers have selected this city for its popularity not only within Europe but because it is a favoured destination from the Americas, Asia and throughout the world.
Thank you for choosing to attend ICNC11. We are pleased that you are here and hope you enjoy the meeting and the wonderful city of Berlin.
Organising Committee
Frank Bengel, DE – Organising Co-Chair
Robert Gropler, US – Organising Co-Chair
Robert Beanlands, CA – Industry Liaison
Robert Hendel, US – Meeting Services
Juhani Knuuti, FI – Scientific Advisor
Programme Committee Chairpersons
Sharmila Dorbala, US – Programme Chair
Michael Zellweger, CH – Programme Chair
Randall Thompson, US – Programme Chair
Acknowledgements
The Programme Committee for the International Conference of Non-Invasive Cardiovascular Imaging gratefully acknowledges the assistance of the following individuals who served as Abstract Graders for the original contributions sessions. Our experts graded the abstracts anonymously. The author’s names and details were not known at any point in time during the grading process.
Stephan Achenbach, Germany
Denis Agostini, France
Erick Alexanderson Rosas, Mexico
Adel Hassan Allam, Egypt
Kevin Allman, Australia
James Arrighi, United States of America
Jeroen Bax, Netherlands
Rob Beanlands, Canada
George Beller, United States of America
Frank M Bengel, Germany
Ron Blankstein, United States of America
Filippo Cademartiri, Italy
James Case, United States of America
Manuel Cerqueira, United States of America
Alberto Cuocolo, Italy
Johan De Sutter, Belgium
Victoria Delgado, Netherlands
Gordon Depuey, United States of America
Rafael Doig, Peru
Sharmila Dorbala, United States of America
Andrew Einstein, United States of America
Abdou Elhendy, United States of America
Edward Ficaro, United States of America
Albert Flotats, Spain
Oliver Gaemperli, Switzerland
Guido Germano, United States of America
Raymond J Gibbons, United States of America
David Glover, United States of America
Robert Gropler, United States of America
Joerg Hausleiter, Germany
Robert Hendel, United States of America
Milena Henzlova, United States of America
Anastasia N Kitsiou, Greece
Juhani Knuuti, Finland
Dominique Le Guludec, France
Jeffrey Leppo, United States of America
Oliver Lindner, Germany
Jacques Machecourt, France
Jamshid Maddahi, United States of America
Claudio Marcassa, Italy
Ichiro Matsunari, Japan
Jennifer H Mieres, United States of America
James Min, United States of America
Fernando Mut, Uruguay
Tomoaki Nakata, Japan
Danilo Neglia, Italy
Stephan Nekolla, Germany
Pasquale Perrone-Filardi, Italy
Steven C Port, United States of America
John O Prior, Switzerland
Paolo Raggi, Canada
Ornella Rimoldi, Italy
Dieter Ropers, Germany
Terrence D Ruddy, Canada
Michael Schaefers, Germany
Heinrich R Schelbert, United States of America
Thomas Hellmut Schindler, Switzerland
Arthur Scholte, Netherlands
Stephen Schroeder, Germany
Joanne D Schuijf, Netherlands
Karl Heinz Schuleri, United States of America
Markus Schwaiger, Germany
Udo Sechtem, Germany
Albert Sinusas, United States of America
Riemer Hja Slart, Netherlands
Piotr Slomka, United States of America
Paola Smanio, Brazil
Stephen Stowers, United States of America
Raymond Taillefer, Canada
Nagara Tamaki, Japan
Randall Thompson, United States of America
Mark Travin, United States of America
Mustafa Unlu, Turkey
Berthe Van Eck-Smit, Netherlands
Joao V Vitola, Brazil
Juergen Vom Dahl, Germany
Frans Wackers, United States of America
Lee Samuel Wann, United States of America
Kim Allan Williams, United States of America
Michael JohannesZellweger, Switzerland
STATISTICS
Topic | Accepted Abstracts |
00.01 – Acute ischaemia / Acute ischaemic syndromes/ Injury imaging | 7 |
00.02 – Attenuation correction clinical | 5 |
00.03 – Comparative techniques clinical | 11 |
00.04 – Congestive heart failure | 5 |
00.05 – Free fatty acid imaging | 1 |
00.06 – Myocardial viability and hibernation | 5 |
00.07 – Pacemakers, ICD | 3 |
00.08 – Coronary revascularisation | 3 |
00.09 – Perfusion imaging methods and protocols | 15 |
00.10 – Stress techniques | 8 |
00.11 – Image patterns, artifact | 2 |
00.12 – Transplant, Cardiomyopathy, Myocarditis | 5 |
00.13 – Ventricular function clinical | 4 |
00.14 – Exercise ECG | 2 |
00.15 – Other clinical general | 8 |
00.16 – Neurohumoral imaging | 9 |
00.17 – Arrhythmias and sudden death | 2 |
00.18 – CAD and diabetes, renal disease, gender risk factors | 18 |
00.19 – Cost effectiveness, health economics, quality assurance and guidelines | 3 |
00.20 – Diagnosis of CAD | 16 |
00.21 – Risk assessment and outcome in CAD | 18 |
00.22 – Risk assessment before non-cardiac surgery | 0 |
00.24 – Microvascular heart disease | 1 |
00.25 – Molecular imaging | 8 |
00.26 – Myocardial perfusion and coronary flow | 12 |
00.27 – New radiopharmaceuticals | 1 |
00.28 – Instrumentation, software and image processing | 8 |
00.29 – RNA (gated, first-pass) for LV and RV | 3 |
00.30 – SPECT gated and regional wall motion | 11 |
00.32 – Instrumentation – other | 1 |
00.34 – PET imaging perfusion | 6 |
00.35 – PET imaging metabolism | 4 |
00.37 – Calcium scoring | 8 |
00.38 – CT angiography | 26 |
00.39 – CT – Other | 7 |
00.40 – Radiation exposure | 3 |
Total | 249 |
Committees
Organising Committee
Frank Bengel, DE – Organising Co-Chair
Robert Gropler, US – Organising Co-Chair
Robert Beanlands, CA – Industry Liaison
Robert Hendel, US – Meeting Services
Juhani Knuuti, FI – Scientific Advisor
Programme Committee
Sharmila Dorbala, US – Programme Chair
Michael Zellweger, CH – Programme Chair
Randall Thompson, US – Programme Chair
S Achenbach, DE
C Anagnostopoulos, GR
M Al-Mallah, SA
K Allman, AU
J Arrighi, US
T Bateman, US
R Blankstein, US
J Cullom, US
A Cuocolo, IT
G DePuey, US
M Freeman, CA
E Garcia, US
G Germano, US
D Glover, US
G Heller, US
L Hofstra, NL
P Kaufmann, CH
A Kitsiou, GR
J Maddahi, US
S Nekolla, DE
P Perrone-Filardi, IT
S Schroeder, DE
L Shaw, US
P Smanio, BR
N Tamaki, JP
H Ukkonen, FI
S Wann, US
Advisors to the Programme Committee
D Agostini, FR
E Alexanderson, MX
A Allam, EG
G Beller, US
D Berman, US
H Bom, KR
P Camici, GB
M Cerqueira, US
T Chua, SI
B Chow, US
M Cohen, US
H Dakik, LB
P DeFeyter, NL
J DeSutter, BE
M Di Carli, US
M Gerson, US
R Gibbons, US
M Hedman, FI
B Hesse, DK
A Lahiri, UK
D Le Guludec, FR
J Leppo, US
J Mahmarian, US
S Merlano, CE
F Mut, UY
T Nishimura, JP
P Pieri, IT
J Prior, CH
P Raggi, IT
R Russell, US
I Saeed, US
Y Sasaki, JP
M Schaefers, DE
H Schelbert, US
M Schwaiger, DE
U Sechtem, DE
A Sinusas, US
H Sochor, AT
H Strauss, US
J Udelson, US
R Underwood, GB
M Unlu, TK
N Vita, AR
J Vitola, BR
J Vom Dahl, DE
K Williams, US
N Zafrir, IL
B Zaret, US
J Ziffer, US
Oral Abstract Session
Young Investigator Award Competition
Monday 6 May, 2013, 14:00–15:30 Room 4 – A05
38
Effects of MR contrast agents on attenuation map generation and cardiac PET quantification in PET/MR
S. Fuerst1; M. Souvatzoglou1; C. Rischpler1; S.I. Ziegler1; M. Schwaiger1; S.G. Nekolla1
1Hospital rechts der Isar of the TU Munich, Department of Nuclear Medicine, Munich, Germany
Purpose: Gadolinium-based MR contrast agents (CA) do not significantly affect PET annihilation photons. However, by enhancing the MR signal they possibly influence the MR-derived attenuation correction in hybrid PET/MR. The aim was to assess this effect on attenuation map (μmap) generation and PET quantification with the Biograph mMR PET/MR.
Methods: μmaps were generated by acquiring MR data with a 2-point DIXON sequence and segmenting them using thresholds. 22 patients referred for viability imaging were scanned before and after CA administration. These PET images were reconstructed: post-CA data/μmap and post-CA data/pre-CA μmap. Volumes of lung, fat and soft tissue in the μmaps were determined and the response to CA investigated over time. Myocardial uptake in the left ventricle (LV) was volumetrically quantified in 17 segment and regional differences between the data sets were assessed.
Results: For all patients, the volume of lung tissue and fat in the μmaps after injection of CA was reduced, whereas the amount of soft tissue was increased. The changes were on average (−12.9 ± 24.9)%, (−35.8 ± 18.4)% and (16.2 ± 8.3)% for lung, fat and soft tissue. In none of the patients, the μmap composition recovered to the state before CA injection until the exam finished. An effect on the SUV of more than 10% was found in 42.9% of the segments, whereas the respective global SUV variations ranged between −3.0% and +26.8%.
Conclusions: MR CA has both significant local and global effects in cardiothoracic imaging. Tissue misclassifications are independent of the investigated range of delays after CA injection, leading to hampered quantification of otherwise adequate PET raw data. Thus, μmaps should be acquired pre-CA and CA-optimized segmentation parameters are needed.
39
The influence of coronary artery calcium score on the interpretation of myocardial perfusion imaging
M. Mohamed Mouden1; J.P. Ottervanger1; J.R. Timmer1; S. Reiffers1; A.H.J. Oostdijk1; S. Knollema1; P.L. Jager1
1Isala Hospital, Zwolle, Netherlands
Purpose: We investigated the influence of coronary artery calcium (CAC) scores on the visual interpretation of myocardial perfusion imaging in stable patients referred for the diagnostic work-up of suspected coronary artery disease (CAD).
Methods: Patients without a previous history of CAD in whom CAC scoring was concomitantly performed with a hybrid 64-slice SPECT/CT device were retrospectively identified. For the current analysis we selected all 151 patients who underwent invasive angiography within 3 months after myocardial perfusion imaging. Experienced readers interpreted myocardial perfusion images in two separate sessions with and without knowledge of a patient’s CAC score. We compared both readings with regard to the frequency of equivocal readings, and calculated changes in diagnostic accuracy using angiography with ≥70% luminal narrowing as a reference standard for obstructive CAD.
Results: The addition of the CAC score changed the interpretation of myocardial perfusion images in 56 patients (37%) with a major effect on diagnostic accuracy in 39 patients (26%). The frequency of equivocal perfusion interpretations decreased from 21% to 9% (P = .002). Sensitivity of myocardial perfusion imaging increased from 48% to 64% (P = .019) with comparable specificity (72% to 68%, P = .628).
Conclusions: In this highly selected group knowledge of the CAC score improved the interpretation of myocardial perfusion imaging and reduced the number of equivocal readings.
40
Comparison between 99mTc-HYNIC-AnnexinA5 and 99mTc-AnnexinA5-128 for in vivo detection of experimental auto immune myocarditis
K. Khadija Ben Ali1; R. Ben Azzouna1; L. Louedec2; M. Milliner1; D. Barbato3; C. Bucci3; F. Rouzet1; M. Jean-Baptiste2; D. Le Guludec1; L. Sarda-Mantel1
1AP-HP-Hospital Bichat-Claude Bernard, Department of Nuclear Medicine, Paris, France; 2Inserm U698-Hospital Bichat-Claude Bernard, Paris, France; 3Advanced Accelerator Applications, colleretto Giacosa, Italy
Objectives: 99mTc-HYNIC-AnnexinA5 (99mTc-HYNIC-Anx) has been shown to allow in vivo scintigraphic detection of cardiomyocytes death in experimental myocarditis, via high-affinity binding to phosphatidylserines. Anx-128 is a new mutant of AnnexinA5 which possesses an endogenous peptidic chelation site at its N terminus. 99mTc-Anx-128 has been produced according to GMP procedure. The aim of this study was to compare 99mTc-Anx-128 to 99mTc-HYNIC-Anx in a rat model of acute myocarditis, to determine its potential interest for further clinical applications in patients with myocarditis.
Methods: Acute myocarditis was induced in 13 Wistar rats by immunization with purified rat cardiomyosin (600 μg × 2, in Freund adjuvant). Rats were imaged 3 weeks after immunization with both 99mTc-Anx-128 then 99mTc-HYNIC-Anx or vice versa at 2 days intervals. SPECT/CT images were acquired on a NanoSPECT/CTplus (Bioscan Inc.) device, 1 hour after tracers injection (60 MBq). Autoradiography (Beta Imager™, Biospace Lab) and histological studies of heart sections were performed after the second scan. All experiments were also performed in eight control rats injected with Freund adjuvant.
Results: All immunized rats had positive dual imaging, with similar myocardial uptake of the two tracers in terms of topography and intensity. Myocardial-to-background activity ratio was 2.3 ± 1.46* in immunized rats vs 0.9 ± 0.32 in controls P = .01 using 99mTc- HYNIC-Anx, and 2.7 ± 1.3* vs 1.16 ± 0.18; P = .004 using 99mTc-Anx-128 (*NS). Autoradiographic and histological data confirmed co-localization of both tracers in myocardial areas of cardiomyocytes death, and no uptake in normal myocardium of control rats.
Conclusions: 99mTc-Anx-128 is accurate and comparable to 99mTc-HYNIC-Anx for in vivo detection of cardiomyocytes death in experimental acute myocarditis. These results confirm potential interest of this new tracer for clinical application in patients with myocarditis.
41
Combining preoperative information from speckle tracking echocardiography, cardiac CT scan and MRI scan adds important information in patients receiving cardiac resynchronization therapy implants
Z. Bakos1; H. Markstad2; E. Ostenfeld3; A. Roijer4; M. Carlsson3; R. Borgquist1
1Lund University, Skane University Hospital, Department of Arrhythmias, Lund, Sweden; 2Lund University, Skane University Hospital, Department of Radiology, Lund, Sweden; 3Lund University, Skane University Hospital, Department of Clinical Physiology, Lund, Sweden; 4Lund University, Skane University Hospital, The Clinic for Heart Failure and Valvular Disease, Lund, Sweden
Purpose: To evaluate the incremental value of using preoperative cardiac CT and MRI in combination with echocardiography evaluation of segmental mechanical delay, for guiding optimal left ventricular lead placement in cardiac resynchronization therapy (CRT).
Methods: 23 patients (70 ± 9 years, 78% male, 86% with LBBB, 57% with ischemic CMP, 91% ≥ NYHA 3) eligible for CRT were included consecutively. The left ventricular segment with latest mechanical activation was determined using echocardiography with speckle tracking radial strain. Cardiac CT scan was used for evaluation of coronary sinus anatomy. Cardiac MRI was used for evaluation of viability in each segment. A composite bulls-eye plot was constructed for each patient, indicating the optimal site for LV lead placement (Figure 1).
Composite bullseye plot optimal position
Results: The latest mechanical delay was in the mid inferolateral segment (n = 4), base inferolateral (5), mid anterolateral (3), base anterolateral (2), mid anterior (3), base anterior (1), mid inferior (3) or base inferior (2). There were 2.5 ± 0.8 veins of suitable size (≥1.5 mm in diameter), and in 13 patients there was a matching vein in the segment with the latest mechanical delay, i.e. an optimal placement was possible. In 9/10 of those patients who had no eligible vein anatomy at the optimal segment, an adjacent segment was available. In the total group, MRI showed nontransmural (<50%) infarction in 24% of all segments and transmural infarction (50-100%) in 7%. In one patient there was transmural infarction in the optimal segment, thereby altering the optimal LV lead placement.
Conclusions: Using cardiac CT in combination with echocardiography and MRI makes it possible to determine if an optimal lead placement is possible already preoperatively, and can be helpful in planning the targeted implant procedure.
42
68Ga-Siglec-9 peptide targeting VAP-1 is accumulated in atherosclerotic plaques
J.M.U. Johanna Silvola1; H. Ahtinen1; S. Hellberg1; T. Saanijoki1; H. Liljenback1; S. Yla-Herttuala2; S. Jalkanen3; J. Knuuti1; A. Saraste4; A. Roivainen1
1Turku PET Centre, University of Turku & Turku University Hospital, Turku, Finland; 2A.I. Virtanen Institute for Molecular Sciences at the University of Eastern Finland, Kuopio, Finland; 3MediCity Research Laboratory, University of Turku, and National Institute of Health and Welfare, Turku, Finland; 4Turku University Hospital, Department of Medicine, Turku, Finland
Purpose: Vascular adhesion protein-1 (VAP-1) plays a key role in recruiting leukocytes into sites of inflammation. VAP-1 is stored in intracellular granules of endothelial cells, but upon inflammation it is rapidly translocated to the endothelial cell surface. Using a phage display approach, we have recently discovered that sialic acid-binding Ig-like lectin 9 (Siglec-9) is a granulocyte ligand for vascular adhesion protein 1 (VAP-1) and a 68Ga-Siglec-9 peptide specifically detects VAP-1 in vasculature at sites of inflammation. Since the inflammation has a prominent role also in atherosclerosis, the novel 68Ga-Siglec-9 peptide may be a potential tracer for imaging of inflammation associated with atherosclerotic plaques. This study investigated the uptake of 68Ga-Siglec-9 in atherosclerotic plaques in mice.
Methods: Six-month-old atherosclerotic low-density lipoprotein receptor deficient mice expressing only apolipoprotein B100 (LDLR−/−ApoB100/100, n = 15) fed with high-fat diet for four months and normally fed two-month-old C57BL/6 control mice (n = 11) were intravenously injected with 19 ± 5 MBq of 68Ga-Siglec-9. The aorta and other tissues were excised at 25 minutes after tracer injection and measured by gamma counter to clarify biodistribution of radioactivity. The uptake of 68Ga-Siglec-9 in aorta was studied in more detailed by autoradiography and histology analyses.
Results: The six-month-old LDLR−/−ApoB100/100 mice demonstrated highly inflamed and extensive atherosclerotic plaques after 4 months of a high-fat diet, presenting a suitable model for studying the imaging of atherosclerotic plaque inflammation. The 68Ga-Siglec-9 peptide was rapidly excreted through the kidneys to the urine. At 25minutes post-injection the blood radioactivity was still relatively high. However, the uptake of 68Ga-Siglec-9 in the aorta was significantly higher in the LDLR−/−ApoB100/100 mice (0.88 ± 0.32%IA/g) than in the control mice (0.45 ± 0.11%IA/g, P = .0003), and an autoradiography demonstrated focal uptake of 68Ga-Siglec-9 in atherosclerotic plaques.
Conclusion: Our preliminary results provide evidence that 68Ga-Siglec-9 peptide is accumulated into the plaques of atherosclerotic mice and that it might be a promising and novel PET tracer to detect plaque inflammation. Further studies are warranted to determine the expression level of VAP-1 at different stages of atherosclerotic plaque development.
43
Dynamic computed tomography perfusion imaging for the detection of functionally significant coronary lesions
A. Rossi1; A. Wragg2; A. Dharampal1; S.E. Petersen2; E. Klotz3; P.J. De Feyter1; F. Pugliese2
1Erasmus MC, Rotterdam, Netherlands; 2Barts and The London NIHR Cardiovascular Biomedical Research Unit, London, United Kingdom; 3Siemens Healthcare Sector, Forchheim, Germany
Purpose: To evaluate the performance of hyperaemic myocardial blood flow (MBF) derived from stress computed tomography perfusion (CTP) imaging in the detection of functionally significant coronary lesions in a prospective cohort of patients with stable chest pain. Lesions were defined functionally significant by fractional flow reserve (FFR) ≤0.75.
Methods and Materials: Coronary computed tomography angiography (CTCA) and CTP were performed in 80 patients (63 males/17 females; mean age 60 ± 10 years) referred for invasive angiography. A second-generation dual-source CT scanner (Somatom Definition Flash, Siemens) with a dynamic ECG-triggered axial shuttle mode was used. This technique provides an arterial input function and myocardial time-attenuation curves fitted to a two-compartment model to give MBF. Hyperaemia was induced by infusion of adenosine (140 μg/kg body weight). Three to four minutes into the infusion, 60 mL of contrast were injected. Gantry rotation time was 285 ms, collimation 64 × 0.6 mm, tube voltage 100 kV and the tube current-time product was 300 mAs/rotation.
Results: Data from 210 coronary vessels and 210 corresponding myocardial territories were available for comparison and were included in the analysis. Functionally significant coronary lesions were found in 56/210 vessels (27%). MBF was 62 (51-74) mL/100 mL/minute in myocardial territories supplied by vessels with functionally significant coronary lesions and 109 (92-136) mL/100 mL/minute in the remote myocardium (P < .001). The optimal cut-off value of MBF to discriminate functionally significant coronary lesions was 78 mL/100 mL/minute. MBF had 88% sensitivity and 90% specificity and an area under the receiver operating characteristics curve (AUC) of 0.95 (95% CI, 0.92-0.98, P < .001). By comparison, visual CTCA analysis yielded 80% sensitivity, 76% specificity and an AUC of 0.78 (95% CI, 0.71-0.85, P < .001).
Conclusions: MBF performs better than visual CTCA analysis to predict functionally significant coronary lesions (FFR ≤ 0.75).
Oral Abstract Session
SPECT MPI: New approaches and applications
Monday 6 May, 2013, 16:30–18:00 Room 4 – A05
56
Diversity of high-efficiency CZT SPECT Tc-99m imaging protocols: Results of an international survey
M. Milena Henzlova1; B. Songy2; P.L. Jager3; M.H. Cherk4; P.A. Kaufmann5; A. Gimelli6; T.D. Ruddy7; F.P. Esteves8; W.L. Duvall1
1Mount Sinai School of Medicine, New York, United States of America; 2North Cardiology Hospital, Paris, France; 3Isala Hospital, Zwolle, Netherlands; 4Alfred Hospital, Melbourne, Australia; 5University Hospital Zurich, Zurich, Switzerland; 6Gabriele Monasterio Foundation, Department of Cardiovascular Medicine, Pisa, Italy; 7University of Ottawa, Ottawa, Canada; 8Emory University, Atlanta, United States of America
Purpose: The introduction of high-efficiency SPECT cameras for MPI represents one of the most important hardware developments in decades. Approximately, 30 laboratories have the multi-pinhole CZT camera installed as of the summer of 2012. There are no current guidelines for dosing and imaging times for these cameras.
Methods: A questionnaire was distributed to eight early adopters who published peer reviewed papers utilizing the multi-pinhole CZT camera in Europe (N = 4), Australia (N = 1) and North America (N = 3) requesting yearly patient volume, low and high Tc-99m doses, low and high dose imaging times, time from low and high dose injection to imaging, and information about the use of attenuation correction.
Results: Surveyed labs perform close to 20,000 studies a year with 6 of 8 using a stress-rest protocol (rest imaging optional). The stress:rest dose ratio varies from 1:2 to 1:3, with stress doses ranging from 3 to 10 mCi and stress imaging time from 5 to 11 minutes. The largest variation was noted in time to rest imaging (3-60 minutes). North American labs are more likely to perform rest-stress imaging with a 1:3 to 1:4 rest:stress dose ratio and rest doses usually of 5 mCi. Calculated radiation dose to the patients for low-dose stress only studies was ≤3 mSV per study and 3.6-9.1 mSv for a full study. All sites use either CT or prone imaging attenuation correction.
Conclusions: Using CZT SPECT technology results in significant decreases in radiation doses and imaging time. Sufficient data is now available to propose unified guidelines for CZT SPECT imaging.
Table of the abstract 56
Stress-rest site | Annual volume | Stress dose | Stress imaging time | Time to stress imaging | Rest dose | Rest imaging time | Time to rest imaging | Rest-stress ratio | Attenuation correction | Stress-only exposure | Stress-rest exposure |
|---|---|---|---|---|---|---|---|---|---|---|---|
Paris | 5,000 | 3 mCi | 10–12 | 5–10 | 9 mCi | 5–6 | 45–75 | 1:3 | Prone | 0.9 mSv | 3.6 mSv |
Zwolle | 2,750 | 10 mCi | 5 | 45–60 | 20 mCi | 5 | 45–60 | 1:3 | CT | 3.0 mSv | 9.1 mSv |
Melbourne | 1,900 | 5.7 mCi | 8 | 10–15 | 15 mCi | 4 | 5–10 | 1:2.6 | Prone | 1.7 mSv | 6.3 mSv |
Zurich | 1,400 | 6 mCi | 5 | 60 | 15 mCi | 5 | 3 | 1:2.5 | CT | 1.8 mSv | 6.4 mSv |
Pisa | 1,400 | 4–5 mCi | 7 | 10–15 | 8–10 mCi | 8 | 15–30 | 1:2 | Prone | 1.4 mSv | 4.1 mSv |
New York | 2,300 | 10 mCi | 5 | 30–60 | 20 mCi | 3 | 40 | 1:2 | Prone | 3.0 mSv | 9.1 mSv |
Rest-stress site | Annual volume | Rest dose | Rest imaging time | Time to rest imaging | Stress Dose | Stress imaging time | Time to stress imaging | Rest-stress ratio | Attenuation correction | Rest-stress exposure |
|---|---|---|---|---|---|---|---|---|---|---|
Ottawa | 1,600 | 4–5 mCi | 10 | 30–45 | 12–15 mCi | 6 | 30–45 | 1:3 | Prone | 5.5 mSv |
Atlanta | 1,600 | 5 mCi | 7–9 | 60 | 20 mCi | 5–7 | 15–60 | 1:4 | CT | 7.6 mSv |
New York | 1,500 | 5 mCi | 5 | 30–60 | 15 mCi | 3 | 40–60 | 1:3 | Prone | 6.1 mSv |
57
Warranty periods of a normal stress-rest myocardial perfusion SPECT
J.G. Romero Farina1; S. Aguade-Bruix1; G. Cuberas-Borros1; M.N. Pizzi1; G. De Leon1; J. Castell-Conesa1; D. Garcia-Dorado1; J. Candell-Riera1
1Hospital Universitari Vall d’Hebron, Barcelona, Spain
Purpose: To evaluate the warranty period (WP) of a normal stress-rest myocardial perfusion SPECT for exercise stress (ES), ES plus pharmacologic stress (PhS), and PhS and in different clinical conditions. WP of normal SPECT is important in order to establish appropriate use of this technique in different subgroups of patients.
Methods: A cohort of 2,922 patients (62.9 ± 13 years; 53.4% women) with normal stress-rest myocardial perfusion SPECT was studied. WP was defined as the time in which a patient remained at low risk (<1% complications/year) for total mortality (TM) and for hard events (HE) (cardiovascular death or nonfatal acute myocardial infarction. Multivariate Cox proportional hazards models and Kaplan-Meier curves analysis were used to estimate the WP.
Results: 2051 patients underwent ES, 461 underwent ES plus PhS, and 410 underwent PhS. During a follow-up of 5 ± 3.3 years, a significant (P < .05) increased of annual TM (1.47%, 2.3% and 4%) and annual HE (0.4%, 0.9% and 2%) were observed for ES, ES plus PhS, and PhS respectively. A significant (P < .05) WP reductions of TM [13.5, 9.6 and 8 months], and HE [34.8, 20.5 and 8.2 months] was observed for ES, ES plus PhS, and PhS respectively. Clinical variables (age, gender, diabetes and known coronary artery disease) were other determinants of the WP. An abnormal gated SPECT (ejection fraction < 50%) significantly decreased WP for HE in patients underwent ES plus PhS (P = 0.001) or PhS (P = .007).
Conclusions: WP of a normal stress-rest myocardial perfusion SPECT is very variable since it is mainly determined by the type of stress, clinical characteristics and left ventricular ejection fraction.
58
A protocol for the provisional use of perfusion imaging with exercise stress testing
M. Milena Henzlova1; E.J. Levine1; S. Moonthungal1; M. Fardanesh1; L.B. Croft1; W.L. Duvall1;
1Mount Sinai School of Medicine, New York, United States of America
Purpose: Previous literature suggests that the results of myocardial perfusion imaging (MPI) add little to the prognosis of patients who exercise ≥10 METS during stress testing. With this in mind, we attempted to determine if a provisional injection protocol could be developed in which a patient would not receive an injection of radioisotope if adequate exercise was achieved without symptoms and a negative ECG response. This protocol would save a substantial amount of time, radiation exposure, and cost.
Methods: All patients who underwent a stress SPECT MPI over a 6.5 year period from 2004 to 2010 were included. Patients who would have been considered for a standby injection protocol were: exercise stress, age < 65, no known CAD, and an interpretable ECG. Patients were retrospectively divided into two groups based on whether they would have received radioisotope or not. Criteria for not injecting included a maximal predicted heart rate ≥ 85%, ≥ 10 METS of exercise, no symptoms of chest pain or shortness of breath, and no ECG changes (ST depression or arrhythmia). The two groups were then compared based on MPI results and all-cause mortality derived from the Social Security Death Index.
Results: A total of 24,689 patients underwent SPECT MPI during this period, and 5,352 would have been eligible for a provisional injection protocol. There were 3,791 (70.8%) who would have been injected and 1,561 (29.2%) who would not have been. Perfusion results were abnormal in 5.9% of non-injected group compared to 14.4% in those who would have been injected. After a mean follow-up of 60.6 ± 21.4 months, 1.1% had died in the non-injected cohort compared to 2.2% in the injected group.
Conclusion: A provisional injection protocol defined as age <65, normal rest ECG, no history of CAD, and high level exercise with a negative ECG response and no symptoms, has a very low 5 year all-cause mortality and low yield of MPI. If adopted it would decrease radiation exposure, save time and health care costs without jeopardizing prognosis.
59
Is necessary to perform an exercise myocardial perfusion gated SPECT in patients with D-Transposition of the great arteries after arterial switch operation? A single centre long-term follow-up
M.N. Pizzi1; S. Aguade-Bruix2; E. Franquet2; G. Cuberas-Borros1; B. Manso3; J. Casaldaliga4; G. Romero-Farina5; J. Castell-Conesa2; D. Garcia-Dorado6; J. Candell-Riera6
1Universitary Hospital Vall d’Hebron, Cardiology Department, Nuclear Cardiology and Cardiac CT Unit, Barcelona, Spain; 2Universitary Hospital Vall d’Hebron, Nuclear Medicine Department, Barcelona, Spain; 3Universitary Hospital Vall d’Hebron, Paediatric Department, Barcelona, Spain; 4Universitary Hospital Vall d’Hebron, Cardiology Department, Adult Congenital Heart Disease Unit, Barcelona, Spain; 5Hospital Vall d’Hebron, Cardiology Department, Epidemiology Unit, Barcelona, Spain; 6Universitary Hospital Vall d’Hebron, Cardiology Department, Barcelona, Spain
Objectives: Arterial switch operation (ASO) is the preferred technique for the correction of transposition of the great arteries (TGA), but translocation and re-implantation of the coronary arteries can produce myocardial ischemia. There is no consensus on the need to monitor these patients to detect abnormalities in myocardial perfusion. The purpose of this study is to report our experience with exercise myocardial perfusion gated SPECT with 99mTc-tetrofosmine to evaluate myocardial perfusion and exercise tolerance after ASO.
Methods: We performed exercise-rest myocardial perfusion gated SPECT in 67 patients (48 boys, 9.9 ± 3.2 years old), including five who had referred symptoms and 62 who were asymptomatic. Myocardial perfusion and left ventricular (LV) wall motion, thickening, volumes and ejection fraction (EF) were evaluated. We compared patients with (n: 4) and without (n: 63) peri-operative complications, and patients with A (normal) (n: 45) and non-A (n: 22) coronary pattern.
Results: During exercise testing 67 patients reached 9.8 ± 3.05 METs and 73.58 ± 14.24% of the predicted peak heart rate. Fifty-nine patients (88%) had normal myocardial perfusion while only 2 patients (3%) had reversible defects, and 6 patients (9%) had fixed defects. All patients with peri-operative ischemic complications had myocardial perfusion defects (100%) while only 4 patients (6.35%) without ischemic complications had an abnormal perfusion (P = .0005). We did not find a significant difference between patients who had an A and non-A coronary pattern.
Conclusions: The high rate of normality of myocardial perfusion gated SPECT in our study suggests that myocardial perfusion gated SPECT should be reserved for patients who have suffered peri-operative ischemic complications, or those with symptoms, at least during the first 10 years after the surgery.
60
Time to myocardial perfusion positivity after heart transplant
L. Longmore1; K.A. Bybee2; S. Bhatti2; K. Kennedy2; G. Dhillon1; T.M. Bateman2
1University of Missouri-Kansas City, Kansas City, United States of America; 2St. Luke’s Mid America Heart Institute, Kansas City, United States of America
Purpose: Cardiac allograft vasculopathy (CAV) is common among orthotopic heart transplant (OHT) patients and is the major factor affecting mortality. Serial myocardial perfusion imaging (MPI) is useful diagnostically and prognostically, and with current technology can be performed at minimal dosimetry. However, neither the time course to positivity nor the correlates of this are known.
Methods: Using the OHT and MPI electronic databases at a single center, we identified 192 patients who had undergone OHT and serial MPI’s between January 1, 2000 and December 31, 2011. Collected data included gender, age, diabetes, hyperlipidemia, hypertension, smoking, family history of premature CAD and time to an abnormal MPI (AMPI) defined by a summed stress score >3.
Results: The 192 OHT patients underwent 801 MPI’s over a mean follow up period of 5.6 (+2.7) years. A total of 54 patients (28%) ultimately developed an AMPI. Of these 54 patients, 11% (6 patients) had an AMPI by 1 year, 57% (31 pts) by 3 years, 78% (42 pts) by 5 years, 93% (50 pts) by 7 years, and thereafter only 1 patient per year had an AMPI in the final 4 years. The average time to AMPI was 6 years. Demographic and atherosclerotic risk factor data were not statistically different between the 54 patients who developed an AMPI vs those who did not.
Conclusions: Serial MPI is helpful in identifying CAV following OHT, with significant conversion to abnormality even during the first several years following OHT. Traditional risk factors do not correlate with those OHT patients who develop early post-transplant cardiac allograft vasculopathy.
Conversion to abnormal MPI over time
Moderated Posters
Advances in instrumentation
Monday 6 May, 2013, 08:30–12:30 Poster Area
61
New approach to decrease the radiation dose for CT-based attenuation-corrected SPECT imaging using a hybrid 64-slice SPECT/CT
D. Daniel Zalkind1; V.T. Tsatkin1; Y.L. Liu1; A.S. Sinusas1; R.R.R. Russell1
1Yale-New Haven Medical Center, New Haven, United States of America
Purpose: The utility of CT based attenuation correction (AC) has been shown in previous multi-center trials for SPECT cameras with sodium iodide (NaI) detectors, although remains undefined for hybrid high-sensitivity cadmium-zinc-tellurium (CZT) SPECT cameras with diagnostic 64-slice CT (Discovery NMCT570c). The CZT detectors allow imaging with decreased radiotracer dose. The aim of this study was to further reduce the dose by applying one higher dose AC CT scan to both rest and stress images, and to evaluate the impact on quantification of SPECT integrated defect size (IDS, %LV volume).
Methods: Forty-four consecutive hybrid SPECT/CT rest and stress scans were processed using the GE Xeleris software. Patient had a mean age of 63.1 ± 15.8 years, mean BMI 29.4 ± 5.4 and 66% male gender. IDS was calculated at rest using a gender-matched low-risk database, after attenuation correction with either the phase-matched rest CT (120 kV and 20 mA) or the phase mismatched stress CT (120 kV and 80 mA) AC maps using the Yale WLCQ software. A paired two-tail Student t-test and Pearson correlation were used to compare IDS within each coronary distribution (LAD, LCX, and RCA) after processing with the low and high dose CT attenuation maps.
Results: The AC CT for the stress phase resulted in a radiation dose of 2.72 mSv (high dose) and the CT for the rest phase resulted in a low radiation dose of 0.33 mSv (low dose). There was no statistically significant difference in IDS between the rest perfusion processed with the low-dose CT at rest, and the rest perfusion images processed with the high-dose stress CT within each coronary distributions (LAD: 0.39 ± 0.31, P = .9, r = 0.61; LCX: 1.2 ± 4.8, P = .93, r = 0.97, RCA: 0.62 ± 0.77, P = .52, r = .87).
Conclusions: The application of the stress CT AC map to the rest SPECT images did not significantly change the rest IDS. Therefore, one can eliminate the low dose rest CT AC map without compromising SPECT quantification, further reducing the radiation dose associated with hybrid CZT SPECT/CT.
62
Assessment of left ventricular ejection fraction (LVEF) with hybrid solid-state cadmiun zinc telluride (CZT) SPECT imaging with and without CT attenuation correction: comparison to 2D echocardiography
M.J. Maria Jimena Salas P.1; V. Tsatkin1; Y. Liu1; R. Russell1; A.J. Sinusas1
1Yale University, New Haven, United States of America
Purpose: Gated SPECT is used to calculate LVEF and provides results comparable to other methods. However, data is limited on accuracy of hybrid solid state CZT SPECT for estimation of LVEF using an integrated 64-slice CT for attenuation corrected (AC). We sought to compare the LVEF determined by gated SPECT with and without AC (no AC) and 2D echocardiography (2DE).
Methods: We retrospectively reviewed all rest 99mTc-tetrofosmin SPECT scans performed on a hybrid CZT SPECT/CT (Discovery NM570c) in patients having 2DE within 24 hours of SPECT processed with AC and no AC over a 6 month period. CT was performed using low dose protocol and free breathing. LVEF was calculated from SPECT with WLCQ software with and without AC. Two operators independently processed the LVEFs. 2DE EF was measured by the biplane disk method. Interobserver variability was defined and Pearson’s correlation coefficients used for comparisons.
Results: 52 patients were identified, 32 males and 20 females, meeting the inclusion criteria. The interobserver variability for LVEF was low (SEM = 2.7%) and correlation high (r = 0.99). There was excellent correlation between no AC and AC LVEF (r = 0.98). 2DE LVEF correlated with SPECT LVEF with AC (r = 0.73) and no AC (r = 0.74). There were differences in the correlation between 2DE and SPECT LVEF when patients were grouped by gender (females: r = 0.90; males: r = 0.70), presence/absence of LV hypertrophy (LVH: r = 0.89; no LVH: r = 0.81), and patients with high (>80 mL) or low (<80 ml) LVEDV (low EDV: r = 0.60; high EDV: r = 0.78).
Conclusions: LVEF assessed using a hybrid CZT SPECT/64-slice CT was similar with AC and no AC, and correlated highly with 2DE LVEF. There was an improved correlation in females, high LVEDV, and no LVH, suggesting an influence of LV wall thickness.
63
Effect of spill-over from right ventricular cavity to cardiac PET radio water perfusion study
C. Chunlei Han1; H. Merisaari1; V. Oikonen1; S. Nesterov1; M. Teras1; J. Knuuti1
1Turku PET Centre, Turku, Finland
Purpose: In analysis of cardiac PET water perfusion data, several studies have suggested that the spillover activity from right ventricular cavity (RV) to the septum should be corrected. Despite this, the correction is not implemented in routine analysis. This study investigates the bias in perfusion estimation without RV spill-over correction, based on simulation data.
Methods: Time-active curves (TAC) from left (LV) and right ventricular cavities were derived from typical clinical 15O-labelled water studies. One-tissue compartment model (Iida et al., 1989) was employed to simulate noise free curves according to our study protocol. Water model without RV spill-over correction (LVModel) as implemented in Carimas v2.6 (a data analysis package) was compared with a new model with RV spill-over correction (LV_RVModel), which was implemented to Carimas v2.6 as a modeling plugin. In LV_RVModel, the myocardial ROI TAC was expressed as: ROI(t) = Va_lv*LV(t) + Va_rv*RV(t) + alpha*C(t), where Va_lv and Va_rv are spill-over fractions from LV and RV, respectively, and alpha is perfusable tissue fraction.
Results: RV affects significantly the perfusion estimation and this effect becomes bigger for higher perfusion values and larger Va_rv. When ground values of Va_rv = 0.1, 0.15, 0.2, 0.25 mL/mL, for ground flow value of 0.98 mL/g/minute (as rest condition), estimated flow values with LVModel were 0.94(-13%), 0.85(-20%), 0.78(-27%) and 0.72(-33%) mL/g/minute, respectively; for ground flow value of 3.2 mL/g/minute (as stress condition), estimated values with LVModel were 2.66(-17%), 2.34(-27%), 2.07(-36%) and 1.84(-43%) mL/g/minute, respectively. Meanwhile, estimated flow values from LV_RVModel were very close to ground values (error < 2%).
Conclusions: Simulations confirm that spill-over from RV leads to severe underestimation of perfusion in septum, unless correction is applied in the analysis tool.
64
Simultaneous acquisition in 64 × 64 and 128 × 128 matrix of Gated SPECT myocardial perfusion (GSPECT) and comparison of parameters of image quality in coronary patients
I. Casans-Tormo1; R. Diaz-Exposito1; A.C. Orozco-Molano1; E. Plancha-Burguera2
1Nuclear Medicine, Hospital Clínico Universitario, Valencia, Spain; 2Cardiology, Hospital Francisco de Borja, Gandia, Spain
Purpose: To assess the influence of 128 × 128 acquisition matrix in GSPECT image quality analyzed in function of patients (p) characteristics.
Material and Methods: We have studied a prospective group of 71 p (31 women-43.7%), mean age 65 ± 10 (42-82 y/o, more than 70 (28/71-39.4%) with known or suspected CAD, submitted to detect possible myocardial ischemia. GSPECT was performed 1 hour after injection of a 99mTc-tracer (2 day-protocol, 20 mCi-70 kg), obtaining two simultaneous acquisitions with 64 × 64 and 128 × 128 matrix at stress and at rest in 52 p and stress only in 16 p, with a total of 240 explorations, 120 with each matrix size (68 stress and 52 rest), Butterworth filter (order 5, cutoff 0.56 (64)-0.30 (128), pixel size mm 6.3 (64)-3.1(128), QGS program. We perform visual semi-quantitative analysis of global image quality (IQ), delimitation of ventricular cavity (VC) and of perfusion defect (PD) considering 1-poor, 2-middle, 3-good, 4-excellent, analyzing differences between the two matrix size studies respect to age, gender, body mass index (BMI), rest end-systolic volume (ESV) existence of perfusion defects or rest FE < 50%, obtained from usual 64 × 64 GSPECT, and also assessing possible interference of intestinal activity.
Results: Mean BMI was 31.2 ± 6.5 (22.5-58.6), with 21/71 (29.6%) more than 30. 31/71 p (43.7%) with ESV < 25 mL, 32/71 (45.1%) with PD, 18/71 (25.3 %) with FE < 50% and 15/71 (21.1%) with intestinal interference. Visual parameters graded 2-4. Global Q was in general better in 128 than 64, without age differences. Better IQ at S and R in 128 than 64 in women and p with ESV < 25 mL (24/31-77.4% of women had ESV < 25 mL), higher IQ and PD in 128 than 64 at R in p with BMI more than 30 (80.9%) vs lower than 30 (32%) p:0.03, better VC in 71.8% p without perfusion defects or attenuation only vs 40.6% with perfusion defects (p:0.04) and in p with FE ≥ 50% than <50% (p:0.002). Better delimitation with intestinal activity in 11/15 (73%) of p that showed intestinal interference.
Conclusion: In this study with simultaneous acquisition in 128 × 128 and 64 × 64 matrix size, we obtained higher quality images in general with 128 than 64, specially in patients with BMI > 30, ESV < 25 ml (77% were women), without perfusion defects, with FE > 50%, and also better delimitation with intestinal activity, all of that could improve interpretative certainly and diagnostic accuracy.
65
Rapid SPECT MPI using 128 × 128 matrix acquisition with iterative resolution recovery and attenuation correction
A. Amelia Jimenez-Heffernan1; A. Ortega-Carpio2; C. Salgado-Garcia1; E. Sanchez De Mora1; J. Lopez-Martin1; C. Ramos-Font1; R. Lopez-Aguilar1; S. Aguade-Bruix3
1Hospital Juan Ramón Jiménez, Department of Diagnostic Imaging, Huelva, Spain; 2Centro de Salud El Torrejon, Huelva, Spain; 3Hospital Vall d’Hebron, Department of Nuclear Medicine, Barcelona, Spain
Purpose: To assess the contribution of 128 × 128 matrix acquisition to improving the diagnostic quality and reducing LVEF overestimation of rapid SPECT/CT reconstruction with ordered subset expectation maximum and resolution recovery (OSEM-RR) with attenuation correction (AC).
Methods: We studied 461 consecutive patients (54% male, age: 64.5 ± 11.7 years, weight: 79.5 ± 15.2 kg) referred for 99mTc SPECT/CT MPI using a 128 × 128 matrix and OSEM-RR reconstruction with AC. For comparison we used a group of 572 patient who underwent rapid SPECT with the usual 64 × 64 matrix, all other parameters identical. 60 frames of 12 second duration were acquired over 90º using a standard hybrid system. Our protocol performs 12 iterations with a maximum number of 10 subsets. A 2-day stress/rest protocol was used. Stress was exercise combined with adenosine in 365 and regadenoson in 96 patients respectively. Image quality (poor, medium, good or very good), diagnostic performance (normal, abnormal and normalcy rate) and LVEF quantification were assessed.
Results: Images were of very good quality, clearly showing or suggesting the papillary muscles in all cases. MPI was reported as normal in 46.7%, abnormal in 51.3% and equivocal in 2% of patients respectively. Normalcy rate using a very low pretest likelihood of disease (Miller’s score modified) was 57.8%. In the 64 × 64 matrix group reports were normal in 55%, abnormal in 43.6% and equivocal in 1.4% of patients respectively and the normalcy rate was 68.6%. The lower normalcy rate and increment of abnormal studies with the 128 × 128 matrix was mostly due to small basal inferolateral defects, which we hypothesize could be related to the higher activity of the adjacent posteromedial papillary muscle. Mean LVEF in normal perfusion patients was 63.3% for 128 × 128 and 67.2% for 64 × 64 matrix respectively, a significant difference (P < .05).
Conclusion: The 128 × 128 matrix produces higher quality images with lower overestimation of LVEF, nevertheless careful attention must be paid to the area basal to the posteromedial papillary muscle in order to avoid false positive readings.
66
Towards sub-mSv radiation dose for myocardial perfusion SPECT
R. Conwell1; C. Chuanyong Bai1; L. Abreu1; J. Maddahi2
1Digirad Corporation, Poway, United States of America; 2UCLA-David Geffen School of Medicine, Los Angeles, CA, United States of America
Purpose: Patient radiation dose in conventional myocardial perfusion SPECT (MPI) is approximately 11.4 mSv using the standard one-day rest/stress protocol with 370 MBq rest and 1017.5 MBq stress Tc-99m sestamibi injection. In this work, we evaluated the potential of sub-mSv (<1 mSv) patient radiation dose through the use of high-sensitivity SPECT systems, advanced reconstruction algorithms, and modified imaging protocols.
Methods: Sixty-six consecutive patient studies with list-mode data acquisition were performed on a triple-head dedicated cardiac SPECT camera with solid-state detectors. The average injection was 340.4 and 1306.1 MBq and the average acquisition time was 11.4 and 4.2 minutes for rest and stress studies, respectively. For each patient, a full time dataset and a 1/3 time dataset were generated from the list-mode data with the latter using every third of the list-mode events. The full time data was reconstructed using a 3D-OSEM algorithm with resolution recovery (nSPEED). The 1/3 time data was reconstructed with an improved 3D-OSEM algorithm (nSPEED2) that incorporated a 3D maximum a posteriori technique and a weighted-Gaussian filter for better noise/resolution trade-off. Images were interpreted by a blinded expert nuclear cardiologist for quality and diagnostic equivalence.
Results: The 1/3 time nSPEED2 images showed diagnostic agreement with the full time nSPEED images in 64/66 (97%) of the studies. The quality of the 1/3 time nSPEED2 images was better than or equivalent to that of the full time nSPEED images in 65/66 (99%) stress and 62/66 (94%) rest studies. The 1/3 time data corresponded to 3.8-minutes rest and 1.4-minutes stress acquisitions; hence, if using longer acquisition time, the patient dose can be reduced to <1 mSv at 15 minutes (see Table).
Conclusion: Patient studies showed potential sub-mSv rest and stress radiation dose when using a high-sensitivity camera for data acquisition and an advanced algorithm (nSPEED2) for image reconstruction. Overall sub-mSv MPI radiation dose can be achieved for patients with normal stress diagnosis when using stress-only protocols.
Patient dose vs acquisition time
Stress | Rest | |||
|---|---|---|---|---|
Acq. time (minutes) | Injection (MBq) | Radiation dose (mSv) | Injection (MBq) | Radiation dose (mSv) |
10 | 183.2 | 1.49 | 131.0 | 1.06 |
15 | 122.1 | 0.99 | 87.3 | 0.71 |
67
Caution is required when comparing left ventricular function calculated using newer gated SPECT iterative reconstruction algorithms to the previously used filtered backprojection reconstruction method
D. Doumit Daou1; C. Coaguila2; M. Tawileh1
1APHP, Cochin Hospital, Department of Nuclear medicine, Paris, France; 2Hospital Sud-Francilien, Corbeil-Essonnes, France
Purpose: Gated SPECT myocardial perfusion (GSPECT) has been extensively validated for the quantification of left ventricular (LV) function especially with QGS. This was done with filtered backprojection reconstruction method (FBP). Recent developments in nuclear medicine technologies allow simple application of iterative reconstruction with and without resolution recovery. We aimed to compare the performance of the QGS software for the quantification LV function when using FBP as compared to iterative reconstruction (OSEM) and iterative reconstruction combined to resolution recovery (3D-Flash, Siemens).
Methods: Our study included 51 consecutive patients addressed for myocardial perfusion scintigraphy. Studies were acquired on a two-headed gamma-camera (Symbia, Siemens). GSPECT studies were reconstructed using three different methods (FBP, OSEM, and 3D-Flash) and then processed with the QGS software. LV end diastolic volumes (EDV), end systolic volumes (ESV) and LVEF were compared.
Results: LVEF was higher with FBP (72 ± 13%) than OSEM (70 ± 11%, P < .0001) and 3D-Flash (69 ± 12%, P < .0001), respectively.
LV EDV was lower with FBP (70 ± 23 mL) than OSEM (74 ± 25 mL, P < .0001) and 3D-Flash (80 ± 26 mL, P < .0001), respectively.
LV ESV was lower with FBP (22 ± 14 mL) than OSEM (24 ± 16 mL, P < .0001) and 3D-Flash (27 ± 17 mL, P < .0001), respectively.
Bland-Altman analysis for the combined EDV and ESV (n = 102) between FBP and 3D-Flash showed that the difference in LV volumes between the two methods increased with their average LV volumes (r = 0.61, P < .0001). This also was also verified for FBP and OSEM: r = 0.44 (P < .0001).
Conclusions: Newer iterative reconstruction methods (OSEM, 3D-Flash) give significantly different LVEF and volumes than those obtained with FBP. This should be considered when adopting newer reconstruction algorithms in clinical practice.
Poster Session 1
Advances in Instrumentation
Monday 6 May, 2013, 08:30–12:30 Poster Area
70
Correlation of myocardial ischemia with contraction asynchrony measured by single photon emission computed tomography synchronized with electrocardiogram
C. Carlos Guizar1; E. Alexanderson1; S. Hernandez1; M. Jimenez1; H. Hernandez1;
1National Institute of Cardiology “Ignacio Chavez”, Mexico City, Mexico
Objective: To establish the correlation between regional changes in the synchrony of ventricular contraction and the presence of moderate to severe ischemia on gated-SPECT.
Methods: We included men and women over age 40 who underwent gated-SPECT in the period from January 1, 2006 to January 1, 2008 and had moderate to severe myocardial ischemia, expressed as a summed difference score (SDS) ≥ 9 points, with no evidence of infarction. For the image analysis we used Emory Cardiac Toolbox™ 3.1 (Emory University Atlanta Georgia) software. Myocardial perfusion was analyzed in 17-segment polar maps, obtaining the summed stress score (SSS), the summed rest score (SRS) and the summed difference score (SDS). End diastolic volume, end systolic volume and ejection fraction of the left ventricle were also obtained. The sequential activation of the left ventricle was assessed in visual form from the polar map, thereby detecting the territories in which the activation occurred delayed. Synchrony indices were obtained as the standard deviation of timing phase angles and bandwidth.
Results: We included 34 patients, with a mean age of 67.5 ± 9.2 years, 67% were male patients (n = 23) and 33% female (n = 11). The 47% had severe ischemia and 53% moderate ischemia. The mean SSS was 14.12 ± 5.77, whereas for the SRS was 0. The mean ejection fraction was 66.21 ± 12.31%, the end diastolic volume of 84.85 mL, and the end systolic 32.84 ± 33.03 ± 23.89 mL. Ischemia was observed on the anteroseptal region in 38% of cases, on the inferior wall in 29%, on the lateral wall in 21% and on the apex in 12%. The synchrony polar map showed contraction delay in the ischemic region in 58.8% of cases. Patients with asynchrony in the polar map had a significantly larger bandwidth than those without delay in the polar map, with 60 ± 22° and 44 ± 16°, respectively (P = .02). There was no significant difference in the standard deviation (21.5 ± 10° vs 21.44 ± 9°, P = .94). There was also no association between the degree of ischemia and the presence of asynchrony in the polar map (P = .315).
Conclusions: Moderate to severe ischemia was associated with the presence of delay in the contraction of the same region with considerable frequency (58.8%), but the delay was slight. Only the bandwidth measurement was significantly increased in these cases, so this index is probably more sensitive than the standard deviation to detect slight delays in contraction associated with myocardial ischemia.
71
Coronary stent evaluation with MDCT: comparison between low-osmolar, high-iodine concentration iomeprol-400 and iso-osmolar, lower-iodine concentration iodixanol-320
S. Mushtaq1; D. Andreini2; G. Pontone1; E. Bertella1; E. Conte1; A. Baggiano1; S. Cortinovis1; G. Ballerini1; M. Pepi1; C. Fiorentini2
1Cardiology Center Monzino (IRCCS), Milan, Italy; 2Cardiology Center Monzino (IRCCS), Department of Cardiovascular Sciences, University of Milan, Milan, Italy
Purpose: To compare Iomeprol-400 with Iodixanol-320 for multidetector computed tomography coronary angiography (MDCT-CA) evaluation of coronary stents. Appropriateness of MDCT-CA stents evaluation is still a matter for debate and is unknown if contrast medium characteristics may affect MDCT-CA diagnostic performance.
Methods: We randomized 254 patients undergoing MDCT-CA coronary stent follow-up to Iomeprol-400 at 5.0 mL/second flow rate (group 1, n = 83), Iodixanol-320 at 6.2 mL/second flow rate (group 2, n = 87) and Iodixanol-320 at 5.0 mL/second flow rate (group 3, n = 84). Heart rate (HR) before and after scanning, HR variation, premature heart beats (PHB) and heat sensation by visual analog scale (VAS) during scanning were recorded. Mean attenuation was measured in the aortic root and coronary arteries. Image quality score and type of artifacts were assessed.
Results: In group 3, VAS was significantly lower than in groups 2 (4.3 vs 5.3 mm) and 1 (4.3 vs 8 mm) and HR after imaging was significantly lower than in groups 2 (53.7 vs 56.7 bpm) and 1 (53.7 vs 56.2 bpm). Number of patients with PHB during the scan was significantly lower in group 3 than in other groups. Mean attenuation was significantly lower in group 3 than in other groups. In group 3, stent evaluability was significantly higher and artifact rate was significantly lower than in group 2 (99% vs 91% and 4% vs 15%) and 1 (99% vs 92% and 4% vs 17%), respectively.
Conclusions: Iodixanol-320 provides better image quality of coronary stents, allowing higher MDCT-CA evaluability in comparison with Iomeprol-400.
72
Clinical evaluation of Monte Carlo and triple energy window-based scatter correction in myocardial perfusion scintigraphy
V. Vitaliy Androshchuk1; L. Hossen1; E. Reyes1; K. Wechalekar1; J. Bailey1; S. Gregg1; S.R. Underwood1
1Royal Brompton Hospital, London, United Kingdom
Background: Myocardial perfusion scintigraphy (MPS) is degraded by scattering of photons, which can reduce diagnostic accuracy. Scatter correction (SC) using the triple-energy-window (TEW) technique can correct for the degradation but Monte Carlo (MC) simulation is thought to be more accurate. We have compared a MC-based SC reconstruction (Hybrid recon, Hermes Medical Solutions) with a TEW technique (Xeleris, GE Healthcare).
Methods: Twenty consecutive patients with known or suspected coronary disease and a clinical referral for MPS were selected retrospectively. MPS was performed using 99mTc-tetrofosmin (250 + 750 MBq 1-day stress-rest protocol) with a dual detector camera and CT attenuation correction (Infinia Hawkeye, GE Healthcare). Tomograms were reconstructed using iterative reconstruction alone (NC) and were compared with reconstructions using MC correction with attenuation and resolution recovery (AR-MC), and TEW correction with attenuation correction (A-TEW). The studies were reviewed by an experienced observer blinded to the reconstruction technique and to the previous clinical report. Parameters recorded were diagnostic interpretation (normal, reversible, fixed or mixed defects), interpretative confidence (3-high to 0-absent), image quality score (3-0), artefact scores (3-0), summed segmental scores, left ventricular ejection fraction (LVEF) and end-diastolic volume (EDV). The reconstructions were then viewed in pairs for observer preference.
Results: There was no difference in diagnosis between NC, AR-MC, A-TEW (P = .98). Also, there was no difference in diagnostic confidence scores between NC, AR-MC and A-TEW (1.90 ± 0.72, 2.00 ± 0.73, 1.95 ± 0.89, respectively; P = .68). Stress image quality was higher with AR-MC (2.30 ± 0.66) and NC (2.25 ± 0.64) than A-TEW (1.65 ± 0.59) (P = .0029 and P = .0018, respectively). AR-MC had less stress low count artefact than A-TEW (0.25 ± 0.55 vs 0.75 ± 0.55, P = .0066). AR-MC and NC were both preferred over A-TEW but were equally preferred to each other. Left ventricular functional data and summed perfusion scores were not significantly different between techniques.
Conclusion: Imaging performance of MPS with iterative reconstruction (NC) can be improved more by AR-MC than by A-TEW. Although the advantage of AR-MC over NC is small at conventional doses of tracer, it may allow reduction of dose without loss of diagnostic performance, but this application remains to be studied.
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Impact of image processing in the detection of ischemia using CZT-SPECT/CT
D. Danielle Koopman1; J.A. Van Dalen2; C.H. Slump1; D. Vink3; D. Lots3; P.L. Jager3
1University of Twente, MIRA-Institute for Biomedical Technology & Technical Medicine, Enschede, Netherlands; 2Isala Hospital-Department of Clinical Physics, Zwolle, Netherlands; 3Isala Hospital-Department of Nuclear Medicine, Zwolle, Netherlands
Introduction: The new multipinhole cardiac SPECT/CT cameras with cadmium zinc-telluride (CZT) detectors are highly sensitive, produce high image quality but rely on dedicated reconstruction algorithms. The influence of image processing steps may be different as compared to standard SPECT protocols. We determined the intra- and inter-operator variability of these processing steps on the final result of myocardial perfusion imaging studies.
Methods: The population consisted of 20 consecutive patients (7 women and 13 men, BMI 22-40, age 34-79) who underwent a one-day protocol stress- and rest CZT-SPECT/CT (GE Discovery NM/CT 570c) using Tc99m-tetrofosmin. Data were processed twice by three experienced operators. Processing steps include determining of myocardial axes and boundaries, masking of the myocardium and manual SPECT/CT co-registration for attenuation correction. We used a 17-segment cardiac model and calculated the difference between stress and rest of % segmental uptake values (after normalisation of peak activity to 100%) for non-corrected (NC) and attenuation-corrected (AC) image sets. AC includes one extra processing step, i.e. SPECT/CT co-registration. Operator variation was considered significant for the diagnosis of ischemia when greater than 5%.
Results: As a measure of inter-operator variation, the mean operator variation across all 340 segments was 2.5% (Q1-Q3: 1.8-2.8%) for the NC—and 4.2% (Q1-Q3: 3.2-5.1%) for AC images (P < .01). In more than 3% (NC) and 28% (AC) of the cases, inter-operator variation was greater than 5%. The mean intra-operator variation across all 680 segments was 2.2% (Q1-Q3: 1.6-2.2%) for the NC—and 3.4% (Q1-Q3: 2.6-3.9%) for AC images. In more than 5% (NC) and 13% (AC) of the cases, intra-operator variation was greater than 5%.
Conclusion: Intra- and inter-operator variation in image processing of SPECT-CT CZT gamma camera data is significant and may influence the final diagnosis of ischemia. Especially the use of attenuation correction significantly increases this variation. Clearer guidelines for image processing are necessary in order to improve the reproducibility of the results and to obtain a more reliable diagnosis of ischemia.
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How reliable is left ventricular parameters measured by QGS?
A. Alp Notghi1; G. James1; A. Jennings1; J. O’brien1
1Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom
We have looked at repeatability of LV function parameters in the same patient using gated myocardial perfusion scan (MPS).
16 patients (6 male, 10 female) were entered into this study, median age of 69 (range 34-69 years), mean weight of 76 kg (range 44-90 kg). Each patient had three consecutive MPS. Rest MPS (400 MBq tetrofosmin) was followed on the same day with stress MPS (800 MBq), pattient then returned for a second rest MPS (400 MBq) the next day. On each occasion two consecutive MPI acquisitions were performed (180 degrees, 60 projections 18 seconds/projection, 8 bin gating). The two consecutive studies were added to obtain the equivalent of a standard full time acquisition for each occasion. Cedar Sinai QGS (Autoquant7 Philips Medical Systems) was used to obtain EDV, ESV and LVEF. Paired t-test (P) and Pearson correlation (r) was calculated to compare data.
There was a wide range of EDV (76-333 mL), ESV (7-226 mL) and EF (21-73%). The full-time stress data were analysed twice (n = 16), to establish the repeatability of the QGS calculations. There was no significant difference in the EDV, ESV and EF when same data were analysed twice (Pearson correlation 0.993, 0.998 and 0.971 respectively, mean difference 0.38 mL, 0.68 mL, 0% respectively, P NS).
Then day one and day two rest studies were compared (n = 16). This compared results obtained at separate occasions from the same patient. There was no significant difference in calculated EDV, ESV or EF between the two separate rest studies (Pearson correlation 0.989, 0.992 and 0.938 respectively, mean difference 0.44 mL, 0.81 mL, 0.37% respectively, P NS).
Finally the half-time consecutive studies where compared (n = 32) to see if the QGS calculations are reliably reproducible in low count acquisitions when conceivable the ventricular wall delineation may be difficult. There was again no difference in the results of paired EDV, ESV, and EF (Pearson correlation 0.996, 0.996 and 0.961 respectively, mean difference 0.61 mL, 1.00 mL, 0.82% respectively, P NS).
Conclusion: QGS gives reproducible parameters for consecutive measurements of left ventricular function. The results suggest very high accuracy of reproducibility for individual patients even with very low count studies.
75
Gated blood pool SPECT: QBS software performs better with iterative reconstruction combined to resolution recovery than with filtered backprojection
D. Doumit Daou1; C. Coaguila2; C. Meyer1; F. Amegassi1
1APHP, Cochin Hospital, Department of Nuclear Medicine, Paris, France; 2Hospital Sud-Francilien, Corbeil-Essonnes, France
Purpose: Gated blood pool SPECT (GSPECT RNA) radionuclide angiography (RNA) is interesting for the evaluation of cardiac function. We previously validated the use of QBS software (Cedars Sinai) for the quantification of both left ventricular (LV) and right ventricular (RV) function. This was done with filtered backprojection reconstruction method (FBP). We aimed to study the performance of the QBS software for the quantification LV and RV function when using FBP as compared to iterative reconstruction with resolution recovery (3D-Flash, Siemens).
Methods: Our study included 83 patient addressed for LV and RV function evaluation with planar (left anterior oblique view, planarLAO) and GSPECT RNA. Studies were acquired on a two-headed gamma-camera (Symbia, Siemens). PlanarLAO studies were processed with the NXT program (Vision, GEMS) and provided both planarLAO LVEF and RVEF. GSPECT RNA studies were reconstructed using two different methods (FBP and 3D-Flash) and then processed with the QBS software. Results provided with the maximal activity threshold method (MAT) method of QBS were noted for both FBP and 3D-Flash: LV and RV end diastolic volumes (EDV), end systolic volumes (ESV) and stroke volumes (SV), as well as LVEF and RVEF (ratio of activities of MAT method). For comparison of the performance of FBP vs 3D-Flash, planarLAO LVEF and RVEF were considered gold standard. And for RV and LV volumes, we hypothesized that the best reconstruction method would be the one providing the highest correlation between RV-SV and LV-SV.
Results: LVEF provided by planarLAO (58 ± 10%) is highly correlated to LVEF measured with QBS-FBP 69 ± 16%, r = 0.8; P < .0001) and QBS-3D-Flash (68 ± 16, r = 0.82; P < .0001). On Bland Altman analysis, the limits of agreement of LVEF for QBS-FBP vs planarLAO (mean ± sd = −11.2% ± 10.5%) are slightly wider than those for QBS-3D-Flash vs planarLAO (−10.5% ± 9.6%). RVEF provided by planarLAO (45 ± 9%) was better correlated to RVEF measured with QBS-3D-Flash (53 ± 12%, r = 0.45; P < .0001) than QBS-FBP (49% ± 13%, r = 0.28; P < .05).
Linear correlation between LV-SV and RV-SV is higher with QBS-3D-Flash (80 ± 22 mL and 91 ± 27 mL, r = 0.6; P < .0001) than with QBS-FBP (86 ± 26 and 116 ± 36 mL, r = 0.2; P < .05).
Conclusions: QBS performs better when using 3D-Flash than FBP for the quantification of cardiac function particularly for the RV.
76
The effect of a beta-blocker on myocardial blood flow under adenosine quantitatively measured with N-13-ammonia PET
O. Oliver Lindner1; R. Preuss1; R. Weise1; W. Burchert1
1HDZ NRW, Ruhr-University Bochum, Institute for Radiology, Nuclear Medicine & Molecular Imaging, Bad Oeynhausen, Germany
Purpose: Despite maximal vasodilation by pharmacologic vasodilators such as dipyridamol, adenosine or regadenoson an interaction with beta-blockers has been suggested. However, the results of some recent SPECT studies on the impact of beta blockers on the results of stress testing with adenosine in myocardial perfusion imaging are contradictory.
Methods: We studied seven male patients with history of CAD with N-13-ammonia PET-CT (Siemens mCT) under adenosine infusion (infusion time 6 minutes, injection of N-13-ammonia 2 minutes after onset of the infusion) with beta blockers and after withdrawal of the individual beta blocker for at least three half-lives. Myocardial blood flow (MBF) was quantified based on an irreversible two-compartment model.
Results: MBF under beta blockade was 195.4 ± 51.6 mL/100 g/minute and significantly lower than after withdrawal of the individual beta blocker (215.5 ± 47.6 mL/minute/100 g). RRsys did not change and was 109 ± 13 mmHg with beta blocker and 112 ± 14 without beta blocker (P = .23). RRdia and heart rate increased significantly after withdrawal of beta blocker (51 ± 7 mmHg vs 55 ± 6 mmHg and 65 ± 10/minute vs 80 ± 6/minute, P < .05). Coronary resistance was 0.40 ± 0.12 mmHg × 100 g × minute/mL with beta blocker and 0.36 ± 0.09 mmHg × 100 g × minute/mL without beta blocker. Related to a rate pressure product of 10,000 mmHg/minute MBF with beta blocker was 290.6 ± 112.0 mL/minute/100 g and without beta blocker 245.2 ± 72.3 mL/minute/100 g (P = .07).
Conclusions: Beta blockers have a significant impact on MBF which is decreased by about 10%. This effect is not exclusively related to hemodynamic changes. However, we conclude that the impact on the accuracy of SPECT imaging with adenosine under beta blockade is small due to the uptake-flow characteristics of the current radiopharmaceuticals. Nevertheless, we recommend to withdraw a beta blocker in myocardial perfusion imaging if possible.
77
Reduced radiation exposure in patients with new cadmium-zinc-telluride cardiac cameras
B. Bernard Songy1; M. Guernou1; D. Lussato1; M. Queneau1
1Centre Cardiologique du Nord (CCN), Paris, France
Purpose: Myocardial perfusion imaging is an essential tool for management of coronary artery disease but leads to relative high radiation exposure and contributes up to 20% of the estimated annual collective radiation dose and could potentially result in additional cancers. The American Society of Nuclear Cardiology recommends that laboratories use imaging protocols that achieve a radiation exposure of no more than 9 mSv in 50% of studies by 2014. Cadmium-zinc-telluride (CZT) cardiac cameras have high myocardial counting efficiency that allows to decrease injected activities.
Methods: We explored 20,000 patients with CZT cameras (GE DNM 530c) since 2009. We study here the feasibility of low dose protocols and the consequences on effective dose in clinical practice.
Results: For patients without known coronary artery disease, we use Tc99m-sestaMIBI or tetrofosmin. We inject activity from 1.5 to 2 MBq/kg, i.e., 3 mCi for 70 kg weight. Effective dose is thus less than 1 mSv. Myocardial raw counts are higher with CZT cameras (343 ± 87 kcounts) than with conventional Anger cameras and regular injected activities (209 ± 40 kcounts). We observe fewer artifacts with the CZT cameras leading to fewer equivocal results. Thus more patients can undergo only stress imaging, leading to an even more important decrease in radiation exposure. For patients with known coronary artery disease, we use thallium-201 because its high uptake, especially at stress. Additionally, it offers an alternative to molybdenum–technetium shortage. Because radiation exposure is an important concern with thallium-201, we dramatically decrease injected activities down to 0.66 MBq/kg, i.e. 1.2 mCi for 70 kg weight, leading to an effective dose of 7 mSv. Myocardial raw counts are higher with CZT cameras (446 ± 53 kcounts) than with conventional myocardial perfusion imaging. We observe fewer artifacts (P < .01), especially in inferior (−78%) and anterior territories (−45%). The diagnostic agreement between CZT and cardiac cameras is high (97%).
When a dual isotope protocol is used, with stress thallium and rest technetium agent, the effective dose remains lower than 9 mSv.
Conclusions: The CZT cardiac cameras allow very low dose protocols with high myocardial imaging quality and high diagnosis performances.
Stress only protocols with technetium agents lead to an effective dose lower than 1 mSv.
Thallium-201 or dual isotope protocols achieve a radiation exposure of no more than 9 mSv, complying with the recommendations of the American Society of Nuclear Cardiology.
78
Monte Carlo simulations of a small animal PET system for small rodent heart imaging
M.J. Park1; M. Lassmann2; R. Dominik2; L. Lemeunier3; T. Yamane2; F. Kaiser1; T. Higuchi1
1Würzburg University, CHFC/Nuclear Medicine, Würzburg, Germany; 2University Hospital of Würzburg, Department of Nuclear Medicine, Würzburg, Germany; 3Siemens healthcare, Imaging & Therapy division, Erlangen, Germany
Purpose: A combination of a realistic digital phantom of anatomical structure and Monte Carlo methods based on high-energy physics allows simulating realistic PET projections of anatomy and physiology. The aim of this study is to develop and validate the simulation platform to study image degradation and compensation methods in rodent cardiac PET imaging.
Methods: We built a simulation platform using a MC simulation method (Geant4 Application for Emission Tomography, GATE) and Software for Tomographic Image Reconstruction (STIR) based on the scanner configuration and the data collecting system of a dedicated small animal PET system (SIEMENS Inveon). In order to validate the simulation platform, the simulation was compared to the measurement on the real scanner using a line source filled with 16.4 MBq F-18. Moby phantom was used to simulate heart images of mouse and rat. Attenuation and partial volume artifacts were measured on the reconstructed images.
Results: The difference of average full width at half maximum (FWHM) between simulated and measured sinograms was less than 1% for spatial resolution. Rat and mouse heart images were successfully obtained on the simulation platform. Photon attenuation reduced the counts of the left ventricular wall by 36% and 20% in rat and mice, respectively. Modifications of the left ventricular wall thickness to 2.6 mm (rat, end-diastolic), 1.8 mm (rat, end-systolic), 1.0 mm (mice, ED), and 0.7 mm (mice, ES) resulted in count losses of 22%, 44%, 77%, and 87%, respectively, reflecting partial volume artifacts.
Conclusions: We established a computer simulation platform to study small rodent heart micro PET images. The potential use is to study various image degradation artifacts, as well as to develop and test new compensation algorithms.
Partial volume effect on rodent hearts
79
Reducing patient radiation exposure: A novel method of coronary artery calcium scoring using images derived from CT angiography
C.W. Chris Pavitt1; A.C. Lindsay1; R. Ray1; S. Zielke1; S. Padley1; M. Rubens1; E. Nicol1
1Royal Brompton National Heart & Lung Hospital, London, United Kingdom
Introduction: Coronary artery calcium scoring (CACS) requires an additional acquisition prior to coronary CT angiography (CTA). We hypothesised that the CACS can be accurately derived from CTA using a novel analysis technique.
Methods: 120 consecutive patients undergoing CACS and CTA between January and May 2011 were included. A 0.1 cm2 region of interest was used to determine the mean contrast density on CTA in the left main (LM), or the right coronary (RC) artery if the LM was significantly calcified (n = 8). From this, a new attenuation threshold was calculated as: mean LM/RC contrast density + 2SD (HU). Applying this threshold CACS was calculated from axial CTA images using conventional CACS software. Results were compared to conventional CACS (130HU threshold). Agatston risk categories (0, 1-10, 11-100, 101-400 and >400) were derived from both methods. Linear regression and Bland-Altman analysis (Figure) were performed.
Results: The mean traditional CACS was double (2.0; 95% CI 1.84-2.14) the mean CTA-derived CACS (108.3 vs 55.4, respectively). CTA-derived CACS correlated well with traditional CACS (R 2 = 0.86; P < .001) representing 18.5 ± 10.3% of the total radiation dose.
Conclusion: CACS can be accurately quantified from coronary CTA images using a semi-automated method that reduces acquisition time and radiation exposure. At higher CACS values correlation is less robust but remains clinically valuable in its ability to identify high risk patients.
80
Bismuth breast shield and adaptive statistical iterative reconstruction (ASIR) in coronary CT angiography: lower dose without loss in image quality
J.O. Jussi Oskari Tuomi1; S. Kajander1; A. Saraste1; J. Knuuti1
1Turku PET Centre, University of Turku & Turku University Hospital, Turku, Finland
Purpose: To compare the effects of bismuth breast shield and image reconstruction method on image quality in coronary CT angiography.
Background: Despite efforts to contain irradiation, collective dose due to CT continues to grow. Therefore, new ways to combine diagnostic image quality and acceptable radiation dose are important. Female breast is one of the tissues most prone to harmful biological effects of irradiation and is within field-of-view in CT coronary angiography. The breast dose may be reduced by 26.9-52.4% by using a bismuth shield but the effects of such protection on diagnostic image quality remains disputed. New reconstruction techniques, now feasible due to improvements in data handling, are available and reduce patient dose.
Methods: 30 women underwent scheduled coronary CT angiography. After randomization, 15 women were scanned with a bismuth breast shield and 15 without. Each patient’s BMI was calculated and raw CT data was reconstructed with standard filtered back projection (FBP) and various degrees (20%, 40%, 60% and 80%) of adaptive statistical iterative reconstruction (ASIR). Two experienced physicians graded the created images using a 4-point scaling system according to their apparent diagnostic quality. In addition, image signal and noise was recorded at predetermined areas from each reconstruction.
Results: There was a statistically significant difference in subjective image quality between reconstructing with filtered back projection (=ASIR 0%) and ASIR 40 %: ASIR 0 % results worse image quality than ASIR 40% (P = .002). Further increase of ASIR percentage seemed to impair subjective image quality. Bismuth breast shield does not deteriorate the subjective diagnostic quality of images (P = .70). However, bismuth breast shield decreases image signal approximately by 14.9 HU and causes more noise in predetermined areas (P = .027).
Conclusions: Moderate (40%) ASIR reconstruction improves image quality in CT angiography. Use of bismuth breast shield in women is possible without sacrificing diagnostic image quality.
81
Gated SPECT phase analysis in LBBB
H. Pena1; G. Cantinho1; A. Veiga2; J. Monteiro3; F. Godinho3
1Faculdade de Medicina de Lisboa, Instituto de Medicina Nuclear, Lisbon, Portugal; 2Hospital Lisbon North, Hospital Santa Maria, Lisbon, Portugal; 3Atomedical, SA, Lisbon, Portugal
Introduction: Cardiac resynchronization therapy (CRT) has shown benefits in patients with severe heart failure. However, 20-30% of the patients selected by conventional criteria show no response. Predicting which ones will respond is a challenge.
Methods based on cardiac cycle analysis from myocardial perfusion (gSPECT) have proved to be promising.
To assess the sensitivity of the technique, we used it in the characterization of individuals with LBBB, selected by QRS duration.
Material and Methods: From the patients investigated because of coronary heart disease (CHD), without evidence of MI, we selected:
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60: QRS < 90 ms and gSPECT normal, 30 women (68 ± 11 years) and 30 men (65 ± 12);
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150: LBBB and QRS > 120 ms, 85 women (69.5 ± 10.5) and 65 men (69.5 ± 9.7).
According to the result of gSPECT, they were divided in three groups: (1) dilated (without coronary disease), (2) normal LV size and perfusion and (3) evidence of coronary disease (CD).
All underwent 30 mCi 99mTc-MIBI gSPECT (rest and pharmacological stress), reconstructed iteratively by WBR. Germano’s QGS and QPS methods were used to quantify LV function and perfusion. To analyze the onset of LV mechanical contraction, we used Garcia’s method: phase histogram by Fourier analysis with determination of: peak phase (PP), standard deviation (SD), bandwidth (HB), skewness (HS) and kurtosis (HK) of the histogram.
We calculated the mean, the standard deviation and non-paired Student t test was applied. These parameters were then correlated with the QRS duration.
Cases were calculated with 1 SD, as used in the theoretically normal phase parameters
Results: We found no statistically significant differences in the variables age and heart rate.
The parameters of LV function revealed differences in the population with LBBB.
The diastolic parameters showed erratic changes (weak robustness of the methodology).
There was no correlation between the histogram variables, QRS duration and sex.
In the phase histogram, 4 of the 5 parameters were abnormal in individuals with LBBB (P < .05), with greater significance in dilated LBBB with CD (P < .0001). Over 90% of cases showed abnormal values in four parameters.
Conclusions: This gSPECT phase analysis revealed a strong discriminative power on four parameters that quantify desynchrony in patients with LBBB, reinforcing its promising capacity to select patients for CRT. It permits to determine the later contraction location, excluding areas of necrosis, which can guide therapy. It requires however further studies of correlation with conventional parameters.
82
Bolus administration of ultra-short acting esmolol is safe and effective for heart rate control during coronary computed tomography angiography
M. Karolyi1; A. Bartykowszki1; N. Pinter1; C.S. Csobay-Novak1; G.Y. Balazs1; B. Merkely1; P. Maurovich-Horvat1
1Semmelweis University, Heart Center, Budapest, Hungary
Purpose: Heart rate (HR) control of patients undergo coronary CT angiography (CCTA) to achieve diagnostic image quality is optimally limited to the time of scan. Thus, intravenous administration of ultra-short acting esmolol may be an alternative to iv metoprolol for safe HR control during CCTA.
Methods: iv esmolol or metoprolol was administered on alternating days to patients referred to CCTA (Brilliance iCT 256, Philips Healthcare) if HR was ≥60 bmp before scan. Ascending doses of esmolol (100-200-200 mg independent of patient’s weight; maximum 500 mg) or metoprolol (5-10-15-20 mg according to SCCT recommendations; maximum 25 mg) were administered. HR and blood pressure (BP) was recorded at arrival (T0), prior (T1), during (TS), immediately after (T2) and 30 minutes after examination (T3).
Results: 572 consecutive patients were scanned (306 male, mean age 58 ± 11, BMI 28.3 ± 5.3). 202 received iv esmolol (E), 208 iv metoprolol (M) and 162 no iv drug. Median HR of the E and M group were similar at T0 (76.5 bpm [69-87] vs 76 bpm [69-84], P = .79) and at T1 (67 bpm [62-74] vs 68 bpm [63-73], P = .55). However HR at TS, T2 and at T3 was significantly higher in the E group (58 bpm [54-61] vs 60 bpm [56-64], P = .00009; 67 bpm [63-72] vs 65 bpm [60-70], P = .0025; 65 bpm [60-69] vs 62 bpm [57-69], P = .0013, respectively). BP showed no difference between the E and M group at T0, T1, T2 and T3. HR ≤ 60 was reached in 72.8% (147/202) of the E vs 56.7% (118/208) of the M group (P = .0009); HR ≤ 65 was reached in 89.6% (181/202) of the E vs 78.4% (163/208) of the M group (P = .002). No side effects were registered.
Conclusion: Intravenous bolus administration of esmolol with a novel administration protocol independent of body weight is safe and effective for heart rate control in patients assigned to CCTA.
83
Aortic annulus area assessment by multidetector computed tomography for predicting paravalvular regurgitation in patients undergoing balloon-expandable transcatheter aortic valve implantation
G. Gianluca Pontone1; D. Andreini1; E. Bertella1; S. Mushtaq1; S. Cortinovis1; A.D. Annoni1; A. Formenti1; G. Ballerini1; M. Pepi1
1University of Milan, Foundation Monzino (IRCCS), Center Cardiology, Department of Cardiology, Milan, Italy
Purpose: Transcatheter aortic valve implantation (TAVI) is a valid alternative to surgery in high risk patients with severe aortic stenosis (AS). Aortic annulus (AoA) sizing is crucial for TAVI success. The aim of the study is to compare AoA dimensions measured by multidetetctor computed tomography (MDCT) vs those obtained with transthoracic (TTE) and transesophageal echocardiography (TEE) for predicting paravalvular aortic regurgitation (PVR) after TAVI.
Materials and Methods: AoA maximum diameter, minimum diameter and area were assessed with MDCT and compared to TTE and TEE diameter and area for predicting PVR after TAVI in 151 patients (45 men, age 81.2 ± 6.4 years).
Results: AoA maximum, minimum diameter and area detected by MDCT were 25.04 ± 2.39 mm, 21.27 ± 2.10 mm, and 420.87 ± 76.10 mm2, respectively. AoA diameter and area measured by TTE and TEE were 21.14 ± 1.94 mm, 353.82 ± 64.57 mm2, 22.04 ± 1.94 mm and 384.33 ± 67.30 mm2, respectively. A good correlation was found between AoA diameters and area evaluated by MDCT vs TTE and TEE (0.61, 0.65 and 0.69, and 0.61, 0.65, and 0.70, respectively) with a mean difference of 3.90 ± 1.98 mm, 0.13 ± 1.67 mm and 67.05 ± 55.87 mm2, and 3.0 ± 2.0 mm, 0.77 ± 1.70 mm and 36.54 ± 56.43 mm2, respectively. Grade ≥ 2 PVR occurred in 46 patients and was related to male gender, higher BMI, pre-procedural aortic regurgitation and lower mismatch between the nominal area of the implanted prosthesis and AoA-AMDCT.
Conclusions: Mismatch between prosthesis area and AoA area detected by MDCT is a better predictor of PVR as compared to echocardiography mismatch. Specific MDCT-based sizing recommendations should be developed.
84
Cardiac and respiratory dual-gated PET imaging of the rat heart
T. Yamane1; M.J. Park2; F. Kaiser2; S. Samnick1; R. Dominik1; T. Higuchi2
1University of Würzburg, Department of Nuclear Medicine, Würzburg, Germany; 2University of Würzburg, Comprehensive Heart Failure Center, Würzburg, Germany
Purpose: Movement of the heart from cardiac contraction and respiration potentially causes degradation of the myocardial PET images. The purpose of this study is to characterize these motion artifacts in a setting of rat heart and small animal PET system using dual-gated imaging approach.
Methods: Dual-gated PET acquisition for ECG cardiac and respiratory cycles was performed after an administration of approximately 74 MBq F-18 FDG in the male Wister rats (27 scan sessions in 10 animals) using high-resolution dedicated small animal PET system (Siemens Inveon) and external trigger system (BioVet). The acquired list mode data were sorted and reconstructed into 64 frames of dual-gating images consisted with 8 frames per ECG cycles and 8 frames per respiratory cycle. Non-gated single frame images were also reconstructed. Movement of the hearts and myocardial activity distribution were evaluated for both cardiac and respiratory cycles. Influence on respiratory motion by the animal position during the scan session (spine or prone) and presence of myocardial infarction were analyzed.
Results: The mean and standard deviation of ventricular wall movements estimated from the gated PET images were 1.0 ± 0.4, 1.2 ± 0.4, 0.5 ± 0.2, 0.5 ± 0.2 and 0.5 ± 0.2 for respiratory gating, and 1.4 ± 0.4, 0.9 ± 0.3, 0.7 ± 0.2, 1.5 ± 0.5 and 1.7 ± 0.5 for cardiac cycle at the apex, septal, lateral, anterior and inferior walls, respectively. Measured ventricular activity increased in the systolic phase due to the less partial volume effects compare to diastolic phase and non-gated images. Respiratory motion caused count reduction significantly (P < .01) at non-gated image with 6.0 ± 5.4%, 3.1 ± 5.7%, 2.6 ± 4.3% and 3.0 ± 6.4% in septal, anterior, lateral and inferior walls, respectively. Animal position during the scan and presence of a myocardial infarction did not change the respiratory motion effects significantly.
Conclusions: Dual-gated imaging with small animal PET system allows estimating motion artifacts of the rat hearts for both cardiac and respiratory cycles. There was a minimal but significant count reduction caused by the respiratory motion in the myocardial walls.
85
Phase gated SPECT in LBBB heart failure
H. Pena1; G. Cantinho1; A. Veiga2; F. Godinho3
1Faculdade de Medicina de Lisboa, Instituto de Medicina Nuclear, Lisbon, Portugal; 2Hospital Lisbon North, Hospital Santa Maria, Lisbon, Portugal; 3Atomedical, SA, Lisbon, Portugal
Aim: Phase analysis applied to gated SPECT myocardial perfusion studies (GMPS) allows determining the regional onset timing evaluation of mechanical left ventricular contraction.
This method (E. Garcia) uses 5 indices in its normal database, four of which are consistently abnormal in LBBB patients without heart failure (HF). In our study, we pretend to evaluate how powerful these indices are to discriminate LBBB patients with and without HF, allowing a more accurate selection of potential candidates for cardiac resynchronization therapy (CRT).
Material & Methods: G1: 21 men (65 ± 10 y/o) (G1 m) and 11 women (67 ± 11 y/o) (G1w) with LVEF ≤ 35%, EDV ≥ 130 ml, QRS ≥ 120 ms and no CAD.
G2: 36 men (65 ± 10 y/o) (G2 m) and 66 women (67 ± 11 y/o) (G2w) with LVEF > 35%, EDV < 130 ml, QRS ≥ 120 ms and no CAD.
All were submitted to GMPS rest and gated stress with 20 mCi 99mTc-Tetrofosmin, reconstructed iteratively by WBR Xpress3. Germano’s QGS and QPS were used to quantify LV function and perfusion.
E. Garcia’s Phase Analysis was used to evaluate LV dyssynchrony with determination of peak phase (PP), phase standard deviation (SD), as well as histogram bandwidth (HB), skewness (HS) and kurtosis (HK).
We calculated the mean and its standard deviation and applied unpaired student t test for G1 and G2 subgroups comparison. These parameters were also correlated with QRS duration, LVEF and volumes.
We used 1 and 2 SD from the normal mean database values to determine the percentage of patients outside that range.
Results: In the phase histogram, all the indices (except PP) were consistently different (P < .01).
All the HF patients (G1) had SD and HB above normal range and 95% showed low HS (even with 2SD), while the same doesn’t happen for G2. LV functional parameters (LVEF, EDV and ESV) were statistically different (P < .005)
We found no statistically significant differences in age, heart rate or QRS duration.
There were no significant differences between sexes, except for the functional parameters in dilated LVs (G2).
Conclusions: GMPS phase analysis of in HF seems to be a useful method to evaluate LV dyssynchrony.
HB, phase SD and HS are the most consistently and greater abnormal variables, depicting a greater dyssynchrony (independently of LVEF or QRS duration), as a potential independent discriminative parameter.
The lower number of patients with low HK (2SD) is yet to be explained. These 4 GMPS phase analysis parameters may therefore play a potential adjuvant role in the future to select HF patients for CRT.
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Accuracy of aortic root annulus assessment with cardiac magnetic resonance in patients referred for transcatheter aortic valve implantation: A comparison with multi-detector computed tomography
G. Gianluca Pontone1; D. Andreini1; E. Bertella1; S. Mushtaq1; P. Gripari1; S. Cortinovis1; A.D. Annoni1; A. Formenti1; G. Ballerini1; M. Pepi1;
1University of Milan, Foundation Monzino (IRCCS), Center Cardiology, Department of Cardiology, Milan, Italy
Purpose: To compare the accuracy of cardiac magnetic resonance (CMR) evaluation of the aortic root as compared to multi-detector computed tomography (MDCT) in patients referred for transcatheter aortic valve implantation (TAVI).
Materials and Methods: In 50 patients, the following parameters were assessed with CMR and compared with those obtained with MDCT: aortic annulus (AoA) maximum diameter (AoA-Dmax), minimum diameter (AoA-Dmin), and area (AoA-A), length of the left coronary, right coronary, and non-coronary aortic leaflets, degree (grades 1 to 4) of aortic leaflet calcification and distance between AoA and coronary artery ostia.
Results: AoA-Dmax, AoA-Dmin and AoA-A were 26.45 ± 2.83 mm, 20.17 ± 2.20 mm, 444.88 ± 84.61 mm2 and 26.45 ± 2.76 mm, 20.59 ± 2.35 and 449.78 ± 86.22 mm2 by MDCT and CMR, respectively. The length of left coronary, right coronary, and non-coronary leaflets were 14.02 ± 2.27 mm, 13.33 ± 2.33 mm, 13.39 ± 1.97 mm, and 13.95 ± 2.18 mm, 13.30 ± 2.14 mm, 13.46 ± 1.80 mm by MDCT and CMR, respectively, while the scores of aortic leaflet calcifications were 3.4 ± 0.7 vs 2.97 ± 0.77. Finally, the distance between AoA and left main and right coronary artery ostia was 16.21 ± 3.07 mm, 16.02 ± 4.29 mm and 16.14 ± 2.83 mm, 16.14 ± 4.36 mm by CCT and CMR, respectively. There was close agreement between CMR and MDCT measurements, whereas aortic leaflet calcifications were underestimated by CMR.
Conclusions: Aortic root assessment with CMR including AoA size, aortic leaflet length and coronary artery ostia height is accurate in comparison to MDCT. CMR may be a valid imaging alternative in patients unsuitable for MDCT.
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Comparison of two different strategies of intravascular ultrasound guidance during percutaneous coronary intervention
J.B. Jae Bin Seo1; H.S. Kim2
1Boramae Hospital, Seoul, Republic of Korea; 2Seoul National University Hospital, Seoul, Republic of Korea
Background: Intravascular ultrasound (IVUS) is helpful during percutaneous coronary intervention (PCI), because we can confirm the good apposition or optimal expansion of stents. In DES era, there has been one study to show the utility of IVUS guidance compared with no-guidance. In this study, we compared the angiographic result as well as clinical outcome between the two different strategies of IVUS-guidance, the selective vs the routine.
Methods and Results: For this study, we have divided physicians for 3 years into two groups; doctors to do PCI under ‘routine’ IVUS-guidance vs PCI under ‘selective’ IVUS-guidance. Among total 279 patients (384 lesions) who underwent PCI with TAXUS stent, 87 patients underwent it under the strategy of ‘routine’ IVUS-guidance whereas 192 patients under ‘selective’ IVUS-guidance where IVUS was used only when it is judged to be necessary by physicians. Baseline clinical features of the patients are similar between two groups. The actual rate of IVUS usage was 89.2% in the routine group whereas 68.2% in the selective group (P < .01). Remarkable procedure-related parameter was the high rate of adjunctive ballooning, which was comparable between the two groups (72.5 vs 76.1% in routine vs selective, P = .57). We analyzed serial angiographic data, pre-PCI, immediate post-PCI, and follow-up at 6-9 months. The minimal lumen diameter at the immediate post-PCI was significantly wider in routine IVUS group than in selective one (2.58 vs 2.48 mm in routine vs selective, P = .03). But the difference disappeared at follow-up period (1.98 vs 1.98 mm in routine vs selective, P = .94). Clinical outcomes at 1 year were not different between the two groups, including death, myocardial infarction, target lesion revascularization, or composites.
Conclusions: PCI under the strategy of ‘selective’ IVUS-guidance was comparable to PCI under ‘routine’ IVUS-guidance in terms of angiographic and clinical outcomes when we frequently use adjunctive ballooning after stenting.
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Application of a new left ventricular edge-detection algorithm to small hearts: Effects of correction in Japanese patients
K. Nakajima1; K. Okuda1; K. Nystrom2; J. Richter2; S. Matsuo1; S. Kinuya1; L. Edenbrandt3
1Kanazawa University, Kanazawa, Japan; 2EXINI Diagnostics, Lund, Sweden; 3University of Gothenburg, Gothenburg, Sweden
Purpose: In gated SPECT, determination of volume and ejection fraction (EF) in small hearts has been considered inaccurate. In a Japanese female population, in particular, more than half of the patients showed an end-systolic volume (ESV) ≤ 20 mL as calculated by QGS software (Cedars Sinai Medical Center, USA). The aim of this study was to develop a new edge-tracing method for the left ventricular myocardium in small hearts.
Methods: The 3D-segmentation of the left ventricle was based on a heart shaped model and the active shape algorithm (EXINI Diagnostics, Sweden) (ExH). The model contained statistical information of the variability of left ventricular shape. In small hearts, due to the partial volume effect and the short distance to the opposite ventricular wall, the endocardial and the epicardial surfaces were shifted in the epicardial direction. The correction was dependent on the volume of the left ventricle. This algorithm was tested in two groups of patients: (1) normal databases created by multi-center working group activity in Japan (n = 47, m/f = 29/18, ESV < 10 excluded), and (2) consecutive Japanese patients (n = 116, m/f = 79/37) who underwent stress-rest gated SPECT. The end-diastolic volume (EDV), ESV and EF were calculated and compared with the results by QGS. The small heart was defined as ESV ≤ 20 mL: ESV of 0-10 mL (Group SH10) and ESV of 11-20 mL (Group SH20) and compared to ESV ≥ 20 mL (Group NH).
Results: In normal databases, small heart was observed in 43% of the subjects. In the small-heart subjects, EF was 74 ± 4% and 71 ± 7% for QGS and ExH (P = n.s. between QGS and ExH), EDV was 62 ± 8 and 85 ± 11 mL (P < .0001), and ESV was 16 ± 3 and 24 ± 4 mL (P < .0001), respectively. In consecutive 116 patients, frequency of the small heart was 84% for female (43% and 41% in Groups SH20 and SH10), and 37% for male (27% and 10% in Groups SH20 and SH10). With QGS software EFs were 55 ± 16%, 72 ± 7% and 83 ± 5% for Groups NH, SH20 and SH10, respectively (P = .0001). In contrast, with ExH software, EFs were 64 ± 14%, 69 ± 11% and 69 ± 7% for the same ESV groups, respectively (P = n. s.). Particularly in subjects with small hearts (SH10) defined by QGS, EDV was 40 ± 7 and 57 ± 7 mL for QGS and ExH, respectively and ESV was 7 ± 2 and 18 ± 3 mL.
Conclusions: In a Japanese population the incidence of small hearts was high particularly in consecutive female patients (approximately 80%). The optimal technical correction is required to overcome errors in calculation. The algorithm of ExH provided uniform EFs for a wide range of ESV, and common standard EF values might be used in patients with normal and small hearts.
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Individual determination of lesion-associated left ventricular segments on the basis of coronary angiography: Validation by fractional flow reserve measurements and stress perfusion SPECT studies
C.S. Csaba Jenei1; B. Kracsko1; I. Racz1; G.T. Szabo1; F. Gyory1; G. Vajda1; I. Edes1; Z.S. Koszegi1
1University of Debrecen, MHSC-Faculty of Medicine, Institute of Cardiology, Department of Cardiology, Debrecen, Hungary
Background: According to the current guideline the 17 myocardial segments can be assigned to the 3 major coronary arteries. However, the individual coronary artery variation can differ significantly from the standardized assignment. This can explain the recently published disagreements between the results of the fractional flow reserve (FFR) and the perfusion abnormality on the scintigrams (SPECT).
Objectives: To generate an algorithm about the concordance between the individual epicardial coronaries and the left ventricular segments on the basis of the coronary angiography. To compare the overlap between the FFR-predicted ischemic segments and the segments with reversible perfusion defect on the SPECT according to the assignment in our algorithm and on the basis of the guideline.
Methods: Data of 29 patients with at least one angiographically significant lesion (>50% diameter stenosis) and with FFR measurements by intracoronary pressure wire and stress perfusion studies were analyzed. The distribution of the ischemia defined by 1 reversibility score/segment (RSc) on the perfusion polar map was correlated with the individual lesion-associated (L-A) left ventricular segments defined by our algorithm called Holistic Coronary Care (HCC) program. The software used the modified Syntax segmentation for defining the L-A left ventricular region in the 17 segment model.
Results: In the HCC program 2-11 left ventricular segments (altogether 87) were assigned to the 14 FFR positive (<0.80) stenoses on the basis of the coronary angiography. Out of these segments, 56 showed reversible perfusion defect. From these data the per-vessel analysis using the regional ischemia criteria (≥2 RSc) showed 65% sensitivity and 100% specificity for the prediction of ischemia by the HCC and 59% sensitivity and 82% specificity for the prediction of ischemia by the standard alignment. Per-segment analysis revealed 78% sensitivity and 84% specificity, by the HCC and 44% sensitivity and 86% specificity for the prediction of ischemia by the standard alignment, respectively.
Conclusion: The myocardial segments affected by significant epicardial lesions can be defined with higher sensitivity by the HCC program than on the basis of the standard alignment. During a patient follow up in coronary heart disease, if anatomical information of coronary arteries is known (from coronary CT or from coronary angiography), the HCC software is useful to interpret correctly the SPECT images and to determine the ischemic region helping the plan of the revascularization.
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Low-dose axial CT in patients with atrial fibrillation: Is simultaneous assessment of the left atrium and coronary arteries feasible?
P. Pal Maurovich-Horvat1; R. O’connor2; M. Kolossvary1; M. Karolyi1; G. Szeplaki1; A. Bartykowszki1; L. Geller1; B. Merkely1
1Heart Center, Semmelweis University, Budapest, Hungary; 2Erasmus Medical Center, Rotterdam, Netherlands
Atrial fibrillation (AF) is considered a relative contraindication to coronary CT angiography due to irregular heart rates (HR). Aim of our study was to evaluate image quality (IQ) of coronaries in patients who underwent CT angiography to assess the left atrium for electroanatomical mapping and radiofrequency catheter ablation.
Hundred consecutive patients (66 male, 61.3 ± 11.2 years) with AF were examined with a 256-slice CT-scanner (80-140 kV, 200-300 mAs/rot, 0.27 seconds rotation time, 2 × 128 × 0.625 mm collimation, Philips Brilliance iCT) using prospective ECG triggering—”Step-and-shoot”—mode to evaluate left atrial anatomy. Patients were divided into low/medium HR-group [LHR] (mean HR < 80 bpm, n = 55) and high HR-group [HHR]-(mean HR ≥ 80 bpm, n = 45). Coronary segment based IQ assessment was performed using four-point Likert-type scale.
1403 coronary segments were analyzed. Mean IQ score was 1.88 ± 1.05 and 88.8% (1246/1403) of segments had diagnostic IQ (49.2% [690/1403] excellent, 25.5% [358/1403] good and 13.3% [186/1403] moderate IQ). IQ of LHR-group was better than of HHR (mean score 1.59 ± 0.89 vs 2.24 ± 1.11; P < 0.0001). Mean HR of the LHR and HHR group were 68.3 ± 8.7 bpm and 92.7 ± 12.2 bpm (P < 0.0001). The HR variation was lower in LHR group than in HHR group (42.5 ± 24.3 vs 55.0 ± 25.1 bpm; P = .014). Average radiation dose was 4.9 ± 1.6 mSv (range: 0.8-9.5 mSv). Out of 100 patients we identified 22 patients with severe coronary artery disease (CAD), in 13 cases invasive angiography was performed and 7 patients underwent PCI. Axial image acquisition with 256-slice CT provides diagnostic IQ for coronary evaluation. Simultaneous imaging of the left atrium and coronaries is feasible with axial scan mode and provides extra information regarding coronary artery disease in patients who have AF and are scheduled for left atrial ablation procedure.
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Improvement of overall feasibility of multidetector computed tomography angiography using snap shot freeze
G. Gianluca Pontone1; D. Andreini1; E. Bertella1; S. Mushtaq1; S. Cortinovis1; E. Conte1; A.D. Annoni1; A. Formenti1; G. Ballerini1
1University of Milan, Foundation Monzino (IRCCS), Center Cardiology, Department of Cardiology, Milan, Italy
Purpose: Recently, GE SnapShot Freeze (SSF) technology (GE Healthcare, Milwaukee, WI) has been introduced to reduce coronary motion artifacts. The aim of the study is to compare the overall feasibility of MDCT using standard post-processing reconstruction algorithm vs SSF.
Methods and Materials: Twenty-one patients with at least proximal or mid segment or more than 3 segments classified as not evaluable for motion artifacts were enrolled in this study. Image MDCT datasets were analyzed using standard reconstruction (Group 1) and SSF algorithm (Group 2) by two blinded expert reader. The overall number of artifacts (Art), image quality score (QS: 1 no artifacts; Qs: 4 for severe artifacts), the overall feasibility (Fe: evaluable segments/total number of coronary segments) and the prevalence of CAD including all segments with not-evaluable segments censored as positive.
Results: Thirteen patients (62%) received intravenous metoprolol (mean dose 9.62 ± 3.8 mg). The HR during the scan was 67.9 ± 6.6 bpm. Sixteen (76%) and 5 (24%) were performed using retrospective and prospective ECG-triggering, respectively. Group 2 vs Group 1 showed lower incidence of artifacts (17% vs 34%, P < .01), better QS (1.24 ± 0.64 vs 1.84 ± 1.2, P < .01) and Fe (93% vs 83%, P < .01). The prevalence of CAD including all segments with not-evaluable segments censored as positive was higher vs vessel-based analysis including diagnostic segments only in Group 1 (63% vs 20%, P < .01) and not in Group 2 (25% vs 17%, P: not significant).
Conclusions: Given these promising results in this preliminary experience, this novel SnapShot Freeze technology may be a useful tool to freezing coronary motion in higher heart rate variability.
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Comparison of a qualitative interpretation of stress MRI to a SPECT quantitative approach for the segmental evaluation of myocardial perfusion
N. Nicolas Piriou1; B. Laporte1; K. Warin-Fresse1; M. Caza1; F. Valette1; G. Fau1; J. Helias1; D. Crochet1
1University Hospital of Nantes—Hospital Guillaume & Rene Laennec, Nantes, France
Background: Stress magnetic resonance imaging (MRI) evaluates myocardial perfusion (MP).The analysis is most commonly limited to a pure qualitative evaluation of segmental MP, whereas SPECT, the gold-standard for MP imaging, is routinely analyzed with a full automated quantitative approach. We aimed to compare the two methods of analysis with SPECT as a reference.
Methods: We retrospectively analyzed stress MRI and SPECT data of ten patients that had both examinations for myocardial ischemia detection between 2009 and 2012 in our center. MP on stress MRI was analyzed on a 16 segments model, excluding apical segment from the usual AHA segmentation. Each segment was classified as normal perfusion (N), non-transmural sub-endocardial perfusion defect (NT) or transmural perfusion defect (T) after adenosine stress and at rest. SPECT data were analyzed with the QPS software and average percentage of tracer uptake was reported for each segment, at stress and rest. During MRI, late gadolinium enhancement (LGE) sequences were also analyzed and classified as normal (LG−) or positive for LGE (LG+). After stress MRI, each segment was classified as non ischemic (NI : N at stress, N at rest and LG−), ischemic (I: NT or T at stress, N at rest and LG−) or infarcted (INF : LG+).
Results: At stress, 114 on 160 segments (71.25%) were correctly classified by MRI, taking SPECT as the reference. 132 segments were classified N on MRI, whereas 31 (23.5%) had a percentage of tracer uptake <70% on SPECT. The mean percentage of tracer uptake was 75.5 ± 11% for segments classified N on stress MRI perfusion sequences, 67.7 ± 16% for segments classified NT, and 48.7 ± 8% for segments classified T (P < .05 vs N and NT segments). Among the 117 segments classified as NI on MRI, 92 (78.6%) were NI on SPECT (Chi² for association: P < .001). Only 2 on the 10 segments classified I on MRI were I on SPECT (Chi²:NS), and 10 on the 33 segments INF on MRI were INF on SPECT (Chi²: P < .001).
Conclusion: As previously described in the literature, pure qualitative interpretation of MP with stress MRI is less sensitive than SPECT quantitative analysis for the detection of mild to moderate segmental perfusion defects. This seems to be due in our study to non-significant differences of mean SPECT tracer fixation uptake in segments classified N and NT on MRI. Thus, semi-quantitative or multi-parametric analysis of stress cardiac MRI, involving cine-imaging and LGE, must be preferred to reach the diagnostic performance of SPECT in daily practice.
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A hybrid method using two-dimensional echocardiography and myocardial perfusion scintigraphy (MPS) for assessment of myocardial ischaemia
C. Szmigielski1; P. Wood2; J. Newton3; S. Pavlitchouk3; S. Zielke3; H. Becher2; N.K. Nik Sabharwal3
1Medical University of Warsaw, Department of Internal Medicine, Hypertension & Vascular Diseases, Warsaw, Poland; 2Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada; 3John Radcliffe Hospital, Department of Cardiology, Oxford, United Kingdom
Objective: We hypothesized that in patients with stable angina, normal LV function at rest assessed by echocardiography is synonymous with normal perfusion. Thus the normal resting echocardiogram could be used instead of a normal rest MPS scan.
Design: Patients with normal LV function who were referred for MPS because of stable chest pain underwent a comprehensive 2D echocardiogram prior to their nuclear procedure. Rest and stress scans were reviewed with the ECG and clinical data. A second reader analyzed only the stress scans with the ECG, clinical data and resting echocardiogram.
Patients: 94 consecutive patients with chest pain suggestive of ischaemic heart disease were enrolled in this prospective study.
Interventions: Patients underwent an additional transthoracic echocardiogram in addition to the clinical stress-rest MPS.
Main outcome measure: To compare the results of reading stress only MPS with standard reading of both stress and rest MPS in patients with normal LV function on resting 2D echocardiography.
Results: Both readers agreed in calling the studies normal or abnormal in 82 out of 94 patients (kappa = 0.6). In 12 patients there was a minor disagreement between the two readers. There was good agreement in assessing the size of the perfusion defects (kappa = 0.63).
Conclusions: In patients with normal resting LV function resting MPS could be avoided even in the presence of a perfusion defect on the stress MPS scan. This should lead to decreased radiation doses and higher throughput. These findings warrant further investigation in a larger clinical trial.
94
Factors influencing the level of apical LV myocardial perfusion tracer uptake in SPECT/CT attenuation correction: A normal population study
D. Doumit Daou1; C. Meyer1; O. Kotbi1; F. Amegassi1; C. Coaguila2; M. Tawileh1
1APHP, Cochin Hospital, Department of Nuclear Medicine, Paris, France; 2Hospital Sud-Francilien, Corbeil-Essonnes, France
Purpose: Attenuation correction (AC) of myocardial perfusion SPECT allows better quantification of cardiac tracer uptake. In normal patients, the apical left ventricular (LV) tracer uptake with SPECT-AC is variable with frequently observed reduced relative tracer uptake as compared to filtered backprojection without AC. The factors influencing the level of LV apical tracer uptake with SPECT-AC are not well defined. In this study, we aimed to determine in normal patients the factors potentially influencing the level of LV apical tracer uptake with SPECT-AC.
Methods: Our study included 154 consecutive patients with no previously known CAD addressed for myocardial perfusion scintigraphy (MPI) and having clinically and electrically negative stress tests (exercise, dipyridamole, combined) and normal filtered back-projection (FBP) stress MPI (without AC). All patients had SPECT/CT MPI acquisitions (Myoview-Tc99m, Symbia, Siemens) allowing the reconstruction of both FBP (non-AC) and SPECT-AC. These were processed with QPS software and allowed the quantification of LV apical uptake (segment 17): seg17_FBP and seg17_AC. Stepwise regression analysis was used to determine the factors influencing the level of seg17_AC uptake: age, sex, weight, height, type of stress test, LV axis angle in the sagittal plane (angle_S, in degrees), LV axis angle in the transaxial plane (angle_T, in degrees), exercise work level (watts), maximal stress heart rate expressed as percent of age-predicted maximal heart rate, presence of coronary calcification on the CT part used for attenuation correction, and seg17_FBP.
Results: 40% of patients were male and mean age was Seg17_AC was much lower than seg17_FBP: 68.45 ± 7.02% (minimum = 49%; maximum = 87%) vs 83 ± 6.05% (minimum = 72%; maximum = 96%) (P < .0001). On stepwise regression analysis, seg17_AC was only correlated to angle_S (F = 82) and seg17_RPF (F = 74): seg17_CA = 16.301 + 0.559*seg17_FBP—0.406*angle_S (r = 0.729; P < .0001).
Conclusions: The level of normal apical LV tracer uptake with SPECT-AC depends on both its level on FBP and the angle of the LV in the sagittal plane.
95
Automatic segmentation of CT perfusion of the left ventricle
J. De Geer1; M. Gjerde1; E. Olsson1; A. Persson1; J.E. Jan E. Engvall1
1Linkoping University Hospital, Linkoping, Sweden
Purpose: To compare the average global blood flow value obtained by manual AHA-segmentation to that obtained by automated AHA-segmentation in dynamic myocardial perfusion.
Method: Eight patients with manifest cardiovascular disease were included in the study. CT images were acquired under adenosine-induced stress, using a dual source/dual energy CT scanner in single energy dynamic perfusion mode.
The wall of the left ventricle was manually segmented according to the AHA 17-segment model. Each segment (except segment 17) consisted of three sub-segments along the long axis. The blood flow value for each segment was taken as the sum of the values for each sub-segment divided by three (for segments 1-16). The average global blood flow value was taken as the sum of all segment blood flow values divided by 17.
The average global blood flow obtained by manual segmentation was compared to that obtained by using dedicated, automated software, using Student’s t-test.
Results: The average, manually obtained global blood flow value was 127 mL /100 g tissue/minute. The average, automatically obtained global blood flow value was 132.8 mL/100 g tissue/minute. The mean difference was −5, 8 or 4, 4%.
Conclusion: The use of automated segmentation resulted in a slightly higher average global blood flow value. However, the difference was small.
96
Evaluation of left and right ventricular ejection fraction and volumes from Gated Blood-Pool SPECT with new Cadmium-zinc-telluride (CZT) camera: Comparison with cardiac MRI
D. Goulon1; N. Piriou1; A. Pallardy1; K. Warin-Fresse1; M. Caza1; F. Kraeber-Bodere1; F. Valette1
1University Hospital of Nantes—Hospital Guillaume & Rene Laennec, Nantes, France
Objective: New cardiac CZT camera, widely more performant in resolution, dose exposure and acquisition time, has not been evaluated in gated blood-pool single-photon emission computed tomography (GBPS). GBPS with camera CZT was compared with cardiac magnetic resonance (CMR) for the measurement of left ventricular (LV) and right ventricular (RV) ejection fractions (EF) and volumes [end-diastolic volume (EDV) or end-systolic volume (ESV)] in a mixed population.
Methods: Ten successive patients (80% men; mean age: 48 ± 19 years) referred for various symptoms or heart diseases underwent a fast GBPS acquisition (9 minutes) with CZT camera and CMR. GBPS data were analyzed using fully automated gradient software. CMR images were acquired for both ventricles at the same time using a steady-state-free precession sequence and short-axis views. LVEF and RVEF and volumes were assessed with GBPS and CMR and were compared.
Results: We found no statistical difference between GBPS and CMR in the assessment of LVEF (P = .033) and RVEF (P = .769), who were correlated in regression analysis (r = 0.89 for LVEF; r = 0.633 for RVEF; all P < .001). Regarding biventricular volumes, there was no statistical difference between these 2 methods (P = .002 for LV EDV, 0.005 for LV ESV, 0.263 for RV EDV and 0.402 for RV ESV), but there were not significantly correlated (due to the low number of patients included).
Conclusion: GBPS with new camera CZT is a simple, faster and available technique that can assess biventricular EF and volumes with comparable results to CMR.
97
Interpretation of ischemia in myocardial perfusion scintigraphy by two computer aided diagnosis systems
E. Tragardh1; M. Lomsky2; L.B. Johansson2; S.E. Svensson1; L. Edenbrandt1
1Skane University Hospital, Clinical Physiology and Nuclear Medicine Unit, Malmo, Sweden; 2Sahlgrenska University Hospital, Department of Clinical Physiology, Gothenburg, Sweden
Purpose: Visual interpretation of myocardial perfusion scintigrams (MPS) is dependent on the knowledge of the physician, and subject to inter- and intra-observer variability. Inexperienced physicians could benefit from getting “second opinion” from a computerized interpretation. To compare the diagnostic performance for the detection of ischemia of two computer aided diagnosis software packages (EXINI heart 5.0 and PERFEX Emory Cardiac Toolbox 3.0) for interpretation of MPS.
Methods: 1052 consecutive patients, 499 (47.4%) men and 553 (52.6%) women, who underwent 2-day stress/rest 99mTc-sestamibi MPS were included. Patients were stressed using either maximal exercise or pharmacological test with adenosine. The gold standard was obtained from three physicians, with more than 25 years each of experience in nuclear cardiology, who evaluated all MPS images on the presence or absence of ischemia. The majority rule was applied in cases of disagreement. No quantitative results from software packages were available during this evaluation. Automatic processing was done using EXINI (artificial neural networks based) and PERFEX (rule based expert system) software packages.
Results: Ischemia was found in 257 patients according to gold standard. The sensitivity for detecting ischemia was 69.7% for EXINI and 62.6% for PERFEX (P = .045). The specificity was 93.1% for EXINI and 82.4% for PERFEX (P < .0001).
Conclusions: EXINI showed significantly higher sensitivity and specificity for the detection of ischemia compared to PERFEX. The difference in performance should be considered when software packages are used in clinical routine.
98
The impact of advanced reconstruction on myocardial image noise in rubidium myocardial perfusion PET
I.S. Ian Armstrong1; C.M. Tonge1; P. Arumugam1
1Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
Purpose: The benefit of advanced PET reconstruction algorithms, that include resolution modelling and time-of-flight, has been widely demonstrated in FDG oncology PET scanning. However, the assessment of these algorithms in myocardial perfusion PET is currently very limited. This study compared image noise in the left ventricular myocardium in rubidium cardiac PET using standard and advanced reconstruction algorithms.
Methods: Resting rubidium perfusion PET scans from 74 patients (mean [range] body mass index: 33.3 [20.8-55.8]; 34 male) that were reported as normal were used for analysis. Images were acquired on a Siemens Biograph mCT and reconstructed with the standard OSEM and advanced OSEM, which included resolution modelling and time of flight. As a measure of image noise, the coefficient of variation (COV) of pixel values was measured in polar plot data from the two sets of images. COV data were compared against a range of patient related factors—weight, body mass index, cross-sectional chest area, and size of the myocardium.
Results: The COV was overall found to be significantly lower (P < .001) when using the advanced reconstruction. The reduction in COV was correlated most strongly to patient weight, with the greatest reduction occurring at the highest weights. COV was greater in some cases with the advanced reconstruction, which was suspected to be due to subtle perfusion reductions becoming more apparent. COV was less dependent of either patient weight or BMI when using the advanced algorithm.
Conclusion: This study demonstrates the benefit of using advanced reconstruction in rubidium cardiac PET. The effect of patient size is less influential on image noise when using the advanced algorithm. Differences in image appearance are seen with subtle defects becoming more apparent, highlighting the importance of a clinicians’ understanding of the impact of moving from standard to more advanced PET reconstruction algorithms. Further evaluation using data with clinical follow up to assess the impact of image interpretation on patient management is needed.
99
Coronary vein anatomy; exploring the possibilities with preoperative CT evaluation for planning the left ventricular lead placement in cardiac resynchronization therapy
H. Markstad1; Z. Bakos2; E. Ostenfeld3; A. Roijer4; M. Carlsson3; R. Rasmus Borgquist5
1Lund University, Skane University Hospital, Department of Radiology, Lund, Sweden; 2Lund University, Skane University Hospital, Department of Arrhythmias, Lund, Sweden; 3Lund University, Skane University Hospital, Department of Clinical Physiology, Lund, Sweden; 4Lund University, Skane University Hospital, The Clinic for Heart Failure and Valvular Disease, Lund, Sweden; 5Lund University Hospital, Department of Arrhythmias, Lund, Sweden
Purpose: To introduce a novel way of evaluating the coronary sinus vein anatomy, focusing on relevance in the context of left ventricular (LV) lead implantation in cardiac resynchronization therapy (CRT). Accumulating evidence suggests that targeting specific segments with late mechanical or electrical activation in the left ventricle is superior to non-targeted LV lead placement. It is therefore less relevant to discuss the number of veins in preoperative evaluation, but more appropriate to describe which segments can be reached with an LV electrode.
Methods: 23 patients (70 ± 9 years, 78% male, 86% with LBBB, 57% with ischemic CMP, 91% ≥ NYHA 3) eligible for CRT were included consecutively and evaluated prospectively. Cardiac CT scan was performed using a prospective (39%) or retrospective (61%) low-dose protocol. For identification of venous branches in the different cardiac segments, the standard 17-segment bulls-eye plot of the left ventricle was used. To facilitate interpretation, MPR-reconstruction was performed providing a standard short axis view of the left ventricle (LAO 45° projection). The AV plane was identified and in the long axis projection (RAO 45°) the ventricle was divided into basal, mid, apical and apex segments.
Results: The average DLP was 416 ± 217 mGycm and contrast volume was 99 ± 21 mL. All patients had acceptable image quality for detection of clinically relevant venous branches ≥1.5 mm in diameter. On average, 2.5 vein branches were identified excluding the main stems of the middle and the great cardiac veins in the interventricular grooves. An average of 3.9 segments had a suitable vein branch of sufficient diameter. Veins with very short length (<2 cm) or with very acute angles (>150°) from the main stem were excluded as clinically not relevant for lead placement. For all patients, a bulls-eye plot was constructed indicating which segments had suitable veins. Patients with ischemic cardiomyopathy (CM) had 4.1 segments compared to 3.8 for patients with dilated CM (P = n.s). Male patients had 3.8 segments compared to female patients with 4.2 (P = n.s.).
Conclusions: Using cardiac CT preoperatively for CRT is feasible with low radiation doses and sufficient image quality to identify clinically relevant vein branches in the coronary sinus. There are no significant differences between different heart failure etiologies or sex. Presenting data in a bulls-eye plot allows for comparison with echocardiographic data regarding segmental activation times, facilitating a comprehensive preoperative evaluation for optimal LV lead electrode placement.
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Novel method of attenuation correction of CZT camera myocardial perfusion images with CT scans from stand-alone hybrid SPECT/CT
M.A. Dziuk1; S. Piszczek1; A. Mazurek1; A. Budzynska1
1Military Institute of Medicine, Nuclear Medicine Department, Warsaw, Poland
Purpose: Dedicated cardiac CZT scanners are more frequently used for myocardial perfusion SPECT imaging. Not all CZT devices are coupled with the CT. Some imaging centers are equipped with both CZT and standard SPECT/CT cameras. The goal of this study was to assess whether attenuation correction of CZT images can be performed with the CT scans (CTAC) taken from the stand-alone SPECT/CT device.
Methods: We retrospectively estimated 39 patients (24 men, 15 women) in the age of 51-73 years with perfusion abnormalities mostly located in inferior wall and therefore attenuation correction was performed. Three patients had a history of inferior MI. SPECT myocardial perfusion acquisitions were obtained from CZT gamma camera and CT scans from hybrid SPECT/CT scanners. Subsequently SPECT and CT acquisitions were fused with QGS/QPS dedicated software.
33 stress and 21 rest studies before and after attenuation correction were assessed. We performed SPECT imaging 60 minutes after radiotracer injection, mean 99mTc-sestamibi dose was 9.2 mCi (8-10.4 mCi). CT scans were obtained on the day of the SPECT study. Myocardial perfusion was evaluated on the long axis slices before and after CTAC—semiquantitative evaluation was performed in basal, mid and apical segments of inferior and lateral walls as well as in apex with 5-graded scale. We also performed visual analysis for presence or absence of diaphragmatic attenuation.
Results: In 51 from 54 studies there was perfusion improvement in at least 1 segment of inferior wall after CTAC. The most frequent variability was achieved in basal and the least in apical segment of inferior wall, we observed image improvement in 88% (P< 0.05) and 11% segments after CTAC, respectively. There were also image improvements in basal (50%, P< 0.05) and apical (6%) segments of lateral wall. Conversely, image impairment was observed in apex in 50% studies. In visual analysis we revealed perfusion abnormalities typical for diaphragmatic attenuation in 50% studies, all of the patients were men. Beside three patients, who had had myocardial infarction of inferior wall, no significant left ventricular contractility abnormalities were observed: ESV 10-73 mL (median 35 mL), EDV 58-152 mL (median 108 mL), EF 44-85% (median 68%).
Conclusions: The method of attenuation correction presented here is feasible and promising in the interpretation of inferior wall perfusion abnormalities. A new artifact, specific to CZT scanner, the basal lateral wall attenuation defect was found in half of scans.
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When prone SPECT imaging is needed to exclude diaphragmatic attenuation, should we gate the study?
A.A. Sadek1; M. Mohamed Mandour Ali1; S. Sharara2; D. Helmy3; E. Hegazy3; A.H. Allam1;
1Al-Azhar University, Department of Cardiology, Cairo, Egypt; 2Ain Shams University, Cairo, Egypt; 3Alfa scan radiology center, Cairo, Egypt
Background: Male patients undergoing myocardial SPECT imaging are frequently imaged in the prone position following supine imaging to exclude diaphragmatic attenuation. As gated SPECT imaging allow evaluation of ejection fraction (EF), end diastolic volume (EDV) and end systolic volume (ESV) we thought that comparing these functional indices in the prone vs (Vs) supine position could answer the question whether gating both studies is needed.
Methods: We compared EF, EDV and ESV obtained from a commercially available software QGS, in 54 male consecutive patients undergoing routine stress gated supine SPECT followed by gated prone SPECT imaging.
Results: EF 59 ± 6 vs 59.7 ± 5.4% P = .096 and ESV 39.8 ± 13.7 vs 40.8 ± 13.1 mL P = .089 were not significantly different for prone vs supine imaging respectively. While, EDV 94.7 ± 21.1 vs 99.5 ± 21.5 mL was significantly lower in the prone position compared to the supine position (P < .000).
Conclusion: EDV obtained in the prone position is different compared to the supine position. Hence, when prone SPECT imaging is needed, the study should be gated.
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Accurate estimation of radiation exposure in patients undergoing Tc99m-sestamibi myocardial perfusion tests
M. Massimiliano Szulc1; A.M. Collins1; F.J. Wong1
1Weill Cornell Medical College, Greenberg Division of Cardiology, New York, United States of America
Hypothesis: Published data of radiation exposure in patients undergoing a nuclear myocardial perfusion (MP) stress test may be significantly overestimated. Radiation exposure in these patients is commonly calculated on the amount of activity in the isotope syringe as opposed to the actual amount of activity received by the patient. Although it is the standard practice to assay the amount of activity prior to injection, it is not standard to assay the amount of activity in the syringe after injection. We hypothesized that there may be significant amounts of residual activity.
Method: We analyzed the 389 dose syringes used to inject 201 patients undergoing SPECT MP stress tests at our institution. All patients underwent either one day (low dose rest/high dose stress) or two day (high dose rest/high dose stress) imaging protocols with Tc99m Sestamibi. The activity in the syringe containing Tc99m Sestamibi before injection was assayed using a dose calibrator and the activity and time of assay recorded. Each patient was injected for either a rest scan or a stress scan and the time of injection was recorded. The syringe was then re-assayed in the dose calibrator and the residual activity and time of assay recorded. The residual activity was subtracted from the pre-injection activity to determine the actual activity injected into the patient. The pre-injection activity and the activity actual injected were multiplied by the Tc99m Sestamibi ICRP dose factor to estimate the nominal and actual effective doses, respectively.
Conclusion: Based in our analysis there is a significant residual activity remaining in the syringe after injection of Tc99m Sestamibi. Therefore, calculation of radiation exposure using the activity in the syringe prior to administration overestimates the actual exposure. As we are looking for ways to reduce the amount of dose a patient receives from MP imaging procedures, we should be aware of exactly how much activity the patients have received, in order to precisely calculate their exposure. This is especially important if one is calculating total cumulative dose that a patient receives from a MP study, as part of the patient’s cumulative radiation burden from multiple imaging procedures.
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Quantification of myocardial blood flow with Tc-99m tetrofosmin dynamic SPECT using a semiconductor detector
Y. Yasuyuki Takahashi1; M. Miyagawa2; H. Ishimura2; Y. Nishiyama2; T. Mochizuki2; K. Murase3
1Gunma Prefectural College of Health Sciences, Maebashi, Japan; 2Ehime University, Toon, Japan; 3Osaka University, Suita, Japan
Purpose: SPECT systems based on the cadmium-zinc-telluride (CZT) solid-state semiconductor detector have better energy resolution and sensitivity than conventional Anger type systems. Due to improved sensitivity, dynamic SPECT acquisition with good time resolution of a few seconds has become possible. However, acquisition conditions and kinetic analysis in dynamic SPECT has remained controversial. In this study, we attempted the quantification of myocardial blood flow using a semiconductor detector.
Methods: A semiconductor detector, Discovery NM 530c (GE Healthcare corp.) was used. Dynamic SPECT method was carried out for the initial 10 minutes after bolus injection of 259 MBq of Tc-99m tetrofosmin. We compared analytical parameters based on window width, slice thickness, and acquisition times.
In the process of kinetic analysis, the image transformation process of dynamic data used for compartment analysis includes the creation of a transaxial image by multi-file (10 seconds), unit time (per second) image transformation, single-file transformation, and format conversion (from 70 matrix to 64 matrix). The time activity curve of our dynamic SPECT data was conducted as described below. The left ventricle was segmented into the left ventricle myocardial wall and the left ventricle lumen. Blood counts within the former, converted to activity measures served as the output function, whereas blood counts within the lumen converted to activity measures served as the input function. Using compartment analysis (creation of myocardial blood flow, MBF, Transracial data), K1 (unidirectional transfer constant) was calculated by the 3 compartment, 3 parameter model and the 2 compartment model. The K1 to MBF conversion formula was approximated by the 5th polynomial. The Bull’s eye map of MBF (mL/g/minutes) and myocardial perfusion reserve (MPR) is displayed.
Results: Window width variations between 140.5 keV ± 5% to 10% and 15% yielded a count rate increase by a factor of 1.2 and 1.35 respectively. The data was examined with a slice thickness of 4 and 8 mm. The accuracy of the input function on TAC depended and preferred SPECT images consisted of a slice thickness of 4 mm. The kinetic-analysis condition leading to increased accuracy consisted of 140.5 keV ± 10% window width, with a slice thickness of 4 mm, and an acquisition time of 10 seconds.
Conclusion: Extremely high-time-resolution dynamic SPECT using a semiconductor detector is possible. The kinetic analysis yielded a myocardium time activity curve with a clear accumulation process. Moreover, the quantification of myocardial blood flow with Tc-99m tetrofosmin was stabilized.
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Simultaneous ECG-gated cardiac PET of multiple mice in a single scan: A feasibility study
I. Ichiro Matsunari1; H. Aoki2; W. Fujita2; Y. Miyazaki1; K. Kajinami1
1Medical & Pharmacological Research Center Foundation, Hakui, Japan; 2Kanazawa Medical University, Kanazawa, Japan
Purpose: Although ECG-gated cardiac PET of small animals is promising for simultaneous assessment of a molecular process such as glucose metabolism and function, it can usually image only one single animal/scan. The purpose of this study was to develop a preclinical PET system, which enables simultaneous ECG-gated acquisition of three mice in a single scan.
Methods: The system was based on a commercially available small animal PET/CT scanner (Triumph II, Gamma-Medica) with an increased bore size of 15 cm in diameter. A custom made animal bed along with instruments for anesthesia lines for 3 mice was also developed. ECG signals were processed using a multi-channel ECG-triggering system (SAII). For feasibility study, we used 6 mice (ddY, body weight 38-45 g) with myocardial infarction created by ligation of left coronary artery. Approximately 40-60 MBq of FDG was injected (i.p.) 30 minutes after intra-peritoneal injection of glucose and insulin to stimulate myocardial FDG uptake. An ECG-gated acquisition of 3 mice were performed in list-mode for 20 minutes with ECG-leads attached to each mouse (3 mice scan). After completion of the 3 mice scan, each mouse was set-up on a normal bed for single mouse, and was scanned one-by-one (single mouse scan). The 3 mice scan data were reconstructed for each mouse using the ECG-signal of that mouse, resulting in 3 data sets. The single mouse scan data were reconstructed normally using ECG-gating. End-diastolic (EDV), end-systolic volumes (ESV), and left ventricular ejection fraction (LVEF) were calculated using MunichHeart software.
Results: The EDV, ESV, and LVEF could be obtained for each mouse using the 3 mice scan data. As compared to the single mouse scan, the 3 mice scan tended to underestimate left ventricular volumes (EDV: 51 ± 8 vs 59 ± 8 μL, P = .07; ESV: 22 ± 7 vs 28 ± 9 μL, P < .05), and to overestimate LVEF (58 ± 11 vs 53 ± 12%, P < .01) probably because of larger distance from the center and thereby worse spatial resolution in the 3 mice scan. However, there was a significant correlation of LVEF between the 3 mice and single mouse scan (r = 0.93, P < .01).
Conclusions: Although more validation is necessary, our preliminary results indicate that simultaneous ECG-gated PET acquisition of 3 mice is feasible, and may facilitate a high throughput cardiac imaging in animal research.
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Monday 6 May, 2013, 14:00–18:00 Poster Area
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Gender differences in myocardial blood flow with Regadenoson dynamic Rubidium-82 PET/CT
S. Suman Tandon1; J. Moody2; B.C. Lee2; A.V. Srivastava3; R. Fazzone-Chettiar4; E.P. Ficaro5; A.J. Sinusas1;
1Yale University School of Medicine, New Haven, United States of America; 2INVIA Medical Imaging Solutions, Ann Arbor, United States of America; 3University of California San Francisco, School of Medicine, Fresno, United States of America; 4Yale New Haven Hospital, New Haven, United States of America; 5University of Michigan, Ann Arbor, United States of America
Purpose: This study evaluates the impact of gender on myocardial blood flow (MBF) dynamics in patients undergoing routine evaluation for myocardial ischemia with Regadenoson stress/rest Rb-82 PET/CT.
Methods: 91 women and 59 men referred for a clinically indicated Regadenoson stress/rest dynamic Rb-82 PET/CT without perfusion defects formed the study cohort. Absolute MBF and myocardial vascular resistance (MVR) were calculated at rest and during Regadenoson stress using factor analysis. Linear regression analysis was performed to evaluate the relationship between global stress and rest MBF and cardiovascular (CV) risk factors.
Results: Resting heart rate (HR), systolic blood pressure (SBP) and rate pressure product (RPP) were similar between women and men, however, women had a higher peak HR (95 ± 17 bpm vs 90 ± 16 bpm, P = .037) and RPP (12679 ± 3332 vs 11418 ± 3032, P = .02) with Regadenoson stress. Women had significantly higher rest global MBF without RPP correction (1.10 ± 0.35 mL/g/minute vs 0.83 ± 0.26 mL/g/minute, P < .0001) and with RPP correction (1.13 ± 0.38 vs 0.86 ± 0.27 mL/g/minute, P < .0001). Regadenoson-induced hyperemic MBF was significantly higher in women (2.51 ± 1.00 vs 1.85 ± 0.76 mL/g/minute, P < 0.0001) and RPP correction for stress MBF did not alter the findings. No significant difference was noted in coronary flow reserve (stress MBF/rest MBF RPP corrected) (2.31 ± 0.87 women vs 2.26 ± 0.93 men). Prevalence of CV risk factors [age, body mass index (BMI), hypertension, hyperlipidemia, diabetes, tobacco use, family history of coronary artery disease], coronary artery disease and coronary calcium were not significantly different between genders. Regression analysis using the above mentioned covariates showed gender and BMI to be the strongest predictors of hyperemic MBF (adjusted mean difference in flow between women and men 0.70, P < .0001) and rest MBF (adjusted mean difference in flow between women and men 0.28, P < .0001). Gender remained a significant predictor of hyperemic and rest MBF even after adjusting for BMI.
Conclusion: Gender is an independent strong predictor of Regadenoson-induced hyperemic and rest MBF in patients undergoing Regadenoson dynamic Rb-82 PET/CT in a routine clinical setting. Although the risk factor profile and coronary flow reserve were similar between genders, women had a significantly higher resting blood flow and hyperemic response to Regadenoson. Correction for gender and BMI may need to be considered when establishing reference limits for myocardial flow, and when interpreting hyperemic blood flow responses.
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Regadenoson in Europe: First-year experience of regadenoson stress combined with submaximal exercise in patients undergoing MPS
M. Brinkert1; E. Reyes1; S. Walker1; K. Latus1; R. Mizumoto1; Q. Nkomo1; K. Standbridge1; K. Wechalekar1; S.R. Underwood2
1Royal Brompton Hospital, London, United Kingdom; 2Royal Brompton and Harefield NHS Trust Hospital, Imperial College London, London, United Kingdom
Purpose: Regadenoson is a selective adenosine A2a receptor agonist that was developed to avoid the side effects associated with the unselective adenosine receptor agonists. Since approval in Europe in 2011 regadenoson has become the default form of stress at our institution. The aim of this study was to assess its side effect profile and tolerability in consecutive patients undergoing MPS between July 2011 and July 2012.
Methods: We studied 1764 consecutive patients referred to our institution for clinically indicated MPS. Clinical, stress and imaging data were recorded prospectively and analysed using the Excel data analysis toolpak and SPSS. Symptoms during stress were defined as mild, moderate or severe. An adverse event was defined as any symptom that persisted for more than 30 minutes or that required investigation or treatment.
Results: Of 1764 patients, 1581 (90%) received regadenoson combined with sub-maximal exercise unless contraindicated. Symptoms were common (63%) but transient and well-tolerated. The severity of symptoms was recorded in most of the patients as mild (84%). Dyspnoea (36%) and chest discomfort (12%) were the commonest side effects. Adverse events were reported in 8 (0.5%) patients, 7 of these thought to be vaso-vagal. Three events were moderate and two severe, the latter with sinus arrest and asystole lasting 30 and 10 seconds and requiring CPR. All patients recovered fully without sequelae. There were no deaths, myocardial infarction or hospital admissions. Two-hundred and six asthma/COPD patients (12%) received regadenoson without bronchospasm or any other major side effect.
Conclusion: We have studied 1764 stress tests for MPS over a twelve-month period in order to assess the symptom profile of regadenoson in the largest European cohort to date. Regadenoson combined with exercise is well tolerated, notably also in patients with asthma/COPD. The majority of adverse events were vaso-vagal episodes without sequelae. There is no clear direct mechanism by which regadenoson might cause vaso-vagal syncope.
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A comparative study of the safety of Regadenoson in patients with mild or moderate asthma and chronic obstructive pulmonary disease
C. Carlos Salgado1; E. Sanchez De Mora1; A. Jimenez-Heffernan1; J. Lopez-Martin1; C. Ramos1; I. Ynfante2
1Hospital Juan Ramon Jimenez, Department of Diagnostic Imaging, Huelva, Spain; 2Hospital Juan Ramon Jimenez, Department of Pharmacy, Huelva, Spain
Purpose: We aim to assess the safety of Regadenoson (REG), a selective agonist of A2A adenosine receptors, in subjects with mild or moderate asthma or chronic obstructive pulmonary disease (COPD) referred for myocardial perfusion imaging (MPI) and to compare the side effect profile. REG is not marketed in Spain, so the Spanish Agency of Medicines and Health Products (AEMPS) must authorize its use on an individual patient basis.
Methods: 82 patients (60.98% male, mean age 67.7 ± 11.5 years, range 31-87 years) were studied. Group A comprised 48 COPD and Group B 34 asthma patients respectively. Stress was 4 minutes of low-level exercise with bolus intravenous injection of 0.4 mg REG at 1.5 minutes and 99mTc-MPI agent injection at 2 minutes. Patient demographics, past medical history, treatment, clinical symptoms during stress and changes in blood pressure were evaluated. Continuous variable are expressed as mean ± SD and compared using the paired Student’s t-test, whereas Chi-square testing was used for comparison of dichotomous variables.
Results: Both groups were comparable (P = ns) with regards to age, gender, hypertension, dyslipidemia and medication type with the exception of anticholinergic use (Group A 62.5% vs Group B 23.5%, P < .001).
Asthmatic patients showed a higher incidence of feeling hot (Group A 10.42% vs Group B 29.41%, P = .028) and dry mouth sensation (Group A 12.50% vs Group B 35.29%, P = .014). On the other hand COPD patients had a higher incidence of dyspnea (Group A 39.58% vs Group B 14.71%, P = .015). There was no difference between both groups in the incidence of the following side effects: Fatigue (41.67% vs 58.82%), dizziness (18.75% vs 26.47%), chest discomfort (8.33% vs 11.76%), nausea (6.25% vs 5.88%), headache (4.17% vs 14.71%) and flushing (2.08% vs 5.88%). Side effects began soon after dosing and resolved within approximately 3-5 minutes. We didn’t observe significant changes in blood pressure following REG administration (mean baseline systolic pressure was 152.51 mmHg ± 29.88 vs 158.48 mmHg ± 30.89 following REG).
Conclusion: REG combined with low-level exercise shows a good safety profile in our series of COPD and asthma patients undergoing MPI. REG was well tolerated by all patients; with dyspnea, feeling hot and dry mouth sensation showing differences between groups.
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Is regadenoson safe in patients on N-acetylcysteine undergoing stress MPS?
E. Eliana Reyes1; S. Walker1; R. Mizumoto1; Q. Nkomo1; S.R. Underwood1; K. Wechalekar1
1Royal Brompton Hospital, London, United Kingdom
Background: The safety profile of regadenoson is similar to that of other coronary vasodilators with no cardiac death or non-fatal myocardial infarction reported in the largest clinical trials. Life-threatening events appear unlikely after regadenoson. However, an episode of asystole following regadenoson injection was published recently (Grady EC. J Nucl Cardiol 2011;18:521) and a potential interaction between regadenoson and N-acetylcysteine (NAC, an inhibitor of adenosine deaminase) in patients with interstitial lung disease (ILD) was suggested. We investigated the tolerability and safety profile of regadenoson in patients with ILD on NAC undergoing clinically indicated MPS.
Methods: Regadenoson was approved for clinical use at our institution in July 2011. Clinical, stress, graded symptoms and imaging data were collected prospectively as part of a departmental patient database. Symptoms during stress were recorded and classified as mild, moderate or severe. An adverse event was defined as any symptom that persisted for more than 30 minutes or required investigation or treatment.
Results: Between July 2011 and July 2012, out of 1764 patients who underwent stress MPS, 1581 (90%) received regadenoson and of these 10 patients were on NAC at the time of the test (male, n = 7; mean ± SD age, 64 ± 12 years). The main indication for stress MPS was chest pain (70%) followed by worsening dyspnoea. Regadenoson (400 mcg) was coupled with exercise in 6 patients. Side effects were reported in 7 patients (dyspnoea, n = 6; abdominal pain, n = 2; and light-headedness, n = 1). All side effects were mild to moderate in severity and well-tolerated. There were no complications or adverse events. The side effect profile and safety was similar to that of the entire patient population. Three out of ten MPS studies were reported as abnormal with all showing mild myocardial ischaemia.
Conclusion: In a small series of ILD patients on NAC undergoing stress MPS, regadenoson administration was not associated with an increased risk of adverse events or severe side effects.
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Impact of diabetes mellitus on iodine-123 meta-iodobenzylguanidine (I123MIBG) cardiac uptake in patients with heart failure
S. Stefania Paolillo1; G. Rengo2; G. Pagano1; T. Pellegrino3; A. Boemio3; E. Attena4; D. Leosco1; B. Trimarco1; A. Cuocolo3; P. Perrone Filardi1
1Department of Internal Medicine, Cardiovascular and Immunological Sciences, Federico II University, Naples, Italy; 2Division of Cardiology, “Salvatore Maugeri” Foundation—IRCCS—Institute of Telese Terme (BN), Telese Terme, Italy; 3University of Naples Federico II, Department of Biomorphological and Functional Sciences, Naples, Italy; 4Department of Cardiology Fatebenefratelli Hospital, Naples, Italy
Purpose: Patients with heart failure (HF) and diabetes mellitus (DM) have worse prognosis compared to HF patients without DM. Impaired sympathetic nervous system activity has been demonstrated in DM patients without HF and correlated to worse prognosis but few data are available on the effect of DM on cardiac sympathetic nerve activity in patients with HF. The aim of the present study was to assess cardiac sympathetic nerve activity in HF patients with and without DM.
Methods: We evaluated 75 patients with severe HF (left ventricular (LV) ejection fraction 31.03 ± 7.15) with and without DM. HF patients underwent Iodine-123 meta-iodobenzylguanidine (I123MIBG) scintigraphy from which early and late heart to mediastinum (H/M) I123MIBG ratio and washout rate were calculated. Clinical, echocardiographic and biochemical data, including serum NT-proBNP levels and HbA1c, were measured. Patients were assigned to two groups with (n = 37) and without DM (n = 38).
Results: The two groups were matched for cardiovascular risk factors and drug therapy, demography, HF etiology, LV systolic function, NYHA functional class, and serum NT-proBNP. I123MIBG early H/M ratio (1.65 ± 0.21 in DM vs 1.75 ± 0.21 in non DM patients; P < .05) and late H/M ratio (1.46 ± 0.22 in DM vs 1.58 ± 0.24 in non DM patients; P < .03) were significantly lower in DM compared to non DM patients. In all patients a significant inverse correlation between early H/M ratio and HbA1c levels (Pearson = −0.473, P = .001) and between late H/M ratio and HbA1c levels (Pearson = −0.382, P = .001) was observed. In diabetic patients, by multivariate analysis, HbA1c and LV ejection fraction remained the only significant predictors of early H/M ratio, whereas HbA1c remained the only significant predictor of late H/M ratio. No correlation between either early or late H/M ratio and HbA1c was found in non diabetic patients.
Conclusions: DM is associated to reduced cardiac sympathetic activity in HF patients, and the status of glycemic control over the last 1-2 months correlates to I123MIBG uptake. These findings may contribute to explain the adverse prognostic impact of DM in patients with HF.
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Correlation between cardiac sympathetic function, gated SPECT and phase histogram parameters in patients with systolic heart failure
S. Santiago Aguade-Bruix1; G. Romero-Farina1; M.N. Pizzi1; C. Espinet Coll1; J. Perez-Rodon1; E. Galve-Basilio1; J. Candell-Riera1; J. Castell-Conesa1
1Hospital Vall d’Hebron, Barcelona, Spain
Purpose: Cardiac sympathetic function plays an important role in the regulation of left ventricular function and the pathophysiology of LV dysfunction. The aim of this study was to evaluate the correlation between early and late heart-to-mediastinum ratio (H/M ratio) with 123I-metaiodobenzylguanidine (123I-MIBG) and left ventricular (LV) end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), peak phase (PPh), standard deviation (SD), bandwidth (B), skewness (S) and kurtosis (K) of phase histogram.
Methods: 37 consecutive patients (62.9 ± 13 years; 53.4% women) with heart failure and LVEF < 50% were included. Same day early (15 minutes) and late (4 hours) 123I-MIBG and followed by 99mTc-Tetrofosmin gated-SPECT was performed. Early and late 123I-MIBG H/M ratio, gated SPECT (EDV, ESV, and EF), and histogram phase (PPh, SD, B, S, and K) parameters were related by Pearson correlation coefficient statistics and linear regression.
Results: All patients had an abnormal early and late H/M ratio. There were a significant differences (Wilcoxon test, Z: −3.426; P = .001) between early (mean 1.4 ± 0.17) and delayed (mean 1.3 ± 0.20) H/M ratio. Gated-Spect and phase analysis results in Table 1.
Conclusions: In patients with systolic heart failure, early and late 123I-MIBG H/M ratio are related not only with LV volumes and EF but also with phase histogram parameters except peak phase.
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The incremental prognostic value of cardiac 123i-mIBG scintigraphy in predicting serious arrhythmic events in heart failure patients
F. Al Badarin1; A. Wimmer1; K. Kennedy1; T. Bateman1;
1Mid America Heart Institute, Kansas City, United States of America
Purpose: Whereas implantable cardiac defibrillators (ICD) are considered the mainstay of sudden cardiac death (SCD) prevention in patients with heart failure (HF), the current paradigm for selecting ICD candidates is fraught with limitations. The shortcomings of left ventricular ejection fraction (LVEF) in accurately assessing arrhythmic risk in HF patients underscore the need for additional risk assessment tools in this population. Prior studies have shown the role of cardiac mIBG scintigraphy in predicting life-threatening arrhythmias in HF patients. However, existing literature focused mainly on identifying HF patients at higher risk for serious arrhythmias. Moreover, little is known about the incremental benefit of combining mIBG imaging with other clinical, ECG and imaging variables in improving assessment of arrhythmic risk in this population. Accordingly, we examined the incremental value of mIBG imaging in predicting life-threatening arrhythmias among patients with LVEF < 35%.
Methods: Using data from the ADMIRE-HF study, we identified 778 patients with LVEF < 35% and NYHA II-III symptoms who did not have an ICD at the time of enrollment. At baseline, all patients underwent early and late anterior planar imaging following injection of 123I-mIBG (AdreView, GE Healthcare). Late heart/ mediastinum ratio (HMR) was determined as a measure of relative myocardial sympathetic nerve activity. In addition, 99mTc-Tetrofosmin (MyoView, GE Healthcare) resting myocardial perfusion imaging was performed. Patients were followed prospectively for a median of 17 months. The endpoint for this analysis was the first occurrence of serious arrhythmic events (SAE); a composite of SCD, appropriate ICD therapy, resuscitated cardiac arrest or sustained ventricular tachycardia. Multivariate regression was used to determine independent predictors of SAE. Integrated discrimination improvement (IDI) was assessed after inclusion of HMR to a multivariate model that includes other SAE predictors.
Results: SAE occurred in 54 patients (6.9%). After adjusting for age, LVH, BNP and summed-rest score, independent predictors of SAE, were HMR < 1.6 (HR 3.48, 95% CI [1.52-8], P .02), LVEF < 25% (HR 1.97, 95% CI [1.28-3.05], P .04) and SBP < 120 (HR 1.19, 95% CI [1.03-1.39], P .02). Combining HMR with EF and SBP resulted in 45% improvement in the ability to predict SAE (relative IDI 45%, P = .03).
Conclusion: HMR provides incremental prognostic value beyond SBP and LVEF. Knowledge of findings on mIBG imaging helps identify higher- and lower-risk patients among those with LVEF < 35%.
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123I-mIBG Scintigraphy for the assessment of cardiac sympathetic innervation and the relationship to cardiac autonomic function in healthy adults using standardized methods
O. Omar Asghar1; P. Arumugam2; I. Armstrong2; U. Alam1; C. Miller3; M. Schmitt3; S.G. Ray3; R.A. Malik1;
1Univeristy of Manchester, Cardiovascular Research Group, Biomedical Sciences, Manchester, United Kingdom; 2Department of Nuclear Medicine, Central Manchester Foundation Trust, Manchester, United Kingdom; 3University Hospitals of South Manchester NHS Trust, Wythenshawe Hospital, Manchester, United Kingdom
Background: 123I-mIBG scintigraphy has been proposed as an independent prognostic indicator for lethal arrhythmic events and mortality in patients with heart failure. However, normal variations in regional and global innervation are not accurately established nor is their functional relevance clear. The purpose of this study was to quantitatively and qualitatively define global and regional cardiac sympathetic innervation and functional associations in healthy adults, according to recommended guidelines.
Methods: We performed 123I-mIBG scintigraphy and cardiac magnetic resonance imaging (adenosine stress and late gadolinium enhancement (LGE)) to exclude structural, functional and ischaemic heart disease in 15 healthy adults. Using planar and single photon emission computed tomography (SPECT) imaging, we assessed global uptake via the late heart mediastinum ratio (HMR) and sympathetic turnover by determining the washout rate (WR). Regional innervation was assessed semi-quantitatively using a 17 segment left ventricular model by grading tracer uptake according to a scale (0 = normal, 1 = mild, 2 = moderate 3 = severe). Cardiac autonomic function was assessed using established tests of heart rate variability.
Results: One subject was excluded due to structural heart disease. The remaining 14 participants (mean age 54.6 ± 5.3 years, M:F 9:5) had structurally (mean LV Mass 101 ± 25.4 g) and functionally (LVEF 61 ± 6.39%) normal hearts, with no evidence of previous myocardial infarction on LGE and no evidence of perfusion abnormalities on rest or stress MR. Mean late HMR was 1.73 ± 0.16 (1.37-2.08) and WR was 19.09 ± 7.63% (4.20-31.30). Tracer uptake was reduced in all subjects at the apex, apical anterior segment and the inferior wall, predominantly in the basal inferior, inferoseptal and inferolateral segments. HMR correlated with E:I ratio (−0.609, P = .035) and sympatho-vagal balance (LFa/RFa) (0.647, P = .023). WR did not correlate with any functional tests of sympathetic function.
Conclusion: Using standardized methodology for 123I-mIBG scintigraphy in a well-defined group of healthy adults, we confirm HMR values comparable with control data from the ADMIRE HF study. We also confirm a heterogeneous pattern of cardiac innervation affecting the inferior wall and apex. Although WR has wide variability, perhaps limiting its use as an additional prognostic marker, HMR is associated with indices of cardiac sympathetic a function suggesting it might not only be a useful prognostic marker but may also provide insight into the functional integrity of the cardiac autonomic nervous system.
Poster Session 2
New pharmaceuticals: PET, regadenoson and MIBG
Monday 6 May, 2013, 14:00–18:00 Poster Area
115
Association of global and segmental strain abnormalities in sarcoidosis patients with inflammation and scar by 18F-FDG PET
B. Tamarappoo1; T. Negishi1; K. Negishi1; R. Brunken1; T. Marwick1
1Cleveland Clinic, Department of Cardiovascular Medicine, Cleveland, United States of America
Background: Detection of subclinical cardiac sarcoidosis may be important in preventing arrhythmias and sudden death. Diagnosis of subclinical disease using echocardiography, PET and MRI can be challenging; however, global longitudinal strain (GLS), a highly sensitive measurement of altered left ventricular (LV) function, may be able to improve diagnostic accuracy. Our aim was to examine the relationship between GLS, segmental strain and myocardial inflammation or scar in patients with sarcoidosis.
Method: We identified patients with systemic sarcoidosis with an echocardiogram and 18F-FDG PET performed within 60 days at the Cleveland Clinic, between 2007 and 2012. Patients with cardiac surgery, valvular disease and coronary artery disease were excluded. Segments with inflammation and scar by PET were identified by a single observer. Global (GLS) and segmental longitudinal strain by echocardiography was quantified by an independent observer in blinded fashion. Abnormal segmental strain was defined as > −14%.
Result: Among 35 patients (age 51 ± 11, 60% male), 27 had scar, inflammation or both on 18F-FDG PET. GLS was normal in patients without scar or inflammation, −21.6 ± 2.7%. GLS was significantly reduced in patients with scar (−13.1 ± 4% P < .0001) and scar + inflammation (−12.8 ± 4.8% P < .0001) and unchanged in patients with inflammation alone (18 ± 3.9 P = .08). There was a strong correlation between GLS and the amount of scar (scar, r = 0.64 P < .0001; scar + inflammation; r = 0.72 P < .0001). The area under the receiver operating characteristic curve (AUC) for presence of scar by GLS was 0.881 (sensitivity 72.7%, specificity 92.3%) with a cut-off of −14.8%; and for scar, inflammation or scar + inflammation was 0.918 (sensitivity 85.7% specificity 85.7%) with a cut-off at −18.7%. AUC for detection of scar based on the number of segments with abnormal segmental strain was 0.832 for scar (sensitivity 68.2%, specificity 84.6%) with a cut-off of 4 abnormal segments and 0.895 for detection of scar, inflammation or both (sensitivity 67.9%, specificity 100%) with a cut-off of 3 abnormal segments. Segmental longitudinal strain was significantly increased in segments with scar or scar and inflammation compared to segments without abnormalities on PET (−11.9 ± 6.1% vs −18.4 ± 6.7% vs P < .001).
Conclusion: Myocardial scar and inflammation due to sarcoidosis detected by 18FDG PET are strongly associated with abnormal GLS measured by echocardiography. Further studies are required to examine the incremental value of GLS and segmental strain for the diagnosis of cardiac sarcoidosis.
116
Integrated Dual Exercise and Lexiscan (IDEAL): Differing effects on myocardial blood flow in normal and in abnormal PET
V. Lanka1; D. Vangala1; J. Bruyere1; M.F. Di Carli1; S. Sharmila Dorbala1;
1Brigham and Women’s Hospital, Boston, United States of America
Immediate post-exercise vasodilator stress may maximally vasodilate normal coronaries with minimal additional vasodilation of diseased vasoconstricted coronaries.
Objective: To test the hypothesis that exercise + vasodilator compared to vasodilator alone results in lower stress myocardial blood flow (MBF) in patients (Pts.) with defects and higher stress MBF in Pts. without defects.
Methods: Pts. with clinical PET (Rb82/ammonia, IV Regadenoson), underwent a repeat study in 2 weeks (Treadmill exercise + IV Regadenoson, L-exercise). MBF (mL/gm/minute) and global coronary flow reserve (CFR, stress/rest MBF) were computed.
Results: We studied 13 Pts. (age 60 ± 10 years, 54% females, 77% hypertension, 23% diabetes, LVEF 57 ± 11%). Stress hemodynamics were higher with L-exercise (Figure A). Stress MBF was lower with L-exercise only in Pts. with defects; Pts. without defects demonstrated a trend toward higher stress MBF (Figure B).
Conclusions: In this pilot study, stress MBF was lower with exercise + vasodilator in Pts. with perfusion defects. Exercise + vasodilator may be better than vasodilator alone to identify flow changes from coronary disease.
117
Usefulness of MDCT coronary angiography in the evaluation of patients after arterial switch operation for transposition of the great arteries
V. Silvestri1; B. Leonardi2; G. Pongiglione2; P. Toma’2; A. Secinaro2
1Catholic University of the Sacred Heart, Rome, Italy; 2Bambino Gesu Children’s Hospital, Rome, Italy
Background: The arterial switch operation (ASO) has become the surgical approach of choice for transposition of the great arteries (TGA). There is, however, an incidence of adverse sequelae (coronary stenosis, distortion of the pulmonary arteries, dilatation of the neoaortic root and aortic regurgitation) in some survivors. At present, cardiac catheterization is recommended. New CT scans are becoming a useful option to evaluate the congenital heart disease anatomy with acceptable radiation exposure and few risks.
Objective: To evaluate the clinical usefulness of MDCT angiography in the evaluation of coronary anatomy, besides the right and left ventricle outflow in pediatric patients after ASO for TGA.
Methods: At the Children’s Hospital, between May 2011 and July 2012, 24 asymptomatic children after ASO, 19 male (79%), mean age of 12.6 ± 6.8 years, underwent a CT. Examinations were performed on a 2nd generation dual-source CT scanner, using low-dose acquisition protocols (high-pitch spiral or sequential mode). We evaluated the coronary arteries in regard to rule out possible complication at the reimplantation site or at proximal vessel segments, such as looping, stretching, compression, kinking or stenosis. Multiplanar reformation (MPR), maximum intensity projection (MIP) and volume rendering (VR) were used for image interpretation. Image quality was expressed by a numerical value, according to a five points Likert scale from 5 (excellent), to 1 (inestimable), depending on vessel contrast and the presence/absence of motion or “stair-step” artifacts (the latter occurring in sequential examinations). Coronary angiography was reserved to the patients with coronary abnormalities on CT evaluation.
Results: Scanning time was short (approximately 0.25 seconds in high-pitch spiral mode) and acquisition was performed without sedation, with patients breathing freely. The average heart rate variability didn’t show to influence vessel evaluation on ostia and proximal segments, which were always assessable. The diagnostic quality of the images was from moderate to excellent (mean value 4.7) and the diagnostic confidence high. Mean radiation dose was 1.36 ± 1.37 mSv.
Conclusion: CT could be a valid alternative to coronary angiography in the follow up of pediatric patients after ASO. Latest generation of scanner make examination feasible even in patients with high cardiac frequency and non-cooperative, reducing radiation dose, risks related to anesthesia, hospitalization and the stress experienced by children and their family.
118
Myocardial perfusion imaging using dual-energy computed tomography: First experience
G. Gianluca Pontone1; D. Andreini1; E. Bertella1; S. Mushtaq1; E. Conte1; A.L. Bartorelli1; L. Grancini1; A.D. Annoni1; G. Ballerini1; M. Pepi1;
1University of Milan, Foundation Monzino (IRCCS), Center Cardiology, Department of Cardiology, Milan, Italy
Purpose: Dual-energy computed tomography (DECT) may allow improved quantitative analysis of myocardial CT perfusion (CTP) in comparison with single-energy CT by reducing the beam hardening. We present the first human case of stress-CTP using DECT.
Methods and Materials: A 61-year-old man was evaluated by stress-CTP with adenosine using DECT and compared with invasive coronary angiography (ICA). A new stress-CTP was repeated after coronary angioplasty and stent implantation (PCI + stent).
Results: The DECT showed chronic occlusion (CTO) of the left anterior descending artery (LAD) (Panel A-C, circle) with a perfusion defect in the anterior wall of the left ventricle after stress (Panel D-F, with arrow) involving 32 g of myocardial mass (18% of overall myocardial mass). The ICA confirmed the CTO of LAD that was treated by PCI + stent. A stress-DECT performed 3 day later showed a reduction of perfusion defect up to 2 g of myocardial mass corresponding to 1.2% of overall mass (Panel G-I, red arrow). The total amount of contrast agent and overall effective radiation dose for each DECT were 120 cc and 4.4 mSv, respectively.
Conclusions: This is the first human case in which DECT has been used for the quantitative analysis of perfusion defect.
119
Quantitative analysis of stress-rest myocardial perfusion SPECT using solid state gamma camera: Validation and usefulness to facilitate stress-only low-dose protocol
T. Tali Sharir1; M. Pinskiy1; V. Prochorov1; V. Gottfried1; A. Bojko1; K. Merzon1; M. Motro1
1Assuta Medical Center, Tel Aviv, Israel
Purpose: To validate quantitative analysis of myocardial perfusion imaging (MPI) acquired with a solid state technology having dedicated normal limits, and use it for standardized interpretation of stress only protocol.
Methods: Forty four patients with low likelihood of CAD and 86 patients with intermediate-high likelihood and perfusion defects underwent MPI using a solid state camera. MPI protocol comprised of stress (10 mCi)/ rest (25 mCi) Tc-99m sestamibi, 5 minutes stress supine acquisition, 3:20 stress prone and 3 minutes rest supine. Visual summed stress score (SSS) was determined using a 17 segment model (0-4 score) and converted to %SSS by dividing by 68. Quantitative %SSS and total perfusion deficit (TPD) were derived using a commercial software. Custom new normal limits (NNL) were developed for the new technology from data of another 30 females and 30 males with low CAD likelihood. Results of quantitative analysis using NNL were compared to those based on standard (commercial)normal limits (SNL) with visual %SSS as gold standard. Stress-only protocol was performed in 24 low CAD likelihood patients with NNL %SSS.
Results: Among patients with low pretest CAD likelihood mean stress NNL TPD was close to zero and significantly lower compared to SNL TPD (0.95% ± 0.99 vs 3.5% 1 ± 1.9, p4% (normalcy rate 100%), while 15 had TPD > 4% using SNL (normalcy rate 65.9%). Of the 44 patients 24 (54.5%) had a low-dose stress only protocol (10 mCi Tc-99m sestamibi, patient exposure < 3 mSv) with NNL SSS% ≤ 4% in all cases. Of these 24 patients only 7 (29%) had SNL TPD ≤ 4%. Among the 86 patients with intermediate-high likelihood quantitative %SSS was similar to visual %SSS using either NNL or SNL (NNL: 23.6% ± 11.6, SNL: 22.4% ± 11.0, vs visual: 21% ± 9.3, P = NS). Quantitative %SSS (both NNL and SNL) highly correlated to visual %SSS (R = 0.84 for both, P < 0.0001).
Conclusion: Quantitative analysis of solid state SPECT using custom normal limits and commercial software provided very high normalcy rate among patients with low CAD likelihood, and correctly detected the amount of perfusion abnormality among patients with intermediate-high likelihood. This standardized analysis may facilitate the use of low-dose, stress only protocol with very low patient radiation exposure (<3 mSv).
120
Angiographic coronary stenosis versus (15)O-water PET myocardial blood flow
A. Anders Thomassen1; P.E. Braad1; A. Johansen1; H. Petersen1; A. Diederichsen2; H. Mickley2; L.O. Jensen2; P. Thayssen2; B. Blomberg1; P.F. Hoilund-Carlsen1
1Odense University Hospital, Department of Nuclear Medicine, Odense, Denmark; 2Odense University Hospital, Department of Cardiology, Odense, Denmark
Purpose: To examine which of stress myocardial flow (MBF) and coronary flow reserve (CFR) determined by (15)-water-PET (PET) correspond most closely with diameter stenosis assessed by quantitative coronary angiography (QCA).
Methods: Twenty-three patients with a ≥40% QCA stenosis underwent baseline and adenosine stress PET. Baseline MBF measures were corrected for myocardial workload and stress MBF and CFR calculated in 17 standard AHA myocardial segments and reassigned to respective feeding vessels. If multiple stenoses, only the most severe stenosis was considered. Pearson’s correlation coefficients were calculated and compared using Fisher r-to-z transformation.
Results: A total of 35 QCA stenoses were identified with a mean diameter stenosis of 75% ± 18%, range 45-100%. Stress MBF and CFR in corresponding vascular territories were: 1.84 ± 0.78 and 1.86 ± 1.05 mL/minute/g, respectively. MBF was significantly correlated to QCA stenosis severity: r = −0.46, P = .006, whereas CFR was not, r = −0.28, P = .097. These two r values did not differ significantly, P = .42. In contrast, stress MBF and CFR were significantly correlated (C): r = 0.86, P < .001.
Conclusions: The correlation between anatomic and functional stenosis was poor, suggesting that the hemodynamic consequences of angiographically proven coronary stenoses should be examined by functional imaging like PET.
121
99mTc-HMDP and 99mTc-DPD have similar performance for the detection of cardiac involvement in patients with TTR-familial amyloid polyneuropathy
F. Francois Rouzet1; V. Algalarrondo2; R. Chequer1; L. Eliahou2; F. Hyafil1; I. Corman1; E. Sorbets1; D. Adams3; M. Slama2; D. Le Guludec1
1AP-HP—Hospital Bichat-Claude Bernard, Paris, France; 2AP-HP—Hospital Antoine-Beclere-University Paris-Sud, Clamart, France; 3AP-HP—Hospital Bicetre, Department of Neurology, French Reference Center for Familial Amyloidosis, Le Kremlin-Bicetre, France
Background: Familial amyloid polyneuropathy (FAP) is a severe hereditary disease, due to liver production of a genetic variant transthyretin (TTR) resulting in amyloidosis. Diphosphonate scintigraphy has been proposed as a diagnostic tool for TTR-related cardiac amyloidosis, so we compared the relative accuracy of radiolabelled hydroxymethylene diphosphonate (HMDP) and diphosphono-propanedicarboxylic acid (DPD) scintigraphy in this setting.
Methods and Results: We prospectively evaluated 50 consecutive patients with proven TTR-FAP. Cardiac involvement was assessed by EKG, echocardiography, right heart catheterization, 123I-MIBG scintigraphy, cardiac MRI, and classified as absent, moderate, or severe. Patients characteristics are presented in Table. Acquisitions were performed 3 hours (planar and SPECT) after i.v. injection of 740 MBq of tracer (HMDP in the first 24 patients). Myocardial uptake was visually scored on planar images (absent, moderate, or intense), and quantified (myocardium to lung ratio [MLR]) on tomographic slices. In patients with cardiac amyloidosis, 9/21 (43%) were positive with HMDP and 14/24 with DPD (58%; P = .4), all but one with severe forms. The main determinant of a positive scan was LV wall thickness assessed by echo, and MLR was correlated to relative wall thickness both with HMDP (r = 0.6; P = .05) and DPD (r = 0.6; P = .04). In patients without cardiac amyloidosis, none was positive whatever the tracer.
Conclusion: In TTR-FAP, diphosphonate scintigraphy was positive in about half of the patients with cardiac involvement, all but one with severe forms. The major determinant of tracer uptake was wall thickness. There was no significant difference in diagnostic accuracy between HMDP and DPD. Since it failed to detect moderate forms, diphosphonate scintigraphy seems unfit to be used as a screening tool, but mostly as marker of severity.
Study population
99mTc-HMDP (n = 24) | 99mTc-DPD (N = 26) | P value | |
|---|---|---|---|
Age (year) | 56 ± 14 | 61 ± 13 | .2 |
Sex (males) n (%) | 11 (46%) | 17 (65%) | .2 |
MET 30 n (%) | 17 (71%) | 18 (70%) | 1 |
Relative wall thickness (Echo) | 0.48 ± 0.20 | 0.49 ± 0.15 | .7 |
Cardiac involvement no/moderate/severe (n) | 3/8/13 | 2/9/15 | .9 |
Positive scan | 0/0/9 | 0/1/13 | >.4 |
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The assessment of myocardial blood flow in patients with cardiac X syndrome using positron emission tomography
D.V. Ryzhkova1; M.V. Kolesnichenko2; S.A. Boldueva2; I.S. Kostina3; S. Nesterov4
1Russian Research Center of Radiology & Surgical Technology, Almazov Federal Center of Blood & Endoc, Saint Petersburg, Russian Federation; 2State Medical Academy named after I. I. Mechnikov (SPSMA), Saint Petersburg, Russian Federation; 3Almazov Federal Center of Heart, Blood and Endocrinology, St-Petersburg, Russian Federation; 4Turku PET Centre, Turku, Finland
Purpose: The myocardial blood flow and coronary flow reserve were studied by positron emission tomography (PET) in patients with cardiac syndrome X (CSX).
Material and Methods: Sixteen patients with the typical triad of CSX: pain in the chest, ST segment depression during stress ECG test and angiographically normal coronary arteries were included. Patients with coronary heart disease (CHD) (n = 12) and volunteers without cardiovascular disease (n = 12) were served as the control groups. Cardiac PET with 82Rb-chloride was performed at rest, during cold pressor test (CPT) and dipyridamole hyperaemia (DH). Absolute values of myocardial blood flow (MBF) was calculated using the software package “Carimas 2.2”. Coronary flow reserve (CFR) was calculated based on the values of MBF at rest and during DH.
Results: We did n’t find any significant differences between values of CFR in patients with CSX and volunteers. In patients with CHD there was observed a significant decrease in CFR compared with control groups. In patients with CSX PET during CPT revealed an insignificant increase of MBF compared to baseline values (6 pts.), or decrease of MBF (10 pts.), suggesting an absence of EDPR or microvascular spasm. MBF during CPT was significant increase (more than 25% of baseline values) in volunteers.
Conclusion: Disturbance of endothelium-dependent vasodilatation plays a role in the pathogenesis of myocardial ischemia in patients with coronary syndrome X.
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Incremental value of Rubidium PET myocardial blood flow measurement over relative perfusion assessment in the detection of coronary artery disease
P. Arumugam1; M. Agelaki1; M.A. Khan1; R.S. Khattar1
1Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
Myocardial perfusion imaging using Positron Emission Tomography (PET) is currently regarded as the most accurate non-invasive method for quantifying Myocardial Blood Flow (MBF). It is well known that relative perfusion assessment with both Single Photon Emission Tomography (SPECT) and PET could potentially underestimate the extent of ischaemia and coronary artery disease in a proportion of patients. We assessed the performance of Rubidium-82 PET against angiographic coronary artery disease. The aim was to assess the additional value of PET MBF over relative perfusion assessment using Siemens’ MBF Circulation software.
Methods: We retrospectively studied 57 consecutive patients who underwent a clinically indicated PET scan and coronary angiography within three months. Coronary angiograms were reviewed by two independent operators and a ≥50% stenosis in a major epicardial coronary artery was considered significant. The patients were dichotomized into those in whom relative perfusion assessment matched coronary stenosis on angiography (concordant group) and those in whom the results lacked agreement (discordant group).
We then compared the Coronary Flow Reserve (CFR = Stress MBF/Rest MBF) data in the standard three coronary vascular territories of the discordant group to determine whether it concurred with the degree of coronary stenosis and location of disease. CFR of less than 1.5 was used as a cut off for significant reduction in blood flow.
Results: A total of 57 patients were studied (46 male, 11 female) with a mean age of 64 years. Fourteen patients (24%) had multivessel disease. The total number of concordant cases was 40 (70%) in whom relative perfusion assessment matched coronary angiographic findings. Among the 17 discordant results, CFR findings corresponded to coronary angiography in 8 patients (48%). Therefore the use of CFR improved the overall concordance rate to 84%. CFR was still discordant in 9 cases of whom 7 had single vessel disease and 2 had multivessel disease.
Conclusions: In this study, relative perfusion assessment was concordant with coronary angiography for the detection and location of coronary artery disease in 70% of cases. The use of CFR with Rubidium-82 PET had incremental diagnostic value showing agreement in disease detection in approximately half of the patients with previously discordant results. We plan to clinically follow up the discordant patient group to assess cardiac event rate in an 18-month follow up period.
124
Low dose “stress-only” gated-myocardial perfusion SPECT scintigraphic protocol: Solid state detector imaging reduces the need for rest injection imaging
A. Atul Verma1; S. Pandey1
1Fortis Escorts Heart Institute, New Delhi, India
Objective: To find out the efficacy of semiconductor detector gamma camera to reduce the need of rest injection imaging on a” Stress-only” gated SPECT myocardial perfusion scintigraphy when compared with the conventional gamma camera using low dose Tc99m-MIBI.
Materials & Methods: 65 subjects irrespective of age and sex with atypical symptoms and normal LVEF were chosen for the study. Each were subjected to stress (treadmill/pharmacological) and were injected 5-10 mCi of Tc99m-MIBI according to the weight . The gated SPECT imaging were performed under both Discovery NM530C (Solid state) and Symbia S (conventional) gamma cameras with the imaging times of 5 and 12 minutes respectively. The resting imaging was performed under both the cameras after injection of 20-25 mCi of Tc99m MIBI. The acquired images were processed using 3D-iterative reconstruction (No of iterations = 70) for discovery NM530C and backprojection reconstruction using butterworth filter of 5 & order of 5 for symbia S. The images were compared using both the segmental distribution & Myocardial contractility.
Observations: The processed images were divided into:
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Group A: 26 cases showed maintained myocardial radiotracer distribution in both the cameras.
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Group B: 29 cases showed photopaenicity in the inferior/inferobasal wall during both stress and rest images with symbia S. The DiscoveryNM530C showed maintained radiotracer uptake and adequate myocardial contractility.
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Group C: 10 cases showed reduced radiotracer uptake in both the cameras with hypocontractility on a gated SPECT study. These showed a near total refilling during stress imaging with improved myocardial contractility.
Inference: From the above observations, 26 subjects with no perfusion defects and maintained myocardial contractility during post stress imaging do not require rest injection imaging; 29 cases where photopaenicity were seen in the inferior/inferobasal wall by a conventional camera. A gated SPECT due to low count images were not able to differentiate low perfusion area from diaphragmatic photon attenuation. However Discovery NM530c showed adequate perfusion with relatively maintained myocardial contractility. The photopaenicity may be ascribable to diaphragmatic photon attenuation and does not require rest injection. 10 cases showed reduced radiotracer distribution in both the cameras with hypokinesia on gated study required rest imaging.
Discussion: The direct energy conversion, increased spatial and energy resolution and pin hole detectors improves low dose image quality which showed increased efficacy over conventional camera on a low dose stress only protocol.
125
Prognostic value of circulating matrix metalloproteinases and brain natriuretic peptide in patients after q-wave myocardial infarction
A. Alexander E. Berezin1; A. Kremzer1; T. Samura1
1State Medical University, Zaporozhye, Ukraine
Background: Following acute myocardial infarction (MI), myocytes and the interstitium are changed immediately. Extracellular matrix reposition after MI is considered as a one of powerful integral mechanisms of cardiac remodeling that determinates individual cardiovascular risk value. Recently clinical trials have been shown that both early post-MI dilatation of left ventricular cavity and spherical transformation of one are tightly associated with poor short-term and long-term prognosis as well. Matrix metalloproteinases (MMPs) play an important and pivotal role in processes around heart architectonic disorders in subjects after acute MI.
The objective of this study was to compare of prognostic value of MMP-3, MMP-9 and NT-pro-BNP for fatal and non-fatal complications in Q-wave myocardial infarction patients in acute MI and post-MI periods.
Materials and methods: 120 patients (male and female) with documented Q-wave myocardial infarction (MI) were observed during 1 year after hospitalization period. Clinical endpoints were identified through the hospital patient tracking system, with review of medical records for each recorded endpoint. LV ejection fraction (LVEF) and wall motion index (WMI) were calculated accordingly conventional methods. Measurements of MMP-3, MMP-9, and NT-pro-BNP concentrations were performed by ELISA.
Results: In the ROC curves, a cut-off value for MMP-3 (9.7 ng/mL) showed the best discriminatory power (sensitivity = 77.8%, specificity = 90.8%). We found also that optimal cut-off for MMP-9 was 18.1 ng/mL (sensitivity = 70.5%, specificity = 75%), and cut-off for NT-pro-BNP was 885 pmol/l (sensitivity = 58%, specificity = 68.6%). Combination MMP-3 and MMP-9 had positive prognostic value of 70% (sensitivity and specificity y are 84% and 82% respectively).
Conclusion: We predispose, that obtained data can be helpful for further stratification of the patients into high cardiovascular mortality risk group.
126
Added value of Rb-82 cardiac PET quantitation of myocardial blood flow over semi-quantitative analysis to select patients eligible for invasive coronary angiography
J.A. Jean-Aibert Collinot1; E. Deshayes1; V. Michiels2; O. Muller2; J.O. Prior1
1CHUV and University of Lausanne, Department of Nuclear Medicine, Lausanne, Switzerland; 2CHUV and University of Lausanne, Department of Cardiology, Lausanne, Switzerland
Aim: To determine whether myocardial blood flow (MBF) quantitation derived from Rb-82 cardiac PET could improve the selection of patients eligible for invasive coronary angiography (ICA) as compared to semi-quantitative analysis using summed difference score (SDS).
Methods: We enrolled 40 consecutive patients with suspected or known CAD who performed cardiac Rb-82 PET/CT and ICA within 60 days, without cardiovascular events in between. Rest and adenosine-induced stress MBF (sMBF) were computed, as well as myocardial flow reserve (MFR = stress/rest MBF) using the 1-compartment Lortie model (FlowQuant) for the whole LV, as well as for each coronary artery territories (vessel-based analysis). Flow parameters were divided in 3 groups: G1 = abnormal MFR < 1.5 & sMBF < 2 mL/minute/g; G2 = intermediate abnormalities 1.5 ≤ MFR < 2 & sMBF < 2 mL/minute/g and G3 = normal MFR ≥ 2 or sMBF ≥ 2 mL/g/minute. Stenosis severity was classified as non-significant (<50% or FFR ≥ 0.8), intermediate (50% ≤ stenosis < 70%) and severe (≥70%).
Results: In patients with abnormal or intermediate flow abnormalities, 21/22 (95%) and 6/7 (86%) had at least one vessel with severe stenosis, respectively. Among patients without perfusion abnormalities, 9/11 (82%) had no significant coronary lesion. Moreover using semi-quantitative analysis criteria only (SDS ≥ 7), 10 patients would benefit from ICA (all in G1 or G2) against 27 patients with sMBF & MFR quantitation. At ICA, 29/40 (73%) patients had at least one vessel with severe stenosis, with 27/29 (93%) in abnormal or intermediate abnormalities groups. Likewise, 52/84 (62%) of vessels analysed in patients of abnormal or intermediate abnormalities groups had a significant stenosis.
Conclusion: Patients with normal flow parameters (MFR ≥ 2 & sMBF > 2 mL/minute/g) could avoid ICA. Patients with 3-vessels low MFR and sMBF would benefit from ICA, as they are likely to present a severe stenosis (≥70%) in at least one vessel. MBF and MFR quantitation improves patient referral to ICA as compared to semi-quantitative analysis alone.
127
The influence of hypoxic preconditioning on the levels of s-NGAL (lipocalin-2) during myocardial revascularization under extracorporeal circulation
Z.H. Vesnina1; S.I. Sazonova1
1Research Institute for Cardiology, Tomsk, Russian Federation
Purpose: To evaluate the effect of hypoxic preconditioning (HPC) on the levels of s-NGAL (lipocalin-2) during myocardial revascularization under extracorporeal circulation (EC).
Methods: We examined 40 patients with CAD (mean age 57.6 ± 1.2 years) who underwent coronary bypass surgery (CABG) under EC. The patients were divided into 2 groups: patients (n = 20) with HPC, conducted during CABG (study group), and 20 patients without preconditioning (comparison group). Preconditioning was performed in single-cycle 10-minute hypoxemia followed by the 5-minute period of reoxygenation before global ischemia. The concentration of serum lipocalin before and 5 hours after CABG was determined in all patients using a test-system Human Lipocalin-2 NGAL, ELISA.
Results: Baseline levels of lipocalin did not differ significantly between groups. We found a reverse correlation between the levels of s-NGAL and left ventricular ejection fraction (R = −0.37, P = .02), and also between the glomerular filtration rate (according to the radionuclide renoscintigraphy) and level of lipocalin (R = −0.28, P = .046). Five hours after CABG has been a significant increase in the concentration of s-NGAL vs pre-operative value in the study group, and in the comparison group (127.58 ± 22.59 vs 70.65 ± 10.72 ng/mL and 171.65 ± 20.10 vs 65.01 ± 8.64 ng/mL, respectively). We found a direct relationship between the duration of the EC and the dynamics of s-NGAL levels in both groups. However, increasing of the NGAL concentration in the comparison group was more significant comparatively to the study group (P = .02). The average value of the difference between pre- and postoperative lipocalin levels in study group was 56.94 ± 19.76, and 106.64 ± 18.94 ng/mL—in comparison group (P = .004).
Conclusion: Hypoxic preconditioning during myocardial revascularization under extracorporeal circulation prevents a critical increasing of serum lipocalin-2.
128
Effectiveness and safety of increasing target clamp serum glucose during the hyperinsulinemic euglycemic clamp for PET viability imaging
J. John Askew1; D. Mihalkova1; T. Miller1; M. Rodriguez-Porcel1; P. Chareonthaitawee1;
1Mayo Clinic, Rochester, Minnesota, United States of America
Purpose: Positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG) is an important tool in the identification of viable myocardium in patients with ischemic left ventricular (LV) systolic dysfunction. The hyperinsulinemic-euglycemic clamping (HEC) is a well-proven technique for optimizing glucose metabolic conditions and FDG PET image quality. Prior to June 2010, the HEC serum glucose (SG) goal in our practice was set at 90 (range 85-95) mg/dL. However, using this protocol, a number of patients experienced significant hypoglycemia (defined as SG < 70 during HEC). The goals of this study were (1) to increase the SG goal to 95 (range 90-100) mg/dL, (2) to measure the incidence of hypoglycemia and (3) assess FDG PET image quality with the new HEC SG goal.
Results: Please see table for details.
Methods: From January 1, 2009 to December 27, 2009, 72 consecutive patients underwent FDG PET viability studies with an HEC SG goal of 85-95 mg/dL. New SG goals (90-100 mg/dL) were implemented from June 1, 2010 to December 31, 2011. During this time, 84 consecutive patients underwent FDG PET viability studies. Data were collected and analyzed for mean blood glucose, episodes of asymptomatic and symptomatic hypoglycemia, and image quality. Image quality was determined by consensus of two experienced readers.
Conclusions: Raising the HEC SG goal from 85-90 to 90-100 mg/dL during FDG PET viability studies significantly reduced hypoglycemic episodes without affecting FDG PET image quality.
Old HEC SG goal (n = 72 patients) | New HEC SG goal (n = 84 patients) | P | |
|---|---|---|---|
Age (years) | 68 | 65 | .05 |
Males | 64 (89%) | 75 (89%) | .94 |
Patients achieving HEC SG goal during steady state | 56 (78%) | 65 (77%) | .95 |
SG during HEC (mg/dL) | 88 | 92 | <.01 |
Patients with hypoglycemia | 7 (10%) | 1 (1%) | .02 |
Patients with symptomatic hypoglycemia | 4 (6%) | 0 (0%) | .04 |
Lowest SG (mg/dL) during HEC | 78 | 83 | <.01 |
Time to FDG injection (minutes) | 95.4 | 95.5 | .79 |
Patients with unsatisfactory FDG PET image quality | 1 (2%) | 1 (1%) | .91 |
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Cardiac metaiodobenzylguanidine scintigraphy in patients with spinocerebellar ataxia type 2
T. Pellegrino1; S. Pappata’1; S. De Luca1; A. De Rosa1; M. De Leva1; M. Tuccillo1; A. Boemio1; A. Filla1; G. De Michele1; A. Alberto Cuocolo1
1University Federico II, Napoli, Italy
Spinocerebellar ataxia type 2 (SCA2) is an autosomal dominant neurodegenerative disorder characterized by progressive cerebellar ataxia, slow saccadic eye movements, and peripheral neuropathy. Autonomic nervous system dysfunction represents also a significant component of SCA2 clinical picture. The aim of this study was to evaluate cardiac autonomic innervation in patients with SCA2 using cardiac I-123 metaiodiobenzylguanidine (MIBG) scintigraphy, a marker of post-ganglionic sympathetic cardiac nerve terminals integrity, in comparison with patients with Parkinson’s disease (PD), usually showing reduced myocardial MIBG uptake.
Methods: Cardiac autonomic innervation was assessed in 8 patients with SCA2 (5 men and 3 women, mean age 40 ± 12 years) and 5 patients with PD (3 men and 2 women, mean age 53 ± 7 years). None of these patients had diabetes mellitus, cardiac disease, or took drugs that may affect MIBG myocardial uptake. All patients underwent I-123 MIBG scintigraphy. Following thyroid gland blocking with potassium iodide, 111 MBq of I-123 MIBG was intravenously injected. Planar scintigraphic imaging in the anterior view was obtained 15 minutes (initial) and 4 hours (delayed) after the tracer injection using a dual-head gamma camera equipped with a low-energy, high-resolution collimator. A preset time of 10 minutes was used for image acquisition with a 159 ± 10 keV of energy window. Region of interest analysis was used to calculate the initial and delayed heart to mediastinum (H/M) ratios. The H/M ratio for both initial and delayed images and the background corrected myocardial washout rate were calculated. Two observers, blinded about patients’ disease, performed data analysis.
Results: Initial H/M ratio and delayed H/M ratio in patients with PD vs patients with SCA2 were 1.6 ± 0.3 vs 1.9 ± 0.2 and 1.4 ± 0.4 vs 1.8 ± 0.1, respectively. In patients with PD, the initial H/M ratio and delayed H/M ratio were significantly lower compared to patients with SCA2 (P < .05). Washout rate in patients with PD vs patients with SCA2 were 63.3 ± 24.5% vs 33.9 ± 7.4%, respectively. In patients with PD, washout rate was significantly higher than in patients with SCA2 (P < .01).
Conclusions: Our preliminary findings show that myocardial I-123 MIBG uptake is reduced more markedly in PD than in SCA2 patients, suggesting a more severe and/or a different sympathetic autonomic dysfunction in patients with PD as compared to those with SCA2.
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Correlation between perfusion abnormalities and myocardial blood flow using 13N-ammonia PET/CT in patients with CAD
E. Erick Alexanderson Rosas1; L.V. Torres-Araujo1; E.A. Penarrieta-Daher1; L.E. Juarez-Orozco1; S. Hernandez-Sandoval1; C.A. Guizar-Sanchez1; A. Meave-Gonzalez1; M. Jimenez-Santos1; M.M. Martinez-Aguilar1
1Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico City, Mexico
Introduction: PET/CT provides anatomical information of the coronary arteries, along with objective evidence of its functional impact. New software provide an automated perfusion scoring of the 17 left ventricular segments, calculating perfusion scores: Summed Rest Score (SRS), Summed Stress Score (SSS), Summed Differential Score (SDS), and the quantification of Myocardial Blood Flow (MBF), Coronary Flow Reserve (CFR) and the quantification of Total Perfusion Defect (TPD).
Methods: We studied 30 patients with known CAD determined by CCTA, who underwent a 13N-Ammonia Gated PET study. The patients were divided, by the severity of ischemia based on visual interpretation of the 13N-Ammonia PET perfusion images, into three groups: mild, moderate and severe ischemia. Ten patients were included in each group. The SRS, SSS, SDS, rest and stress TPD (rTPD and sTPD), rest and stress MBF (rMBF and sMBF) and CFR were calculated, using the CSI Software. The one factor ANOVA test was used to determine if there is a significant correlation in any of the above mentioned values proportional to the severity of the ischemia.
Results: Table 1.
Conclusions: We found an inversely significant proportional relation between the degree of ischemia and the absolute MBF values. Coronary flow reserve was decreased in patients with high score of SDS and sTPD. sTPD can help to identify a patient with low CFR in the absence of flow evaluation.
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Radionuclide renoscintigraphy in evaluation of the nephroprotective effectiveness of hypoxic preconditioning
Z.H. Vesnina1; Y.U. Podoksenov1; Y.U. Lishmanov1
1Research Institute for Cardiology, Tomsk, Russian Federation
Purpose: Using radionuclide renoscintigraphy to evaluate the effectiveness of hypoxic preconditioning (HPC) during myocardial revascularization under extracorporeal circulation (EC).
Methods: We examined 51 patients (mean age 52.8 ± 1.4 years) who underwent coronary bypass surgery (CABG) under EC condition. Patients were randomized into 2 groups: 20 patients with HPC, conducted during CABG (study group) and 31 patients without nephroprotection (comparison group). The precondition was performed in single-cycle 10-minute hypoxemia followed by the 5-minutes period of reoxygenation before global ischemia. Dynamic radionuclide renoscintigraphy with 99m Tc-DTPA were performed before and 6-7 days after surgery with the calculation of the parameters of filtration and evacuation function of the kidneys.
Results: Patients of comparison group after CABG had the negative dynamics of renal filtration function parameters. Thus, there was a significant decrease in the mean values of total and separately for each kidney GFR, combined with a slowing of blood clearance. In addition, in patients of this group there was a significant increase of the radiopharmaceutical clearance from the collecting system of the left kidney and from the parenchyma of both kidneys.
In the study group average values of kidney filtration activity did not change in comparison with the initial data, except for the right kidney GFR. A reduction in the filtration function of one or both kidneys under the influence of non-pulsed blood flow was observed in only 3 patients (19%) and was not significant. Indicators of the kidneys evacuation function in the study group also didn’t changed significantly.
Conclusions: Radionuclide renoscintigraphy allows objectively and with high informativeness to determine the extent and nature of the impact of CABG on the kidney function. HPC has nephroprotective activity in patients undergoing open-heart surgery under EC.
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Impact of diabetes mellitus on cardiac sympathetic denervation in patients with heart failure
T. Pellegrino1; P. Gargiulo1; G. Rengo1; G. Pagano1; S. De Luca1; M. Tuccillo1; A. Boemio1; D. Leosco1; P. Perrone-Filardi1; A. Alberto Cuocolo1
1University Federico II, Napoli, Italy
Patients with heart failure (HF) and diabetes mellitus (DM) have worse prognosis compared to HF patients without DM. Impaired sympathetic nervous system activity has been demonstrated in DM patients without HF and correlated to a worse prognosis but few data are available on the effect of DM on cardiac sympathetic nerve activity in patients with HF. The aim of the present study was to assess cardiac sympathetic nerve activity in HF patients with and without DM.
Methods: We evaluated 75 patients with severe HF (left ventricular, LV, ejection fraction 31 ± 7) with and without DM. HF patients underwent I-123 MIBG scintigraphy from which early and late heart to mediastinum (H/M) ratio and washout rate were calculated. Clinical, echocardiographic and biochemical data, including NT-proBNP levels and HbA1c, were measured. Patients were assigned to two groups with (n = 37) and without DM (n = 38).
Results: The two groups were matched for cardiovascular risk factors and drug therapy, demography, HF etiology, LV systolic function, NYHA class, and serum NT-proBNP. MIBG early H/M ratio (1.65 ± 0.21 in DM and 1.75 ± 0.21 in non-DM) and late H/M ratio (1.46 ± 0.22 in DM and 1.58 ± 0.24 in non-DM) were significantly (P < .01) lower in DM compared to non DM patients. In DM patients, a highly significant inverse correlation between early H/M ratio and HbA1c levels (Pearson = −0.697, P < .000) and between late H/M ratio and HbA1c levels (Pearson = −0.579, P < .000) was observed. Early H/M and late H/M ratios significantly correlated to age, LV ejection fraction, NYHA class, HF etiology, NT-proBNP, presence of DM and HbA1c at univariate analysis. However, in multivariate analysis, HbA1c and LV ejection fraction remained the only significant predictor of early H/M ratio, whereas HbA1c remained the only significant predictor of late H/M ratio.
Conclusions: DM is associated to a more severe impairment of cardiac sympathetic activity in HF patients and the status of glycemic control strictly correlates to cardiac autonomic imbalance. These findings likely contribute to explain the adverse prognostic impact of DM in HF, and should prompt prospective studies to assess whether a strict glycemic control in HF diabetic patients leads to improvement of cardiac sympathetic innervation and of clinical outcome.
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Elevation of high-sensitivity c-reactive protein levels as a predictor of cardiovascular events in patients with arterial hypertension during 1 year after ischemic stroke
A. Alexander E. Berezin1; O. Lisovaya2
1State Medical University, Zaporozhye, Ukraine; 2City Hospital 6, Zaporozhye, Ukraine
Background: C-reactive protein (CRP) is considered as a sensitive indicator of systemic inflammation and direct mediator of atherogenesis that has been shown to be a powerful predictor of future recurrent coronary and cerebral ischemic events in subjects after stroke. However, the pathogenic and clinical significance of these associations is controversial.
The aim of the study was to evaluate the relationship between CRP plasma level and risk of recurrent coronary and cerebral ischemic events in arterial hypertension patients after ischemic stroke.
Methods: 102 mild-to-moderate arterial hypertension patients (67 male, 56-68 aged) were enrolled to the scrutiny at baseline in 3 weeks after ischemic stroke and then they were studied prospectively for 12 months period regarding survival rate and cardiovascular clinical outcomes. Hemispheric location of ischemic focus as leucoareosis was provided by contrast-enhanced computer tomography at baseline. Serum high-sensitivity CRP level was determined study entry only. Clinical interviews were performed every 3 months during 1 year after blood sampling. End point events included the following: certainly diagnosed ischemic stroke or TIA; coronary ischemic events, sudden death, and all cardiovascular events including hospitalization due to ones.
Results: Patients in the highest quartile of high-sensitivity CRP level had a significantly higher adjusted odds ratio for cardiovascular events when compared with those in the first quartile (odds ratio = 7.46; 95% CI = 1.55-19.6; P = .001). A ROC curve detected a cut-off point of high-sensitivity CRP level of 2.47 mg/dL (63.3% sensitivity, 78.3% specificity), which was used to include the variable into the multivariate model. Obtained results clarified that cut-off point closely associated with risk of end point events (hazard ratio = 5.14; 95% CI = 1.27-18.66; P = .005). After adjustment for age, sex, and other conventional risk factors cut-off point of high-sensitivity CRP more 2.47 mg/dL became a significant predictor of clinical outcomes (P = .006).
In conclusion, we predisposed that high-sensitivity CRP levels provide prognostic information in patients with arterial hypertension during 1 year after ischemic stroke.
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Correlation of Fractional Flow Reserve with stress perfusion scintigraphy for the detection of ischemia to intermediate coronary artery stenosis
V. Viktor Solomyanyy1
1A.L. Myasnikov Institute of Cardiology, Moscow, Russian Federation
Objectives: To compare ischemia assessment by Fractional flow reserve (FFR) SPECT scanning by using cardiac gating testing in patients with intermediate coronary artery stenosis.
Background: FFR it is now frequently used to determine the management of intermediate coronary artery stenosis. A cut-off value of 0.75 is used in clinical practice to guide revascularisation supported by long-term outcome data, but a ‘grey zone’ of 0.75-0.8 with uncertain clinical significance exists. Advances in non-invasive imaging tests (gated SPECT) warrant a re-evaluation of FFR at intermediate stenosis severity against non-invasive imaging.
Methods and Results: In this study 50 patients (mean age, 60 ± 9.1 years; 13 women) with coronary artery disease and a 50% to 70% coronary stenosis (target vessel). SPECT by using cardiac gating was performed as a single-day stress (bicycle testing) /rest protocol by use of technetium 99m-MIBI. Within 4 (±9) days, coronary angiography was performed and FFR was calculated by use of a pressure wire (normal FFR, > or =0.8). The mean FFR of all patients was 0.79 ± 0.15. Overall sensitivity of SPECT was 77% whereas specificity reached 92%.
Conclusion: SPECT cardiac gating showed reasonable combination of sensitivity and specificity in patients with intermediate coronary artery stenosis and may thus be the more useful additional test to determine the significance of ‘grey’ lesions on FFR.
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Conformity of “Appropriate Use Criteria for cardiac radionuclide imaging” in Japan
N. Nobuyuki Kuroiwa1; S. Fukuzawa1; M. Inagaki1; J. Sugioka1; S. Okino1; A. Ikeda1; J. Maekawa1; S. Maekawa1; S. Ichikawa1; S. Okamoto1
1Funabashi Municipal Medical Center, Division of Cardiology, Heart and Vascular Institute, Funabashi City, Japan
Background: Myocardial perfusion SPECT is widely used as a screening test for ischemic heart disease. However appropriate use criteria were not well established in Japan.
Purpose: According to ACC/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM “2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging”, we have evaluated the appropriate use of Radionuclide Imaging in our facility which is located in Japan.
Methods and Results: We reviewed 513 patients (age 69.2 ± 9.2, male 339) who underwent stress myocardial SPECT imaging between 1 Dec 2010 to 31 Jan 2012. Purpose of performing SPECT imaging were detection of cardiac artery disease (CAD) n = 310, Post revascularization risk assessment n = 144 and perioperative evaluation n = 59. Among 310 cases of detecting CAD, 192 (61.9%) met appropriate use criteria (AUC) but 118 (38.1%) did not. Summed stress score 3 & over were shown 67 (34.9%) in appropriate group, 47 (39.8%) in inappropriate group and 7 & over were shown 42 (21.9%) in appropriate group, 30 (25.4%) in inappropriate group. Coronary angiography was performed in 61 cases in appropriate group, 32 cases in inappropriate group and significant stenosis were detected 36 (61.0%) and 20 (62.5%) respectively. The characteristics of this 20 patients were all asymptomatic and mostly male age over 60 and classified as low pretest probability. Post revascularization risk assessment met AUC for 79.2% but perioperative evaluation met only 6.8%.
Conclusion: CAD was detected from group not meeting AUC for cardiac radionuclide imaging in relatively high probability. Changing pretest probability for asymptomatic, over 60 years old male from “low” to “intermediate” will resolve this problem.
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Estimate of myocardial perfusion’s disorders in patients with rheumatoid arthritis
D. Denis Shulgin1; V. Sergienko1
1Cardiology Research and Production Center, Institute of Clinical Cardiology, Moscow, Russian Federation
For patients with rheumatoid arthritis (RA) plural lesion of coronary vessels, early occurrence of an acute coronary syndrome, rising of a lethality after the first myocardial infarction (MI), high frequency of occurrence of painless myocardium ischemia, of «painless» MI are typical. The connection of these complications with hyperactivity of an inflammation should be noted particularly.
The purpose: Studying of myocardium perfusion by means of SPECT method with application of 99mTc-MIBI (4,2-metoksiizobutilizonitril) in patients with RA depending on the basic therapy carried out.
Materials and methods: 99mTc-MIBI is a compound which visualizes the perfusion of myocardium, and it has been offered for estimation of the myocardium perfusion’s condition in patients with RA. 20 persons at the age from 18 to 65 years old with reliable diagnosis RA were included in the research. Patients were divided into two groups by the randomizing “envelopes” method: group I—not receiving treatment by Methotrexatum, group II—receiving treatment by Methotrexatum. All patients with RA received pulse-therapy by glucocorticoids. The estimation of perfusion’s condition was made on ten standard deviations (10 sd), meanwhile values exceeding 2 sd are considered to be clinically significant. Scale DAS28 was applied for estimation of RA activity at the patients.
Results: During the analysis of the received results no authentic signs of a transient ischemia were noted at patients receiving therapy by Methotrexatum. At the same time significant defects of depth of perfusion of the myocardium exceeding 2sd were detected at the overwhelming majority of patients who had not take over therapy by Methotrexatum (that corresponds to sites of a transient ischemia of a myocardium (P < .05)). During the interrelation analysis between defect of perfusion at patients with RA and index of illness activity (DAS28) a correlation dependence has been noted, however, statistically significant reliability was not reached (P = .024). On the average the area of defect of perfusion of a myocardium made up 30.7% ± 22.6% in group of patients who were not taking over Methotrexatum, while in group of patients who were taking over the treatment this index was much more low—10.6% ± 6.4%.
The conclusion: SPECT of myocardium is a modern and extremely informative method of estimation which subsequently will help to throw light on the occurrence of cardiovascular complications at patients with RA.
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Association between serum adrenomedullin and coronary atherosclerosis in mild renal insufficiency nondiabetics: MDCT study
A. Racekova1; J. Gonsorcik1; C. Gibarti2; E. Zemberova3
1Department of Cardiology, East-Slovak Institute for Cardiolvascular Diseases, Kosice, Slovak Republic; 2Department of Radiology and Imaging Techniques-Cardiac CT, Kosice, Slovak Republic; 3RIA Laboratory, Kosice, Slovak Republic
Purpose: Plasma adrenomedullin (ADM) levels are elevated in various pathological states including cardiovascular and inflammatory diseases in the general population. Its plasma levels or its precursors have not been evaluated in population of patients chronic kidney diseases. The present study investigated whether an increased ADM level is a marker of vascular complications in nondiabetics with mild renal insufficiency.
Methods: The study group consisted of 67 patients. Fifty-eight percent (39 of 67) of the study group were men, with mean age of 66.7 ± 9.8, and 42% (28 of 67) were women, with mean age of 65.8 ± 11.1. We determined plasma mid-regional pro-adrenomedullin (MR-proADM) levels in patients without documented coronary events in stage 2 and 3 chronic kidney disease. Coronary artery calcification (CAC) and noninvasive coronary angiograms were obtained using a 64 slice scanner (Somatom, Siemens) and a standard protocol using prospective triggering. Coronary artery stenosis of at least 50% was considered significant. Laboratory data MR-proADM were collected and analysed to CT findings.
Results: The mean MR-proADM plasma levels was 0.78 nmol/L, and the mean CAC score was 370.58. Coronary artery calcifications were observed in 86.6% of the patients, with significant coronary artery stenosis in 37.2%. Plasma adrenomedullin correlated with total CAC (r = 0.36; P = .007), glomerular filtration rate (r = −0.59; P = .007) and age (r = 0.41; P = .002). We also found that CAC associated significantly better with significant coronary stenosis (P < .001) than plasma adrenomedullin (P = .03). A receiver operating characteristic (ROC) curve analysis predicting significant coronary stenosis revealed that the area under the curve (AUC) CAC was significantly larger than MR-proADM (0.83 vs 0,68, P < .05). High levels of the plasma peptide mid-regional pro-adrenomedullin was able to detect significant coronary stenosis in mild renal insufficiency nondiabetics with sensitivity and specificity of 85 and 73%, respectively.
Conclusions: Our findings suggest the possibility that plasma ADM is a novel sensitive marker for the presence of vascular lesions in patients with coronary kidney disease.
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Feasibility of 18F-RGD for ex vivo imaging of atherosclerosis in detection of alpha5beta3 integrin expression
R. Reza Golestani1; L. Mirfeizi1; C. Zeebregts1; H. Boersma1; J. Westra1; R. Tio1; R. Dierckx1; P. Elsingha1; R. Slart1
1University Medical Center Groningen, Groningen, Netherlands
Background: Given the fact that angiogenesis plays an important role in atherosclerotic plaque vulnerability, molecular imaging of angiogenesis can be used for determination of rupture-prone atherosclerotic plaques. αvβ3 integrin is a key player in the process of angiogenesis. Targeted imaging of αvβ3 integrin has been shown to be possible in previous studies on tumor models, using radiolabeled arginine-glycine-aspartate (RGD).
Our aim was to investigate feasibility of ex vivo detection of αvβ3 integrin in human carotid endarterectomy (CEA) specimens.
Methods: CEA specimens, immediately after excision, were incubated in 5 Mbq 18F-RGD for one hour followed by 1 hour emission microPET scan. The results were quantified in 4 mm wide segments as percent incubation dose per gram (%Inc/g). A segmental-to-total ratio was calculated by dividing segmental %Inc/g by total specimen’s %Inc/g. Presence of αvβ3 integrin and endothelial cells in each segment was confirmed by immunohistochemical staining for CD31 and αvβ3 integrin, respectively.
Results: 18F-RGD uptake was heterogeneous in CEA specimens and was localized within the vessel wall. Significant correlations were observed between segmental-to-total ratio with αvβ3 integrin staining score (r = 0.58, P = .038) and CD31 staining score (ρ = 0.67, P < .002).
Conclusion: This study, for the first time showed the feasibility of integrin imaging in determination of αvβ3 integrin expression and angiogenesis in human atherosclerotic plaques.
Picture Caption: Saggital view of [18F]-RGD k5 microPET image of an excised carotid endarterectomy specimen (left). Transversal images, 10× magnitude of CD31 staining (arrows), and αvβ3 integrin staining (arrows) of corresponding slices are shown.
RGD microPET and histology
139
Plasma myeloperoxidase level can help to determine high risk patients after Unstable Angina
I. Inga Markava1; A. Miadzvedzeva1; L. Helis1; M. Kaliadka1; I. Russkikh1; I. Lazareva1
1Republican Scientific and Practical Centre of Cardiology, Minsk, Belarus
Purpose: It is assumed that platelet activation has the significant role in the onset of atherothrombosis and that usually precedes acute coronary syndromes. We addressed the role of plasma myeloperoxidase (MPO) level as a marker of oxidative stress and plaque instability in the development of atherothrombotic events in patients with unstable angina (UA).
Materials and Methods: We investigated the prognostic importance of plasma MPO levels in UA at a 1-year follow-up, and we analyzed the correlations between plasma MPO levels and other biochemical values. We evaluated 90 consecutive patients (60 men; mean age, 56 ± 11 years) diagnosed with UA and 36 age- and sex-matched healthy control participants. Patients were monitored for the occurrence of major adverse cardiovascular events (MACE), which were defined as cardiac death; reinfarction; new hospital admission for angina; heart failure; and revascularization procedures.
Results: The mean follow-up period was 18 ± 5 months. Plasma MPO levels were higher in UA patients than in control participants (284 ± 14.3 vs 90 ± 15 pmol/L; P = .001). Composite MACE occurred in 36 patients with UA. In multivariate analysis, plasma MPO level was independent predictor of MACE (OR = 4.7; 95% CI, 2.9-7.7; P = .003). High plasma MPO level identify patients with a worse prognosis after unstable angina at 1-year follow-up.
Conclusion: Evaluation of plasma myeloperoxidase levels might be useful in determining patients at high risk of death and MACE who can benefit from further aggressive treatment and closer follow-up.
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Impact of early morning plasma catecholamines on left ventricular size during viability study with thallium 201
A.A.A. Abdelaty1; T.H.E. Elzawawy1; A.H.Y. Yosry2; A.S.A. Samir3
1Cardiology Department, Faculty of Medicine and Clinical Chemistry Department, Institute of Medical Research, A, Alexandria, Egypt; 2Microbiology Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt; 3Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
Purpose: We noticed transient ischemic dilatation (TID) in patients (pts.) submitted for resting (R) viability (V) study with Thallium (Tl) 201 in the initial R. study in early morning compared to late R. study with reinjection. Is this phenomenon related to the early morning circadian rhythm of ischemia, serum catecholamines (catec.) and plasma cortisol (Co.) or due to anxiety of the pt. about the SPECT study.
Methods: Pts were seen at nuclear cardiology lab. during 6 month period from January to July 2010 coming for post myocardial infarction (MI.) V. study. Every pt. was subjected to a questionnaire; adopted from the American Institute of Stress to evaluate their anxiety, measuring plasma Co, serum Adrenaline(AD) and Noradrenaline(NAD) “before each image” one at 7:30 AM and the second 3 hours later, and Tl 201 R. SPECT with delayed R. with reinjection protocol.
Results: 40 Pts (34 M, 6 FM) mean age 54.88 Y; 40% (16/40) developed TID; they had significantly higher mean NAD, AD, and Co. in the initial study (311.38 ng/L, 100.25 ng/L, 30.44 mcg/dL), compared to (237.29 ng/L, 65 ng/L, 18.71 mcg/dL) (P value = .0021, .0013 and .0001), 40% (16/40) were proved to be anxious about the test, 12 (75%) of them developed TID (P value = .00013)
Conclusion: TID in pts. with IHD in the early morning during resting thallium 201 SPECT viability study is associated with higher catecholamines.,Cortisol and anxiety which are triggering factors for worsen myocardial ischemia. These factors should be considered in the total ischemic burden for these patients.
141
Prognostic evaluation of 123I-MIBG cardiac scintigraphy in ischemic and nonischemic heart failure previous to resynchronizer implant: Preliminary results
A. Ana Abreu1; L. Oliveira2; M. Goncalves3; M. Carrola3; H. Santa-Clara3; S. Silva1; M. Carmo1; P. Cunha1; M. Oliveira1; R. Ferreira1
1Hospital Santa Marta, CHLC, Lisbon, Portugal; 2Quadrantes, Lisbon, Portugal; 3Technical University of Lisbon, Human Kinetics Faculty, Lisbon, Portugal
Background: Cardiac MIBG imaging has been used for noninvasive evaluation of autonomic nervous system. Several MIBG cardiac scintigraphy parameters have been negatively correlated to prognosis.
Aim: To correlate MIBG cardiac scintigraphy parameters with clinical severity, functional capacity, left ventricular ejection fraction (LVEF) and short-term prognosis in patients (P) with Chronic Heart Failure (CHF) disease and indication to cardiac resynchronization (CRT).
Methods: 34 consecutive CHF P, mean age 68.6 ± 14.37 (34-82 years old), 74% male, LVEF < 35%, referred to CRT were included. 12 P (35%) had ischemic cardiomyopathy (ICM) and 22 P (65%) nonischemic cardiomyopathy (NICMP). 35% P were diabetic and 97% had at least one coronary artery disease risk factor. Clinically, 27% P were class I, 31% class II and 42% class III (NYHA).
All P performed echocardiogram, cardiopulmonary testing and cardiac scintigraphy with 123 I-MIBG.
Cardiac events such as cardiac re-hospitalization, severe arrhythmia or cardiac death were evaluated (8 months mean time follow up).
Results: Our preliminary results showed: LVEF < 30% in 62% P; oxygen peak consumption (VO2p) mean value 14.8 ± 5.5 mL/kg/minute; exercise test duration mean value 6.81 ± 4.19 minutes. 4 P (12%) had at least one cardiac event during follow-up (1 P, 8% ICM; 3 P, 13% NICM).
MIBG scintigraphic parameters: Early Heart-Mediastinum rate (HMR) < 1.6 in 74% P; Late HMR <1.6 in 94% P and Washout (WO) mean value 40.6 ± 27.3.
Between ICM and NICM, WO was not statistically different, however HMR were: Early HMR 1.6 ± 0.15 vs 1.4 ± 0.15 (P = .016); Late HMR 1.5 ± 0.19 vs 1.3 ± 0.12 (P = .006), respectively. No significant difference in systolic dysfunction severity was present in ischemic vs nonischemic: LVEF 29% ± 9% ICM vs 25% ± 7% NICM (P > .05).
HMR and WO were not significantly different between: diabetic vs nondiabetic; LVEF0.05).
In the 4 P with events, mean Early HMR and mean Late HMR were not significantly different from the P without events (1.37 vs 1.52) and (1.34 vs 1.42), respectively, however with a tendency for inferior Early HMR in P with events (P = .09 and P = .30).
Conclusion: In this preliminary study, we found in nonischemic patients significantly lower early and late HMR, translating a more severe autonomic dysfunction, as well as a tendency for worst prognosis. There was a high percentage of cardiac events at 8 months follow up (12%), especially in nonischemic patients. Patients with events had lower early HMR, needing a larger population to confirm statistically this difference.
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The role radionuclide assessment of cardiac sympathetic activity in patients with atrial fibrillation
Y. Lishmanov1; S. Stanislav Minin1; Y. Saushkina1; I. Efimova1; S. Popov1; I. Kisteneva1
1Institute of Cardiology, Tomsk, Russian Federation
Introduction: The mechanisms underlying the majority of cardiac arrhythmias are unclear. The disturbance sympathetic innervation of the heart may be the cause of atrial fibrillation (AF), but also reason of myocardial dysfunction of the left ventricle (LV).
The aim of this study was to assessment of cardiac sympathetic activity in patients with atrial fibrillation by planar scintigraphy with 123I-metaiodbenzilguanidine (123I-MIBG).
Materials and Methods. The study included 20 (17 men and 3 women, average age 57.4 ± 11.6 years) patients with suspected coronary artery disease, hypertension 2-3 class. All patients to divide 3 groups: 8 patients (group 1) with paroxysmal AF (ParAF), 5 patients (group 2) with persistent atrial fibrillation (PerAF) and 7 patients with no signs of AF (group 3).
Planar imaging was performed to study initial (imaging started 10 minutes after MIBG injection 148 MBq 123I-MIBG) and delayed (imaging started 4 hours after 123I-MIBG injection). For the anterior planar 123I-MIBG images, regions of interest were constructed for the heart and upper mediastinum, and the heart-mediastinal ratio (HMR) and corrected 123I-MIBG washout were calculated.
Results: The delayed HMR in patients with ParAF and PerAF was significantly lower compared that in patients third group (1.56 ± 0.16, 1.58 ± 0.17 and 1.82 ± 0 19, respectively, P < 0.05). There were statistically significant differences in the washout rate of 123I-MIBG between all treatment groups (44.8 ± 4.9, 38.9 ± 11.81 and 27.8 ± 7.8, respectively, P < 0.05). In this study, the highest washout rate was observed in the group with paroxysmal AF.
Conclusion: Results of this study indicated, that the patients with atrial fibrillation has of regional LV myocardial, according with 123I-MIBG imaging. More sympathetic innervation abnormality was observed in the group with paroxysmal AF.
143
Predictive value of brain natriuretic peptide and c-reactive protein in diabetes mellitus patients with symptomatic heart failure due to ischemic reason
A. Alexander E. Berezin1; A. Kremzer1
1State Medical University, Zaporozhye, Ukraine
The aim of the study was to investigate the nature of the relationship between NT-pro-BNP and C-RP on the one hand and severity and prevalence of coronary atherosclerosis on the other in patients with chronic heart failure due to ischemic reason depending on diabetes mellitus.
Methods: The study included 82 patients of both sexes with chronic heart failure FC II-III (NYHA), which developed as a result of coronary artery disease and 36 healthy individuals. Each patient with chronic heart failure, appropriate criteria for inclusion/exclusion, with verified diabetes mellitus 2 type (DM) in accordance with the criteria IDF (2003) was picked up by the patient without the disease. All patients underwent transthoracic echocardiography, visualization and evaluation of the severity of coronary artery lesions with multislice computed tomography with the calculation of Vessel index and Gensini index as well as measurement of circulating levels of NT-pro-BNP and C-RP.
Results: Analysis of the data showed that the group of patients with chronic ischemic heart failure variance with DM (OR = 5.40, 95% CI = 2.60-9.70, and OR = 4.92, 95% CI = 2.40-8.85, respectively), the level of NT-pro-BNP (OR = 2.88, 95% CI = 1.34-4.56, and OR = 2.59, 95% CI = 1.18-5.02 respectively) and C-RP (OR = 3.02, 95% CI = 1.40-5.20, and OR = 2.90, 95% CI = 1.27-5.80, respectively) had the highest value as predictors of the severity of atherosclerotic coronary artery lesions, evaluated on scales Vessel score and Gensini score. In a cohort of DM patients an excess of cut-off points for both NT-pro-BNP and C-RP plasma level to 812.2 fmol/mL and 5.6 mg/L, respectively, predictive sensitivity and specificity of these biological markers as indicators of the prevalence and severity of coronary atherosclerosis.
In conclusion, we noted that the data support the hypothesis that in stable patients with chronic ischemic heart failure elevation of NT-pro-BNP and C-RP may be due to the severity and prevalence of coronary arteries atherosclerosis
144
The utility of 99mTc-PYP-SPECT in diagnosis of myocarditis in patients with rhythm disorders
I. Svetlana Sazonova1; Y.U.N. Ilyushenkova1; R.E. Batalov1; Y.U.B. Lishmanov1
1Research Institute of Cardiology, Tomsk Scientific Center, Tomsk, Russian Federation
Aim: To compare results of 99mTc-pyrophosphate myocardium SPECT with histology data in patients with suspected myocarditis with rhythm disorders.
Materials & Methods: We examined 15 patients (10 males and 5 females, mean age 44.3 + 5.2) with rhythm disorders (atrial fibrillation, extrasystole) and suspected myocarditis. All patients underwent SPECT with 99mTc-pyrophosphate (99mTc-PYP) at 3 and 18 hours post injection (delayed SPECT), following by SPECT with 99mTc-MIBI at the rest condition. Both images were then combined to define more exactly the localization of 99mTc-PYP uptake in the heart and to exclude ventricles blood pool. Accumulation of 99mTc-PYP was accepted as pathological when focus localized in myocardium area, focus/background ratio exceeded 1.4. Endomyocardial biopsy (EMB) samples were taken during angiography procedure. Scintigraphic results were correlated with the EMB findings.
Results: At 3 hours post injection in all patients the ventricles blood pool of 99mTc-PYP was visualized. The intensity of these accumulations was high (heart to lung ratio 3.2 ± 0.5) that impeded visualization of heart walls. At 18 hours post injection visualization of 99mTc-PYP blood pool remained, but its intensity significantly decreased (heart to lung ratio 1.2 ± 0.2) that allowed to estimate the myocardium. The pathological uptake of 99mTc-PYP was found only in 4 patients. The EBS confirmed intramyocardial inflammation at 5 of 15 patients. The number of true-positive results of delayed 99mTc-PYP SPECT was 4, true negative 8, false-positive—0, false negative 3. The sensitivity was 50%, specificity 100%, accuracy 46%
Conclusion: The results of our pilot study have shown that the diagnosing of myocarditis with 99mTc-PYP SPECT is possible only when delayed studies are performed (at 18 hours post injection), because of significant blood pool effect on early imagings. The sensitivity of 99mTc-PYP SPECT is seemed to be low, in the same time high specificity shows the opportunity of 99mTc-PYP SPECT usage in diagnosing of myocarditis.
145
Osteoprotegerin as independent predictor of coronary vasculature damage severity in type 2 diabetic patients
A. Alexander E. Berezin1; A. Kremzer1; T. Berezina2
1State Medical University, Zaporozhye, Ukraine; 2Private Medical Center VitaCenter, Zaporozhye, Ukraine
Background: Osteoprotegerin (OPG) is a bone-related glycopeptide produced by vascular smooth muscle cells due to arterial damage. OPG is considered as an independent predictor of cardiovascular disease in diabetic populations.
Aim of the study: To investigate the interrelation between OPG plasma level and coronary artery disease (CAD) in type 2 diabetic patients.
Methods: 126 subjects with stable diabetes mellitus 2 type with previously angiographic documented CAD were enrolled to the study. All patients were graduated into two groups depended calculating very high risk cardiovascular events and other. Assessment of risk was performed with contrast multispiral CT-angiography and NT-pro-brain natriuretic peptide (NT-pro-BNP) measurement. Patients with circulating NT-pro-BNP plasma level > 440 fmol/mL and/or Agatston’ coronary calcium score (CCS) ≥ 400 units were stratified as high risk (n = 72) and all other patients as low risk patients (n = 54). Severity of coronary vasculature damage was verified with Gensini score index. NT-pro-BNP and OPG plasma levels were measured with ELISA.
Results: Circulating OPG level in high risk subjects was higher than in low risk patients (5581 pg/mL [95% confidence interval (CI) = 3975-6280 pg/mL] and 2880 pg/ml; 95% CI = 745-3740 pg/ml; P < .01). Among high risk patients increased OPG in plasma was an independent predictor of significant CAD for third and fourth quartile vs first Agatston’ CCS valuesrespectively (adjusted odds ratio (OR) = 2.96 [95% CI = 1.12-9.80] and OR = 3.42 [1.50-11.2]). High circulating OPG was also associated with presence of >70% coronary artery stenosis (adjusted OR = 8.80 [2.96-19.44] for fourth vs first quartile OPG). Gensini score index correlated well with circulating OPG (R = 0.62; P = .012) and was higher in high risk subjects when it had been compared with low risk patients (adjusted odds ratio (OR) = 5.10 [95% CI = 2.90-10.30]; P = .002).
Conclusions: We believe that elevated OPG in plasma can be considered as independent predictor of severity of coronary vasculature damage in type 2 diabetic patients.
146
Failure to predict viability in Takotsubo-cardiomyopathy with cardiac 18F-FDG-PET
T.E. Christensen1; M. Lyngby Lassen1; F. Andersen1; L. Holmvang2; L.E. Bang2; P. Grande2; A. Kjaer1; P. Hasbak1
1Rigshospitalet—Copenhagen University Hospital, Clinical Physiology, Nuclear Medicine & PET, Copenhagen, Denmark; 2Rigshospitalet—Copenhagen University Hospital, Heart Centre, Department of Cardiology, Copenhagen, Denmark
Introduction: Current guidelines assign class I recommendation to 18F-Fluorodeoxyglucose (FDG) PET viability assessment in chronic heart failure patients. The combined evaluation of rest blood-flow and FDG-uptake is assumed to distinguish most reliably between viable and non-viable myocardium. Myocardial viability refers to a state of reversible impairment of contractile function. Thus, the Takotsubo cardiomyopathy syndrome with acute but reversible heart failure represents a unique human heart failure model to test FDG as a cardiac viability marker.
Method: From 2010-2012, as a part of a multimodality cardiac imaging research project in Takotsubo-cardiomyopathy, a total of 22 (1 male, 21 females) patients were included. All the patients were admitted for acute coronary angiography (CAG) on the suspicion of acute myocardial infarction and were included in the study if (a) CAG showed no significant coronary artery disease and (b) left ventriculography or echocardiography showed “apical ballooning.” The patients were examined with echocardiography, cardiac SPECT and FDG-PET within 7 days upon admission and again 3 months after discharge.
Results: Of the 22 patients originally included, 17 (16 females, 1 male) fulfilled the Mayo Clinic Diagnostic Criteria for Takotsubo-cardiomyopathy. The FDG-PET scans were evaluated, Standardised Uptake Value (SUV) within the diseased area was correlated to the non-diseased area, and a “Takotsubo/basilar region activity ratio” (T/B-ratio) was calculated. On acute examinations the normal tissue was based on a Volume of Interest (VOI) placed over the entire heart, with a threshold value of 60% of the SUVmax measured in the VOI. The diseased area was manually drawn with threshold offset which followed the contours of the myocardial tissue. On follow-up examination, since there was no clearcut diseased area, a VOI was manually drawn on the prior Takotsubo-area and compared to a manually drawn VOI on the basilar region.
Acute and follow-up T/B-ratios were 2.06 ± 0.2 vs 1.05 ± 0.03, P < .0001
Acute cardiac SPECT showed apical perfusion defect of 16 ± 7% with normalization at follow-up.
Conclusion: In the presented data, FDG-PET completely failed to visualize viability in the area of the left ventricle involved in the acute state of Takotsubo-cardiomyopathy, despite complete recovery of left ventricle function. Thus, it is important not to rule out viability based on reduced/absent FDG uptake in regions of the left ventricle in these patients.
147
123I-mIBG scintigraphy for the assessment of cardiac sympathetic innervation and the relationship to Cardiac Autonomic Function in Individuals with Impaired Glucose Tolerance using standardized method
O. Omar Asghar1; P. Arumugam2; I. Armstrong2; U. Alam1; M. Schmitt3; C. Miller3; S.G. Ray3; R.A. Malik1
1Univeristy of Manchester, Cardiovascular Research Group, Biomedical Sciences, Manchester, United Kingdom; 2Department of Nuclear Medicine, Central Manchester Foundation Trust, Manchester, United Kingdom; 3University Hospitals of South Manchester NHS Trust, Wythenshawe Hospital, Manchester, United Kingdom
Background: Individuals with impaired glucose tolerance (IGT) are at increased risk of developing type 2 diabetes and cardiovascular disease (CVD). Previous studies in subjects with IGT have confirmed the presence of sub-clinical CVD and microvascular complications however data on cardiac sympathetic imaging and their functional associations in these cohorts is currently lacking. The purpose of this study was to quantitatively and qualitatively assess global and regional cardiac sympathetic innervation and function in individuals with IGT using 123I-mIBG scintigraphy and standard cardiac autonomic function tests.
Methods: We performed 123I-mIBG scintigraphy in 18 subjects with IGT (mean age 57.5 ± 9.6 years, M:F 10:8) and 14 age-matched healthy controls (54.6 ± 5.4 years, 9:5). In addition, subjects underwent cardiac magnetic resonance imaging (CMR) to assess LV mass, systolic function, rest and stress perfusion and late gadolinium enhancement (LGE). Using planar and single photon emission computed tomography (SPECT) imaging, we assessed indices of global (late HMR) and regional innervation respectively. Sympathetic turnover was determined by the washout rate (WR) and cardiac autonomic function was assessed using standard tests of heart rate variability (HRV).
Results: There were no significant differences in LV mass index (47.3 ± 9.0 vs 51.0 ± 11.0 g/m2, P = .349), LVEF (61% ± 6.4% vs 61% ± 1.0%, P = .98) or indices of HRV between the IGT and control groups. There was no evidence of previous myocardial infarction or perfusion abnormalities on LGE and on stress MR in either group respectively. Mean late HMR (1.73 ± 0.18 vs 1.73 ± 0.16, P = .97) and WR (18.6% ± 4.2% vs 19.09% ± 7.6% P = .84) did not differ between groups. Semi-quantitative SPECT analysis revealed reduced tracer uptake in all subjects at the apex and inferior wall however there were no significant differences in total or segmental innervation between groups. HMR correlated with sympatho-vagal balance (LFa/RFa) in both IGT and controls (r = 0.500, P = .013, r = 0.48, P = .024) although WR did not correlate with any functional tests of sympathetic function.
Conclusion: In a well phenotyped cohort of adults with IGT, global and regional measures of 123I-mIBG uptake and washout and functional parameters of cardiac sympathetic function are comparable to healthy controls. Furthermore, HMR correlates with measures of sympatho-vagal balance suggesting it might not only be a useful prognostic marker but may also provide insight into the functional integrity of the cardiac autonomic nervous system.
Oral Abstract Session
Advances in PET
Tuesday 7 May, 2013, 08:30–10:00 Room 4 – A05
160
Mechanistic insights into early post-infarct inflammation: A clinical study using quantitative F-18 FDG PET-CT
T. Wollenweber1; P. Roentgen2; A. Schaefer2; C. Zwadlo2; I. Schatka1; T. Brunkhorst1; G. Berding1; J. Bauersachs2; F.M. Bengel1
1Hannover Medical School, Department of Nuclear Medicine, Hannover, Germany; 2Hannover Medical School, Department of Cardiology and Angiology, Hannover, Germany
Purpose: Myocardial infarction triggers an inflammatory response which determines subsequent healing and remodeling. Recent preclinical studies of post-infarct inflammation showed that progenitor cells are released from bone marrow, hosted in spleen, and migrate to infarct and, to a lesser degree, remote myocardium. Insights into this systemic interaction in the clinical setting are scarce, but relevant for the development of strategies to support cell recruitment for possible regeneration.
Methods: We performed dynamic 18FDG-PET/CT in 10 patients within the first week after acute myocardial infarction as their first cardiovascular event. All had transmural infarct on CMR. Heparin was given before PET to suppress myocyte glucose metabolism. Using Patlak analysis, metabolic rate of glucose (MRGlc) was quantified and used as a marker of immune cell activity. Measurements were obtained for infarct and remote myocardium, for bone marrow and spleen.
Results: MRGlc was significantly elevated in infarct vs remote myocardium (9.4 ± 4.7 vs 2.9 ± 3.2 μmol/100 g/minute; P < .001), but did not correlate with concomitantly measured perfusion defect size, LVEF or CKmax. The magnitude of MRGlc in the infarct correlated with that in remote myocardium (r = 0.783; P = .013) and spleen (r = 0.776; P = .014), but not in the bone marrow.
Conclusions: Using FDG after heparin, noninvasive imaging suggests a strong inflammatory response in the infarct region, which is associated with inflammatory cell recruitment to remote myocardium and with activity of the spleen as a cell depot. Bone marrow activation seems to not occur in the same phase. These clinical observations are consistent with preclinical work. They may serve as a foundation for further studies aiming at therapeutic support of myocardial healing.
161
Cardiac rehabilitation improves coronary endothelial function in patients with dilated idiopathic cardiomyopathy: A (15)-O water positron emission tomography study
D. Legallois1; A. Belin2; D. Agostini1; P. Milliez3; J.J. Parienti4; A. Manrique1
1Department of Nuclear Medicine, CHU de Caen, Université Caen Basse-Normandie; EA4650, Caen, France; 2Department of Cardiology, CHU de Caen, Université Caen Basse-Normandie, Caen, France; 3Department of Cardiology, CHU de Caen, Université Caen Basse-Normandie; EA4650, Caen, France; 4Department of Biostatistic and Clinical Research, CHU de Caen, Université Caen Basse-Normandie, Caen, France; 5Department of Nuclear Medicine, CHU de Caen, Université Caen Basse-Normandie; GIP Cyceron; EA4650, Caen, France
Purpose: Endothelial function is altered in patients with heart failure. Prior studies have demonstrated the ability of exercise training to improve survival and functional capacity in patients with heart failure but its impact on coronary endothelial function is not known. We conducted a prospective study to assess the effect of cardiac rehabilitation on coronary endothelial function using (15)O-water positron emission tomography (PET) in patients with nonischemic heart failure.
Methods: Myocardial blood flow (MBF) was measured before and after cardiac rehabilitation, at rest and during cold pressor test (CPT) using dynamic (15)O-water PET in 16 patients with angiographically proven idiopathic dilated cardiomyopathy (52 ± 12 years; 13 men and 3 women; left ventricular ejection fraction (LVEF): 29 ± 7%). Patients with coronary risk factors that potentially impair endothelial function (diabetes, hypertension, current smoking and hypercholesterolemia) were excluded. The flow response to cold pressor test was evaluated using (i) percent increase in MBF from baseline (%MBF) and (ii) increase in absolute units, i.e., the difference of flow between CPT and baseline (ΔMBF). Statistical analysis were performed using paired Student’s t-test and Spearman correlation test. All tests were two-sided and performed using R statistical software with a P < .05 significance level.
Results: Cardiac rehabilitation significantly improved MBF at rest (0.710 ± 0.193 mL/minute/g at baseline vs 0.824 ± 0.209 mL/minute/g after cardiac rehabilitation; P = .02). After rehabilitation, coronary endothelial function was also significantly improved. %MBF increased from 105.8% ± 12.0% to 118.9% ± 17.2% (P < .01). ΔMBF increased from 0.028 ± 0.094 to 0.156 ± 0.148 mL/minute/g (P < .01). LVEF improved significantly from 28% ± 7% to 44% ± 11% (P < .001); peak oxygen consumption raised from 18.3 ± 4.3 to 22.3 ± 4.7 mL/kg/minute (P < .01). Plasma brain natriuretic peptide decreased from 793 ± 193 to 193 ± 267 pg/mL (P < .01). The Minnesota Living with Heart Failure Questionnaire improved by an average of 20 points (63% of baseline; P < .01). There was no correlation between %MBF or ΔMBF and the parameters listed above.
Conclusion: MBF response to CPT, reflecting the functional state of the coronary endothelium was significantly improved by cardiac rehabilitation in patients with idiopathic dilated cardiomyopathy.
162
Value of flurpiridaz F 18 myocardial SUV analysis in clinical assessment of intermediate to severe coronary stenosis
M. Ming Yu1; M. Kagan1; B. Hsu1; P. Hsu1; S.G. Nekolla2; J. Lazewatsky1; G. Bhat1; D. Washburn1; D. Onthank1; S.P. Robinson1
1Lantheus Medical Imaging, N Billerica, United States of America; 2Technical University of Munich, Department of Nuclear Medicine, Munich, Germany
Purpose: Flurpiridaz F 18 is an investigational PET myocardial perfusion imaging agent, currently in phase III clinical trial. Its myocardial standardized uptake value (SUV) ratio of pharmacologic stress and rest has been indicated to reflect myocardial flow reserve (MFR) in animals. Since MFR measurement has demonstrated an added value in coronary disease diagnosis and SUV calculation is relatively simple, we investigated the utility of flurpiridaz myocardial SUV in assessment of coronary stenosis comparing with image-reader findings.
Methods: Flurpiridaz F 18 data of 22 patients receiving rest and pharmacologic stress imaging from 6 of our phase II sites were included. The time frames for SUV calculation were 5-10 minutes for the rest image and 5-10 or 2-8 minutes for the stress depending on imaging files reconstructed by each sites. Standard 17-segment polar maps at both rest and stress were constructed and aligned using MunichHeart. SUV of each segment was generated for analysis. Two SUV ratios, the stress and rest SUV ratio of each segment (SUVstrs/rst ratio, index of segmental MFR) and the SUV ratio of each individual segment to the segment with maximal SUV at the stress image (SUVindv/max ratio, index of homogeneity of flurpiridaz LV uptake), were calculated. The cutoff values of the two SUV ratios were determined using ROC curve analysis. Cardiac images were analyzed either by SUVstrs/rst ratio only or by initially the SUVindv/max ratio at stress and then further using the SUVstrs/rst ratio in patients with the SUVindv/max ratio > the cutoff value. Patients with at least one segmental SUV ratio < the cutoff value were considered abnormal. The image findings by the 3 readers from the same patient group were summarized for comparison. Angiography was used as the standard with luminal narrowing ≥40% as abnormal.
Results: The cutoff values of SUVstrs/rst ratio and SUVindv/max ratio at stress were 1.56 and 0.54. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 87%, 71%, 87% and 71% when flurpiridaz images were analyzed by the SUVstrs/rst ratio only. These values were same as that of the readers (87%, 71%, 87% and 71%). However, when both the SUVindv/max ratio and SUVstrs/rst ratio were applied, the sensitivity and NPV were better than that of the readers (sensitivity, specificity, PPV and NPV: 100%, 71%, 88% and 100%).
Conclusions: Flurpiridaz F 18 myocardial SUV quantification demonstrates a potential in detection of coronary stenosis. Diagnostic sensitivity and NPV are improved by application of both the SUVindv/max ratio at stress and the SUVstrs/rst ratio.
163
Inflammatory capacity of peri-coronary adipose tissue measured in PET affects plaque destabilization in patients with non ST segment myocardial infarction
T. Tomasz Mazurek1; M. Kobylecka1; R. Wilimski1; J. Kochman1; K. Filipiak1; L. Krolicki1; G. Opolski1
1Medical University of Warsaw, Warsaw, Poland
Background: Extravascular expression of inflammatory mediators may adversely influence coronary lesion formation and plaque stability through outside-to-inside signaling. It has been previously shown, that maximal standardized uptake value (SUV) of 18-fluorodeoxyglucose (FDG) detected by positron emission tomography in peri-coronary adipose tissue (PVAT) is greater in patients with stable coronary artery disease (CAD), than in controls. It also correlates with % of coronary stenosis. We sought to investigate, whether PVAT may influence plaque composition in Non ST Segment Myocardial Infarction (NSTEMI) patients.
Methods: 42 coronary arteries (LM, RCA, LCX, LAD) have been investigated in non-diabetic patients with moderate and low risk NSTEMI (GRACE < 140). SUV was measured in fat surrounding coronary arteries on the sections corresponding to proximal and medial segments. PVAT thickness was measured in two perpendicular dimensions on axial cuts separately for the LM, RCA, LAD and LCX, using steady state free precession cine imaging. Additionally SUV was measured in subcutaneous fat (SC), visceral thoracic fat (VS), epicardial fat over right ventricle (EPI). Conventional and virtual histology intravascular ultrasound (VH-IVUS) was performed to assess plaque composition, which were classified as calcified, fibrous, fibro-fatty, or necrotic core. PET/CT sections were further examined in segments corresponding to coronary plaques.
Results: PVAT SUV in NSTEMI patients was significantly greater than in other fat locations (LM SUV: 1.59; RCA SUV: 1.53; LCX SUV: 1.93 LAD SUV: 2.36 vs SC SUV: 0.57; VS SUV: 0.76; EPI SUV: 0.98, P < .001; ANOVA). There was no significant correlation between PVAT thickness and plaque composition. In contrast PVAT SUV positively correlated with necrotic core plaque rate (r = 0.68, P < .05), and negatively correlated with fibrous plaque rate (r = −0.53, P < .05). There was also positive correlation between PVAT SUV and % plaque volume (r = 0.41, P < .05).
Conclusions: Inflammatory activity of peri-coronary adipose tissue reflected by SUV is greater than in subcutaneous, visceral thoracic, or epicardial tissue in NSTEMI patients; There is no association between amount of pericoronary fat and plaque composition; PVAT SUV correlates with necrotic core component of coronary plaque and plaque volume in patents with NSTEMI; In conclusion, pro-inflammatory activity of PVAT in patients with NSTEMI may contribute to plaque formation, vessel narrowing and plaque rupture, supporting the hypothesis of the outside-to-inside signaling.
164
Abnormal interventricular septal displacement reflects increased oxidative metabolism in right ventricular free wall in patients with PH using cardiac magnetic resonance and C-11 acetate PET
K. Keiichiro Yoshinaga1; Y. Mori1; T. Sato1; C. Katoh1; Y. Tomiyama1; H. Ohira1; O. Manabe1; N. Oyama-Manabe1; I. Tsujino1; N. Tamaki1
1Hokkaido University Graduate School of Medicine, Sapporo, Japan
Background: Echocardiographic measurements of abnormal interventricular septum displacement toward left ventricle (LV) reflects right ventricle (RV) volume or pressure overload. Cardiac magnetic resonance (CMR) is considered the standard of reference for cardiac anatomy and function. However, the association between CMR measured this change in shape and myocardial physiological condition has not been studied. The aim of the study was to evaluate the association between the interventricular septum displacement and oxidative metabolism in RV free wall and interventricular septum in patients with pulmonary hypertension (PH) using CMR and 11C-acetate PET.
Methods: Twenty-two patients with WHO functional class II to III PH [mean PAP 38.1 ± 9.3 mmHg, pulmonary vascular resistance (PVR) 583.0 ± 221.4 dynes/second/cm5] and 8 controls prospectively underwent C-11acetate PET. An eccentricity index, which reflects abnormal interventricular septum displacement, was obtained by echocardiography and CMR in PH patients. C-11 acetate PET was used to simultaneously measure oxidative metabolism (kmono) for LV and RV.
Results: The diastolic eccentricity index (DEI) was similar between CMR and echocardiography (1.28 ± 0.20 vs 1.26 ± 0.22, NS) and showed good correlation (R = 0.95, P < .001). PH patients showed higher RV free wall kmono compared to control (0.049 ± 0.01/minute vs 0.029 ± 0.005/minute, P < .01). However, there was no difference in LV kmono in patients with PH compared to control (0.056 ± 0.007 vs 0.050 ± 0.06, NS). DEI was correlated with PVR (R = 0.64, P = .015) and RV free wall kmono (R = 0.44, P = .042). However, DEI was not correlated with interventricular septum (R = 0.12) or LV lateral wall kmono (R = .11).
Conclusions: CMR measurements of abnormal interventricular septum displacement toward left ventricle is associated with increasing pulmonary vascular resistance and increased oxidative metabolism in RV free wall but not interventricular septum. This CMR index might be useful in predicting elevated oxygen consumption in RV free wall.
Oral Abstract Session
Refining cardiac risk assessment with imaging
Tuesday 7 May 2013, 16:30–18:00 Room 4 – A05
207
Incremental prognostic value of myocardial perfusion imaging in patients with renal dysfunction
M. Al-Mallah1; F. Khalid2; W. Qureshi2; K. Ananthasubramaniam2
1National Guard Hospital, King Abdulaziz Cardiac Center (KACC), Riyadh, Saudi Arabia; 2Henry Ford Hospital, Detroit, United States of America
Background: Coronary artery disease is the main cause of mortality and morbidity in patients with impaired renal function. The aim of this study is to evaluate the prognostic implications of single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in patients with impaired renal function.
Methods: We included 11,829 consecutive patients (mean age, 65 ± 12 years; 52% men) referred for SPECT-MPI between April 2004 and May 2009. Renal function was estimated using the estimated glomerular filtration rate (GFR) formula. Patients were followed up for a composite endpoint of all-cause mortality and nonfatal myocardial infarction (D/MI). Multiple nested Cox proportional hazard models were used to determine the incremental prognostic value of SPECT-MPI over clinical features and renal function.
Results: A total of 916 (8%) and 3,565 (31%) patients had GFR less 30 and between 30-60 mL/minute/1.73 m2 respectively. Patients with decreased GFR were more often older, with higher prevalence of conventional risk factors (P < .001). After a median follow-up of 5 years (25th to 75th percentiles, 3-6.5 years), 2578 (22%) patients experienced D/MI (764 MI and 2113 dead). The risk of death increased with worsening kidney function. At each stage of impaired renal function, patients with abnormal SPECT-MPI had increased hazard of adverse events (P < .0001). Using Cox regression, total perfusion defect offered improved discriminatory ability beyond traditional risk factors (area under the receiver operator curve [AUC] 0.742 vs 0.759, P < .0001).
Conclusions: SPECT-MPI adds incremental prognostic information to identify patients at higher relative risk of D/MI across a wide spectrum of renal function.
208
Which is the best method of risk stratification for coronary artery disease in octogenarians able to exercise?
A. Athanasios Katsikis1; A. Theodorakos1; A. Kouzoumi1; E. Kitziri1; N. Kollaros1; V. Tsapaki1; G. Kolovou2; M. Koutelou1
1Nuclear Cardiology Laboratory OCSC, Athens, Greece; 2Onassis Cardiac Surgery Center, 1st Department of Cardiology, Athens, Greece
Background: Although the elderly represent the fastest growing part of the population in developed countries, the best way to risk stratify them is yet to be determined. As this is especially true for octogenarians, we aimed at evaluating the relative value of two basic non invasive risk stratification methods for CAD in this population.
Methods: 183 patients (37 women, 146 men) aged >79 years with LVEF ≥ 40%, and interpretable ECGs, underwent exercise stress myocardial perfusion imaging (ESMPI) with the Bruce protocol. Duke treadmill score (DTS = duration of exercise in minutes −4 × angina index −5 × ST depression in mm) and summed stress score (SSS) in a 17 segments LV model graded in a 4 point scale were calculated and mortality and morbidity follow up data were collected per patient. Kaplan Meier analysis was used to determine survival free of death, myocardial infarction (MI), late revascularization (LR, >60 days after ESMPI) or combinations of these end points, by risk groups formed according to DTS and SSS.
Results: After a median duration of 7.4 years of follow up there were 36 deaths, 10 cardiac deaths (CDs), 5 MIs and 14 LRs. Neither DTS nor SSS was able to risk stratify for total or cardiac death. However SSS achieved to stratify the different risk groups for the composites of CD, MI or LR (P = 0.002) and MI or LR (P = 0.008) as well as for LR alone (P = 0,003). DTS was effective only in risk stratifying patients for LR (P < 0.001). Figure demonstrates curves of survival free of CD, MI or LR for SSS categories (low 0-2, medium 3-12, high >12).
Conclusions: Simple exercise testing provides limited risk stratification data in octogenarians with mildly reduced to normal systolic function in contrast to ESMPI which should be the preferred risk stratification method for this population.
KM survival free of CD, MI or LR
209
Prediction of five-year cardiac death by I-123 meta-iodobenzylguanidine imaging based on a Japanese multi-center prognostic database
K. Kenichi Nakajima1; T. Nakata2; S. Yamashina3; S. Matsuo1; S. Kasama4; T. Yamada5; M. Momose6; T. Matsui7; M. Travin8; A. Jacobson9
1Kanazawa University Hospital, Kanazawa, Japan; 2Sapporo Medical University, Sapporo, Japan; 3Toho University Omori Medical Center, Tokyo, Japan; 4Cardiovascular Hospital of Central Japan, Gunma, Japan; 5Osaka General Medical Center, Osaka, Japan; 6Tokyo Women’s Medical University, Tokyo, Japan; 7Shiga Hospital, Otsu, Japan; 8Albert Einstein College of Medicine, New York, United States of America; 9GE Healthcare, Princeton, United States of America
Purpose: I-123 meta-iodobenzylguanidine (MIBG) imaging has been widely used for assessment of prognosis in patients with chronic heart failure (HF). However, a robust model incorporating MIBG results for prediction of long-term occurrence of lethal cardiac events has not yet been developed. The aim of this study was to create a prediction model for lethal cardiac events in patients with HF using a Japanese multi-center MIBG database.
Methods: Data from 6 prospective MIBG studies performed in Japan between 1990 and 2009 were combined to make a pooled database of 1322 HF patients. Primary outcome event during extended follow-up was cardiac death, which included HF death, sudden cardiac death (SCD) and acute myocardial infarction (MI). Cardiac MIBG accumulation was quantified using early and late heart-to-mediastinum ratio (HMR) and washout rate (WR) calculated from anterior planar images. Kaplan-Meier survival and Cox proportional hazard analyses were performed. Based upon the latter, which showed HMR, NHYA class and age as significant variables, selected univariate logistic regression analyses of the subpopulation with known survival status at 5 years or later (n = 993) were performed to create prediction models for cardiac death.
Results: Kaplan-Meier survival analysis (n = 1322) showed that late HMR = 1.7 was the optimal threshold for discriminating high-risk patients for cardiac death (P = .0022, <.0001, <.0001 and .05 between HMR ≥ 1.7 and <1.7 for NYHA classes 1 to 4, respectively). In the subpopulation for logistic regression analysis, the average time of follow-up was 7.7 ± 4.3 years (range 0.08-14.6 years). A total of 205 cardiac deaths (22%) occurred including HF death (n = 132, 64%), SCD (n = 61, 30%) and acute MI (n = 12, 6%); mean ejection fraction and HMR were 36% ± 13% and 1.71% ± 0.33%, respectively. Using a univariate logistic regression prediction model for each NYHA class, estimated 5-year cardiac death rate in patients with late HMR = 1.2 was 26%, 38%, 52% and 62% for NYHA class 1 to 4, respectively, and that for HMR = 2.0 was 5%, 5%, 28% and 34%, respectively. The area under the receiver-operating characteristic curves for the prediction models was better in NYHA classes 1 and 2 (0.71, 0.71) compared with class 3 and 4 (0.61, 0.60).
Conclusion: The MIBG HMR provided improved cardiac mortality risk stratification in all NYHA classes. However, performance of the prediction model was better in patients with NHYA class 1 and 2 HF. This NYHA-based prediction model might be of value in the long-term management of HF patients.
210
The prognostic value of normal stress cardiac magnetic resonance in patients with known or suspected coronary artery disease: A meta-analysis
P. Paola Gargiulo1; S. Dellegrottaglie2; D. Bruzzese3; O. Scala1; D. Ruggiero1; C. D’amore1; G. Savarese1; S. Paolillo1; A. Cuocolo4; P. Perrone Filardi1
1University of Naples Federico II, Department of Clinical Medicine, Cardiovascular & Immunological Science, Naples, Italy; 2“Villa dei Fior” Hospital, Department of Cardiology and ICU, Naples, Italy; 3University of Naples Federico II, Department of Preventive Medical Sciences, Naples, Italy; 4University of Naples Federico II, Department of Biomorphological and Functional Sciences, Naples, Italy
Objectives: Aim of this study was to define the prognostic value of stress cardiac magnetic resonance (CMR) for prediction of adverse cardiac events in patients with known or suspected coronary artery disease (CAD).
Background: With stress CMR, ischemia detection is typically based on induction of myocardial perfusion defect (PD) and/or of wall motion abnormality (WMA). Single-center studies have shown the high value of stress-CMR for risk stratification.
Methods: Studies published between January 1985 and April 2012 were identified by database search. A study was included if used stress CMR to evaluate subjects with known or suspected CAD and provided primary data on clinical outcomes of non-fatal myocardial infarction (MI) or cardiac death with a follow-up time ≥3 months.
Results: Eleven studies (11,513 subjects) met inclusion criteria. The negative predictive value (NPV) for MI and cardiac death of normal CMR was 98.2% (95% confidence interval [CI], 97.3-98.9%) over a mean follow-up of 28.5 months, resulting in estimate event rate after negative test (ERNT) equal to 1.81% (95% CI, 1.06-2.74%). The corresponding annualized ERNT was 1.03%. Comparable NPVs for major coronary events were obtained in studies considering the absence of inducible PD compared with those evaluating the absence of inducible WMA (97.5% vs 94.7%, respectively; P = 0.225).
Conclusions: Stress CMR has a high negative predictive value for adverse cardiac events and the absence of inducible PD or WMA show a similar ability to identify low-risk patients with known or suspected CAD.
211
Coronary flow reserve assessment provides incremental prognostic value over clinical factors in subjects without perfusion defects on Rubidium-82 PET/CT
S. Sharmila Dorbala1; V.L. Murthy1; M. Naya1; C. Foster1; M. Gaber1; J. Hainer1; J. Klein1; R. Blankstein1; M.F. Di Carli1
1Brigham and Women’s Hospital, Boston, United States of America
Objective: To test the hypothesis that coronary microvascular dysfunction predicts progression of atherosclerosis and major adverse cardiac outcomes (MACE) in patients (Pts) without perfusion defects on Rubidium-82 MPI.
Methods: Consecutive Pts. with no known CAD, no perfusion defects and left ventricular (LV) ejection fraction (EF) >40% were included. Myocardial blood flow (MBF in mL/gm/minute) and coronary flow reserve (CFR, stress/rest MBF) were computed. The study endpoints included a composite of MACE (N = 87) over 2.0 ± 1.3 years (cardiac death, hospitalization for MI, unstable angina, CHF, new obstructive CAD/revascularization, new drop in LVEF).
Results: We studied 1176 Pts. (age 61.8 ± 12.6 years, 68% women, BMI 31.3 ± 9 kg/m2, LVEF 62% ± 9%), with hypertension (74%), dyslipidemia (55%), diabetes (29%) and chest pain or dyspnea (83%).
Pts. with MACE had lower stress MBF (2.3 ± 0.97 vs 2.1 ± 0.96, P = .04) and lower CFR (2.0 ± 0.67 vs 1.7 ± 0.61, P < .0001) compared to those without MACE.
The middle and lower CFR tertiles independently predicted MACE (Figure). Addition of CFR improved the model C-statistic (0.74-0.84, P = .005). Net reclassification improvement (<1% and >2%/year event rates) was 0.19 (95% CI, 0.077-0.293), the integrated discrimination improvement was 0.144 (95% CI 0.022-0.270).
Conclusions: Abnormal CFR provides incremental prognostic value in predicting progression of atherosclerosis and MACE by appropriately reclassifying risk in 19% of Pts. without perfusion defects.
Moderated Posters
Imaging cardiovascular disease mechanisms
Tuesday 7 May, 2013, 08:30–12:30 Poster Area
212
Short-Term statin fails to suppress plaque inflammation in acute coronary syndrome: Evaluation by fluorodeoxyglucose positron emission tomography/computed tomography
B.-H. Byung-Hee Hwang1; J.H. O1; C.-J. Kim1; E.-J. Han1; E.-H. Chu1; K.-B. Seung1; J.H. Narula2; K.-Y. Chang1
1The Catholic University of Korea, St. Mary’s Hospital, Seoul, Republic of Korea; 2Mount Sinai School of Medicine, Cardiovascular Institute, New York, United States of America
Objectives: We assessed the effect of early statin therapy on plaque inflammation in patients with acute coronary syndrome (ACS) by serial 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT).
Background: Recurrent adverse ischemic events frequently occur within the first month after ACS despite adequate statin therapy.
Methods: We enrolled twenty statin-naïve patients with ACS and non-calcified carotid plaques on ultrasound. After obtaining FDG PET/CT of carotid arteries, all patients received atorvastatin, followed by a second FDG PET/CT of carotid arteries after one month of therapy. 13 patients completed initial and follow-up FDG PET/CT of carotid arteries. Maximum standardized uptake values (SUVmax) of given carotid plaques as well as plasma cholesterol levels were measured and compared.
Results: We quantified and tracked the statin-modulated alterations in inflammation of FDG-positive plaques in 13 patients. Statin therapy failed to reduce plaque inflammation at 1 month after ACS (mean SUVmax 2.2 ± 0.5 at baseline vs 2.0 ± 0.3 after therapy; P = .174), while it significantly reduced plasma low-density lipoprotein cholesterol (LDL-C) (mean LDL-C 101.2 ± 21.1 mg/dL at baseline vs 70.7 ± 12.4 mg/dL after therapy; P < .001). Notably, statin reduced carotid FDG uptake in nine patients but did not in four patients. Changes in SUVmax and plasma LDL-C levels were not correlated (r = −0.15, P = .62).
Conclusions: Serial FDG PET/CT demonstrates that statin alone fails to consistently suppress plaque inflammation within one month in patients with ACS.
213
Impact of cardiac fatty acid metabolism in sub-acute phase on left ventricular functional recovery After Myocardial Infarction
Y. Yukio Arita1; S. Kihara2; H. Hiraoka3; Y. Matsuzawa3
1Department of Cardiology, Toyonaka Municipal Hospital, Toyonaka, Japan; 2Department of Biomedical Informatics, Graduate School of Medicine, Osaka University, Suita, Japan; 3Department of Cardiology, Sumitomo Hospital, Osaka, Japan
Left ventricular (LV) remodeling after acute myocardial infarction (AMI) is an important predictor of mortality. Cardiac fatty acid metabolism is associated with left ventricular function in heart failure. Here we investigated the association of cardiac fatty acid metabolism in sub-acute phase and functional recovery in chronic phase after AMI.
In 95 consecutive patients with AMI successfully treated with primary percutaneous coronary intervention (PCI), I-123 beta-methyliodophenyl pentadecanoic acid scintigraphy was performed 15 minutes and 3 hours after tracer injection within 10 days after AMI. Heart to mediastinal ratio (H/M), wash out rate in whole heart (WOR), WOR in non MI region (non-MI-WOR), and WOR in MI region (MI-WOR) were estimated from the polar map. LV ejection fraction (EF) and LV end-diastolic volume index (EDVI) was assessed with 99m-Tc-tetrofosmin quantitative gated single-photon emission computed tomography performed six months after AMI.
LVEF was correlated with peak CK (r = −0.54, P < .01), H/M (r = 0.29, P < .01), and MI-WOR (r = 0.19, P < .01). LVEDVI was correlated with peak CK(r = 0.49, P < .01), H/M (r = −0.42, P < .01), WOR (r = −0.26, P < .01), and MI-WOR (r = −0.24, P < .05). Multiple regression analyses revealed that LVEF was independently correlated with peak CK (r = −0.48, P < .01), H/M (r = 0.19, P < .05) and MI-WOR (r = 0.17, P < .05). Multiple regression analyses revealed that LVEDVI was independently correlated with peak CK(r = 0.40, P < .01) and H/M (r = −0.24, P < .05).
Altered cardiac fatty acid metabolism in sub-acute phase can predict LV functional recovery in AMI patients.
214
Detection of myocardial ischemia-reperfusion injury using vascular adhesion protein-1 targeting imaging agent
A. Anu Autio1; S. Uotila1; V. Kyto2; M. Kiugel1; H. Liljenback1; T. Saanijoki1; J. Knuuti1; S. Jalkanen3; A. Saraste1; A. Roivainen1
1Turku PET Centre, University of Turku & Turku University Hospital, Turku, Finland; 2Turku University Hospital, Turku, Finland; 3University of Turku, MediCity Research Laboratory, Turku, Finland
Purpose: Vascular adhesion protein-1 (VAP-1) mediates leukocyte trafficking into the sites of inflammation. Recently, we have shown that sialic acid-binding Ig-like lectin 9 (Siglec-9) is a granulocyte ligand for VAP-1 and 68Ga-Siglec-9 peptide can be used as a positron emission tomography (PET) tracer for in vivo imaging of inflammation. We hypothesized that 68Ga-Siglec-9 peptide would facilitate monitoring of the inflammatory processes associated with myocardial ischemia-reperfusion (I-R) injury.
Methods: The myocardial uptake of 68Ga-Siglec-9 was evaluated in rats subjected to temporary myocardial ischemia by transient surgical ligation of the left coronary artery (LCA). The LCA was ligated for 8-12 minutes (group 1, n = 3) or 20 minutes (group 2, n = 5) followed by a reperfusion of 24 hours. In addition, group 3 consisted of rats with 8 minutes ligation and 4-6 hours reperfusion (n = 3). The animals were injected with 36 ± 12 MBq of 68Ga-Siglec-9. Thirty minutes after injection, heart was excised, cut in short-axis slices and stained with triphenyltetrazolium chloride (TTC) for detection of infarcted myocardium. 68Ga-Siglec-9 uptake was measured from cryosections of the left ventricle with autoradiography. Luminal VAP-1 induction was evaluated by immunohistochemical staining of intravenously injected anti-VAP-1 antibody.
Results: All group 2 animals with 20 minutes ligation of LCA showed large TTC positive area of myocardial infarction and increased 68Ga-Siglec-9 uptake in the damaged myocardium compared to preserved myocardium (3.5-fold, P = .002). Although hearts of rats with 8-12 minutes ligation were TTC negative, there was increased 68Ga-Siglec-9 uptake in the area supplied by the left coronary artery. The immunohistochemical staining showed VAP-1 positive vessels in the left ventricle.
Conclusion: The 68Ga-Siglec-9 peptide accumulates in damaged myocardium after transient occlusion of LCA in rats. Further studies are warranted to clarify the value of 68Ga-Siglec-9 PET for the evaluation of I-R severity and recovery.
215
Evidence of systemic plaque vulnerability in acute coronary syndromes with FDG-positron emission tomography and computed tomographic angiography in the BIOCORE-2 study
F. Hyafil1; V. Duchatelle2; E. Sorbets1; F. Rouzet1; L. Mehanaoui2; G. Ducrocq2; D. Le Guludec1; L. Feldman2
1AP-HP—Hospital Bichat-Claude Bernard, Department of Nuclear Medicine, Paris, France; 2AP-HP—Hospital Bichat-Claude Bernard, Department of Cardiology, Paris, France
Purpose: Atherosclerotic plaque vulnerability is a systemic phenomenon and is often associated with a high plaque density of inflammatory cells. 18Fluoro-deoxyglucose (FDG) accumulates in inflammatory cells of atherosclerotic plaques where it can be measured by positron emission tomography (PET), providing an opportunity for non-invasive functional imaging of atherosclerosis. High FDG uptake has been reported in carotid arteries of patients with recent strokes. The aim of this study was to assess whether FDG uptake in the aorta and carotid arteries is associated with morphological markers of plaque instability detected with computed tomography angiography (CTA); and is higher in patients with acute coronary syndromes (ACS) than in patients with stable coronary artery disease (CAD).
Methods: Patients with ACS (n = 50) or stable CAD (n = 28) underwent a PET 90 minutes after iv injection of 5 MBq/kg FDG followed by a CTA of the thoracic aorta and carotid arteries. Tissue-to-background ratios (TBRs) were calculated by dividing maximal standard uptake value (SUV) of the arterial wall by the mean SUV of blood. A global TBR was calculated in each patient as the average of the TBRs from the thoracic aorta and the 2 carotid arteries. Atherosclerotic plaques were classified with CTA as non-calcified/mixed/calcified, and smooth/irregular.
Results: Aortic, carotid and global TBRs were higher in patients with ACS than in patients with stable CAD (1.78 ± 0.19 vs 1.61 ± 0.18; 1.84 ± 0.35 vs 1.64 ± 0.17; 1.81 ± 0.23 vs 1.62 ± 0.16; P < .05 for all). Patients in the highest quartile of global TBR had a higher percentage of non-calcified and irregular plaques in the thoracic aorta and carotid arteries as compared to patients in the lowest quartile of global TBR.
Conclusions: FDG uptake in the thoracic aorta and carotids correlates with morphological markers of plaque instability as assessed by CTA and is higher in patients with ACS. Further studies are required to determine whether PET-FDG of the thoracic aorta and carotid arteries could be used as a surrogate marker for plaque instability in the coronary arteries.
216
Evaluation of myocardial perfusion, metabolism and sympathetic may offer further risk stratification in the management of patients with Takotsubo cardiomyopathy
S. Shinro Matsuo1; K. Nakajima1; K. Okuda1; H. Wakabayashi1; J. Taki1; M. Tobisaka1; S. Kinuya1; M. Yamagishi1;
1Kanazawa University, Kanazawa, Japan
Backgrounds: Takotsubo cardiomyopathy is a heart syndrome with an acute onset defined by chest symptoms, ST segment elevation on electrocardiograms. The entity was named because of the left ventricular apical ballooning event on coronary ventriculography, the shape of which looks like a Takotsubo, a vessel that is used in Japan to trap octopus. Octopus is tako, and pot is tsubo in Japanese. Patients with Takotsubo cardiomyopathy are sometimes misdiagnosed as having acute myocardial infarction. Several studies reported the utility of nuclear imaging including I-123-iodophenyl-3(R,S)methylpentadecanoic acid (BMIPP), I-123-metaiodobenzylguanidine (MIBG), and perfusion scintigraphy (thallium-201, Tc-99m-sestamibi, Tc-99m-tetrofosmin). However, few data exist regarding the clinical impact of nuclear imaging on diagnosis and follow-up of Takotsubo cardiomyopathy.
Methods: We examined 25 patients (aged 69 ± 14) with Takotsubo cardiomyopathy. All patients were studied with resting BMIPP or MIBG in comparison to perfusion imaging. MIBG myocardial scintigraphy was performed 15 minutes and 3 hours after the injection. BMIPP were imaged after 20 minutes after the injection.
Results: Coronary angiography showed the absence of stenotic regions in the subjects. Regional abnormal BMIPP uptake of the myocardium was seen in patients with Takotsubo cardiomyopathy (86%), with complete or partial agreement with perfusion imaging. Abnormal BMIPP uptake was observed more frequently than wall motion abnormalities. Regional 123I-MIBG abnormality was observed in patients with Takotsubo cardiomyopathy (100%) and the abnormalities were observed exclusively in the apical region (total defect score (TDS); 13 ± 4). The discrepancies between myocardial MIBG uptake and perfusion suggest the stunned myocardium in the apical region. The MIBG abnormality recovers later than the improvement of perfusion. Global MIBG uptake shown by the heart-to-mediastinum ratio was lower in patients with Takotsubo cardiomyopathy than that of normal control subjects (2.3 ± 0.3 vs 2.6 ± 0.2, P < .05). The degree of damage in BMIPP ranged from moderate to severe at sub-acute phase, but had almost normalized at chronic phase in patients with Takotsubo cardiomyopathy (total defect score; 6.6 ±4 vs 1.4 ± 1, P < .05). High total defect score is associated with recurrence of hospital admission.
Conclusion: The serial changes in myocardial fatty acid metabolism and sympathetic nerve function could give us information on the severity and risk of patients with Takotsubo cardiomyopathy.
217
Tc-99m-Annexin-V Uptake correlates with Left Ventricular Remodeling in Rats with Ischemia and Reperfusion
J. Junichi Taki1; H. Wakabayashi1; A. Inaki1; F.G. Blankenberg2; J.F. Tait3; I. Matsunari4; S. Kinuya1
1Kanazawa University Hospital, Kanazawa, Japan; 2Lucile Salter Packard Children’s Hospital, Stanford, United States of America; 3University of Washington, Seattle, United States of America; 4Medical and Pharmacological Research Center Foundation, Hakui, Japan
Background: Tc-99m-Annexin-V (Tc-Annex) imaging has been proved to be feasible to detect phosphatidylserine which externalize on the outer cell membrane in the early process of apoptosis. To determine whether apoptotic process correlates with left ventricular (LV) remodeling after myocardial infarction, we studied Tc-Annex uptake in rat model of myocardial ischemia and reperfusion.
Methods: In 15 rats, the left coronary artery was occluded for 20-30 minutes followed by reperfusion for 2 weeks. At the time of study, Tc-Annex (80-150 MBq) were injected, and 1 hour later, to verify the area at risk, Tl-201 (0.74 MBq) was injected intravenously just after the left coronary artery re-occlusion and the rats were sacrificed 1 minute later. Dual tracer autoradiography was performed to assess Tc-Annex uptake and area at risk demonstrated by perfusion defect by Tl-201. Tc-Annex uptake ratio was calculated by dividing the Tc count density of the area at risk by that of the non-ischemic area. In short axis LV slices, LV cavity dilatation index was calculated by dividing the area of LV cavity by that of the LV muscle area. LV wall thinning ratio was calculated by dividing the LV wall thickness in the area at risk by that of the non-ischemic LV area.
Results: In visual analysis, significant Tc-Annex uptake was observed in the area at risk in 10 rats. In the rest of 5 rats, no significant Tc-Annex uptake was observed. Area at risk was not different in rats with and without Tc-Annex uptake (Area ratio of area at risk to whole LV area were 0.52 ± 0.09 and 0.41 ± 0.18, respectively, P = ns). However, LV cavity dilatation index was significantly higher in rats with Tc-Annex uptake than in rats without (0.22 ± 0.088 vs 0.068 ± 0.039, respectively, P < .005). LV wall thinning ratio was more smaller in rats with Tc-Annex uptake than in rats without (0.66 ± 0.10 vs 1.08 ± 0.048, respectively, P < .0001). LV cavity dilatation index and wall thinning ratio were positively and negatively correlated with Tc-Annex uptake ratio, respectively (r = 0.69 (P = .0045) and r = −0.81 (P = .0002), respectively).
Conclusions: These data suggested that Tc-99m-Annexin-V uptake in injured myocardial area correlates with LV remodeling at 2 weeks after myocardial ischemia and reperfusion.
218
The assessment of intramural fibrosis in hypertrophic cardiomyopathy. A new indication for Cardiac CT?
C. Langer1; M. Hohnhorst1; M. Lutz1; M. Eden1; C. Gierloff2; P. Schaefer2; M. Both2; C. Prinz3; L. Faber3; N. Frey1;
1University Hospital of Schleswig-Holstein, Campus Kiel, Department of Cardiology, Kiel, Germany; 2University Hospital of Schleswig-Hostein, Campus Kiel, Department of Radiology, Kiel, Germany; 3Heart and Diabetes Center NRW, Ruhr-University of Bochum, Department of Cardiology, Bad Oeynhausen, Germany
Background: Hypertrophic cardiomyopathy (HCM) is associated with a certain risk of sudden cardiac death (SCD). SCD usually due to ventricular fibrillations is caused by intramural fibrosis (IF). The reference standard for the detection of IF is magnet resonance imaging (MRI) by showing late enhancement (LE) in such areas. But: there is the need of alternative methods. Computed tomography (CT) was shown to reliably demonstrate scar after myocardial infarction. There is very scarce data about CT in the diagnosis of HCM. This study was initiated to prove CT to detect IF in unselected HCM patients.
Methods: This ongoing validation study was approved by the local ethics committee and the German Federal Office for Radiation Protection. At the time of abstract submission we had successively recruited patients echocardiographically suspected HCM (interventricular septum, IVS; ≥ 15 mm). All patients undergo cardiac CT (64 slices) followed by cardiac MRI (Avanto, 1.5T) for assessment of ventricular configuration, volumetry and IF. In cardiac CT the scan is run 7 minutes after injection of contrast medium (2 mL/kg body weigh) in order to detect IF by showing late enhancement (LE). Cardiac MRI for detection of IF is done according to an established protocol. CT based LE is identified visually proved by a significant increase of the regional average HU value when compared to remote myocardium measured in the opposite LV-segment. For analysis of LE presence, distribution and intensity we use the established 17 segment LV model (polar map). For this statistical analysis we only considered patients presenting with LE.
Results: At the time of abstract submission 24 patients (64.0 ± 14.5 years of age; male n = 14) had been recruited diagnosed in echo (IVS 18.1 ± 2.0 mm; E/A 0.8 ± 0.3). So far, of these patients n = 15 presented with LE in both modalities. IF distribution is congruent is observed more often in the basal and mid-ventricular segments as demonstrated in the established 17-segment-model (polarmap). In the areas of suspected IF cardiac CT based LE presented with an average HU value of 154.4 ± 30.9 which is similar to the value left ventricular cavum (158. 3 ± 35.0; P .73) but significantly higher when compared to normal myocardium (92.0 ± 18.0; P < .005). The effective dose using our protocol was 3.43 ± 0.57 mSv for men and 4.98 ± 1.06 mSv for women.
Conclusion: Cardiac CT can detect intramural fibrosis in HCM. Thus, in case of MRI contraindications cardiac CT may be an alternative method for the assessment of HCM patients. However the applied scan protocol needs to be further optimized.
219
Impaired myocardial glucose uptake assessed by 18F-FDG PET under hyperinsulinemic-euglycemic clamp correlate with reduced level of hexokinase 2 expression in a rat model of type 2 diabetes mellitus
F. Franz Kaiser1; T. Pelzer2; P. Arias-Lloza3; M. Kreissl4; T. Higuchi5
1University Hospital Würzburg, Department of Nuclear Medicine, Würzburg, Germany; 2University Hospital Wuerzburg, Department of Internal Medicine I, Pneumology, Cardiology, Würzburg, Germany; 3University Hospital Wuerzburg, Department of Internal Medicine I, Cardiology, Würzburg, Germany; 4Hospital Augsburg, Department of Nuclear Medicine, Augsburg, Germany; 5University Hospital Wuerzburg, Comprehensive Heart Failure Center, Würzburg, Germany
Myocardial insulin resistance, an impaired ability to invoke glucose uptake by insulin stimulation, has been suggested to be an important etiologic factor for diabetic cardiomyopathy. A combination of 18F-FDG PET and hyperinsulinemic-euglycemic clamp allows analyzing the status of the local cardiac insulin resistance. Using the Zucker diabetic fatty (ZDF) rat, a model of type 2 diabetes mellitus, we assessed the cardiac glucose uptake under hyperinsulinemic conditions and examine correlation with gene expression of glucose metabolism biomarkers.
Methods: ZDF rats and control (ZL) rats were studied at age 13 weeks. Under hyperinsulinemic and euglycemic conditions, 37 MBq of 18F-FDG were administered via the tail vein, followed by a dynamic 60 minutes PET acquisition. Cardiac 18F-FDG uptake was determined and compared with biomarkers of glucose metabolism in the heart including GLUT4, hexokinase II, insulin receptor substrate (IRS) 1 and IRS2.
Results: Cardiac 18F-FDG uptake under hyperinsulinemic-euglycemic conditions decreased in ZDF rats compared to ZL controls (SUV: 3.81 ± 2.12 vs 8.05 ± 2.26, P < .01). Expression of IRS1 and IRS2 in the heart showed a significant increase in ZDF rats compare to ZL controls (0.98 ± 0.07 vs 0.71 ± 0.33, P < .05 and 0.75 ± 0.16 vs 0.42 ± 0.27, P < .01, respectively) and GLUT4 and hexokinase II expression showed a significant decrease (1.50 ± 0.21 vs 1.76 ± 0.31, P < .05 and 0.41 ± 0.29 vs 0.81 ± 0.26, P < .01, respectively). There was a positive correlation between 18F-FDG uptake and hexokinase II expression (y = 0.10x + 0.02 R² = 0.56, P < .01), but not for the expression of GLUT4, IRS1 and IRS2.
Conclusion: 18F-FDG PET non-invasively visualized altered myocardial glucose metabolism of insulin resistance in a rat model of type 2 diabetes mellitus. Furthermore, an important role of cardiac hexokinase II expression for the glucose intake reduction under insulin stimulation was emphasized.
Poster Session 3
Imaging cardiovascular disease mechanisms
Tuesday 7 May 2013, 08:30–12:30 Poster Area
222
In asymptomatic patients a score of carotid plaque higher than 6 is a strong predictor of myocardial ischemia assessed by SPECT
V.D. Victor Daniel Martire1; E.R. Pis Diez1; M.V. Martire1;
1CESALP, Fundación Horacio Corrada, La Plata, Buenos Aires, Argentina
Objective: To assess the incidence and severity of inducible myocardial ischemia in patients (P) with different degrees of carotid vascular disease (CVD), using data from the neck carotid Doppler ultrasound (CDU) and from the functional imaging study of de radioisotope myocardial perfusion (SPECT).
Method: A number of 397 asymptomatic P were consecutively studied, 251 men and 146 women with a mean age of 65 ± 9 years old, with multiple cardiovascular risk factors and high pre-test probability of coronary artery disease according to clinical scores. CDU and SPECT were used and P were divided into 5 groups according to the degree of CVD (quantitatively assessed by the sum of intima-media and/or plaque thickness in mm: Plaque Score (PS): G1 (Control, n: 50 P): With no carotid alterations: PS: <1.1 mm, G2 (n: 150 P): With intima/media thickness: between 1.1-1.5 mm, G3 (n: 88 P): PS: between 1.5-6, G4 (n: 62 P): PS: between 6-12, G5 (n: 47 P): PS: >12. Determination of ischemia incidence in each group and correlation between PS was performed by means of CDU and the summed differential score (SDS) by means of SPECT.
Result: Incidence: among all 397 P, 169 evidenced inducible myocardial ischemia (42%): G1: 14 P (28%), G2: 41 P (26%). G3: 30 P (34%). G4: 45 P (72%), G5: 39 P (83%). Correlation between SDS/PS: r: 0.93, P < 0.008.
Conclusion: In asymptomatic patients with multiple risk factors myocardial ischemia was evidenced in all the groups, with high incidence and severity in those P with more extensive carotid artery disease quantified by Plaque Score using carotid Doppler ultrasound.
223
Appropriate use criteria for stress myocardial perfusion SPECT: Applicability and analysis of temporal trends in compliance
A. Alfonso Dos Santos1; J.D. Peirano1; M. Montivero1; G. Rank1
1Sanatorio Mater Dei, Buenos Aires, Argentina
Purpose: Appropriateness Use Criteria (AUC) for Myocardial Perfusion Imaging (MPI) provide information about the best current use of tests and procedures in specific indications. The aim of our study was to assess the applicability in daily practice of the AUC, and to evaluate temporal trends in compliance.
Methods: We prospectively applied the 2009 version of AUC to 836 consecutive patients (P) who underwent SPECT MPI between July 2009 and June 2010 (Group A), and compare them to a second cohort of 693 consecutive P collected between July 2011 and June 2012 in the same single clinical center (Group B). Two experienced nuclear cardiologists assigned, whenever possible, a specific scenario from the AUC that was classified as appropriate, uncertain, or inappropriate.
Results: Of the 1529 P enrolled, only 10 (0.01%) were unclassifiable. Overall, 824 P (54%) were judged as appropriate, 288 (19%) as uncertain and 407 (27%) as inappropriate. We found a significant decrease in the number of inappropriate indications in the temporal comparison, with 243 studies (29%) in Group A and 164 (24%) in Group B (P = 0.02). Table shows the most frequent indications and temporal trends in each one. Risk assessment less than 2 years after percutaneous coronary intervention was the only indication that showed a significant decrease in the temporal comparison.
Conclusions: Application of AUC was feasible in daily practice, with very few P unclassifiable. The number of inappropriate studies observed remains high, although showing a significant decrease in the temporal trend. Analysis of performance measures under this instrument may help identify areas where educational efforts are needed towards a more rational use of technology.
Indications in order of frequency
Indication | Group A | Group B | P | AUC | |
|---|---|---|---|---|---|
1 | Ischemic equivalent in patient with intermediate pretest probability of CAD, electrocardiogram interpretable and able to exercise | 127 (15%) | 116 (17%) | ns | A |
2 | Asymptomatic patient, more or equal than 2 years after PCI | 104 (12%) | 93 (13%) | ns | U |
3 | Detection of CAD in patient with intermediate risk (ATP III criteria) | 76 (9%) | 52 (7.5%) | ns | I |
4 | Evaluation of ischemic equivalent in patient postrevascularization (PCI or CABG) | 67 (8%) | 52 (7.5%) | ns | A |
5 | Asymptomatic patient <2 years after PCI | 62 (7.5%) | 33 (4.8%) | .02 | I |
6 | Asymptomatic patient, more or equal than 5 years after CABG | 43 (5.1%) | 47 (6.8%) | ns | A |
224
Incremental prognostic value of myocardial perfusion SPECT in asymptomatic diabetic patients
E. Zampella1; W. Acampa1; S. Daniele1; R. Assante1; M. Plaitano1; M. Tuccillo1; N. Frega1; A. Boemio1; M. Petretta1; A. Alberto Cuocolo1
1University Federico II, Napoli, Italy
Stress myocardial perfusion single-photon emission computed tomography (MPS) variables are robust estimators of prognosis. No data are available on the comparative ability of stress MPS risk markers using varied iterative and risk classification approaches in asymptomatic diabetic patients. We compared analytical approaches to estimate the added value of MPS variables in estimating coronary artery disease (CAD) outcomes in asymptomatic diabetic patients. We also evaluated the temporal characteristics of cardiac risk according to MPS findings.
Methods: A total of 436 asymptomatic diabetic patients who underwent stress/rest gated MPS were prospectively enrolled. Multivariable Cox proportional hazards model were employed to estimate CAD death or myocardial infarction (MI). Risk reclassification was calculated and parametric survival analysis was used to predict time to events.
Results: At multivariable analysis summed stress score and post-stress left ventricular ejection fraction (LVEF) were significant predictors of CAD death or MI. The net reclassification improvement (NRI) by adding MPS results to a model including pre-test CAD likelihood was 0.26 (95% confidence interval 0.7 to 0.45; P < .001). The parametric survival analysis showed the highest probability of CAD death or MI and the major acceleration in time in patients with abnormal MPS and post-stress LVEF < 45%.
Conclusion: In asymptomatic diabetic patients, analytical approaches that establish the reclassification of events may serve as a quality imaging methodology for estimation of improved health outcomes for stress MPS. Stress-induced ischemia and post-stress LVEF by gated MPS also influence the temporal characteristic of the patient’s risk at long-term follow-up.
225
Prognostic significance of negative myocardial single photon emission computed tomography studies among patients with chronic renal impairment
M. Mohamed Mandour Ali1; A.H. Allam1
1Al-Azhar University, Department of Cardiology, Cairo, Egypt
Background: Prognostic value of a negative myocardial single photon emission computed tomography (SPECT) study is well established in literature. We thought to investigate for the prognostic value of a negative SPECT study among patients with chronic kidney disease (CKD).
Methods: Study cohort consisted of 193 consecutive patients with CKD referred for a clinically indicated myocardial SPECT imaging. 5 patients were excluded due to non-cardiac deaths during the follow up period. 92 (48.9%) out of the study cohort were on regular hemodialysis (group I), 27 (14.4%) had uncomplicated renal transplantation surgery after variable period of hemodialysis (group II) and 69 (36.7%) out of them had chronic renal impairment (CRI) (GFR < 45) required neither regular dialysis nor renal transplantation (group III). SPECT studies were reported as negative for myocardial ischemia in all study population. End points (cardiac death, STEMI/NSTEMI, HF and documented arrhythmia) at 6 months; 1 and 2 years were traced.
Results: Total cardiac events at one year were 17 (18.5%); one (3.7%) and 3 (4.3%) in groups I, II and III respectively (P value < .05). Total cardiac events at 2 years were 21 (22.8%); 3 (11.1%) and 7 (10.1%) in groups I, II and III respectively (P values < .005). Hard cardiac events (cardiac death, STEMI/NSTEMI) were 2 (2.1%), 0% and 0% in groups I, II and III respectively (P value = .5) at one year; and 9 (9.7%), 1 (3.7%) and 2 (2.9%) at 2 years in groups I, II and III respectively (P value < .05).
Conclusion: CKD patients on regular hemodialysis have a higher total cardiac event rate at one and 2 years, and still have a higher hard cardiac event rate at 2 years of follow up even after a negative SPECT study. This group of patients should be followed up more closely, however, a large scale study is needed in this area to clarify and state applicable guidelines.
226
Myocardial viability assessment by rest-redistribution thallium-201 myocardial perfusion scintigraphy in acute left ventricular failure: Improved efficacy by solid state detector gamma camera
A. Atul Verma1; S. Pandey1; R. Jeyachandran1; S. Balani1; M. John1
1Fortis Escorts Heart Institute, New Delhi, India
Purpose: To find out the efficacy of solid state detector over the conventional gamma camera using low dose Tl-201 for myocardial hibernation by Gated Rest-Redistribution study (G-RRT) in cases with increased lung uptake interfering with exact estimation of myocardial hibernation due to over subtraction and normalization.
Materials and Methods: 37 subjects with gross left ventricular dysfunction(LVEF ≤ 25%) and increased lung uptake during immediate post injection phase of the study were subjected to scanning under both Siemen’s-Symbia S (dual head conventional gamma camera) & GE’s dicovery NM 530C (solid state detector). All the subjects were injected low dose(1.5 mci of Tl201) and were imaged under both the cameras with scanning times of 12 and 5 minutes each for symbia-S & Discovery NM 530C respectively. The acquired images were processed using butterworth filter of 4.5 & order of 5 for Symbia-S & 3D iterative reconstruction for Discovery NM 530°C. The processed images were compared using the segmental LV myocardial distribution as well as myocardial contractility and centripetal excursion on a gated study.
Observations: All the 37 patients with increased lung uptake and scanned under Symbia S gamma camera, showed photopenicity in anterior/anteroseptal & apical walls during immediate rest imaging with diffuse synergy (Low count images). On redistribution, 15 subjects showed no redistribution, 13 showed partial refilling and 9 showed a near total refilling. These findings were compared with the processed images of Discovery NM-530C. The results were found to be comparable in cases with fixed or partial refilling but with improved image quality of gated SPECT showing definite Akinesia/hypokinesia. Of the remaining 9 cases which showed a near total refilling, 5 showed the same results inferred as myocardial hibernation; 4 showed maintained myocardial uptake with akinesia in 2 cases inferred as Stunned myocardium; and the rest 2 cases showed maintained contractility & photopenicity may be ascribable to over subtraction by lung uptake and inferred as non ischaemic cardiomyopathy.
Discussion: The improved image quality including gated SPECT by Semiconductor detector gamma camera infers increased efficacy over conventional cameras in detection of myocardial hibernation in cases with significant lung uptake even at low doses of Tl201. This is because of small field of view and direct conversion of energy into counts and high energy and spatial resolution of solid state technology. Also quality gated study helps in demarcation of myocardium from lung uptake & thus negates the use of Tc99m reinjection for the same.
227
Prognostic value of multidetector computed tomography and exercise electrocardiography in patients with suspected coronary artery disease: A long-term follow-up
G. Gianluca Pontone1; D. Andreini1; E. Bertella1; S. Mushtaq1; S. Cortinovis1; A.D. Annoni1; A. Formenti1; A. Baggiano1; G. Ballerini1; M. Pepi1;
1University of Milan, Foundation Monzino (IRCCS), Center Cardiology, Department of Cardiology, Milan, Italy
Purpose: To perform a comparison of the prognostic performance of multidetector computed tomography (MDCT) vs exercise electrocardiography (ex-ECG) in patients with suspected coronary artery disease (CAD).
Methods and Materials: We enrolled 681 patients (age 61.3 ± 10.4 years, 461 men) with atypical or typical angina and no history of CAD. All patients underwent ex-ECG and MDCT and were followed-up for 44 ± 12 months. The endpoints were “all cardiac events”, defined as non-fatal myocardial infarction, cardiac death and revascularization, and “hard cardiac events”, defined as all cardiac events excluding revascularization.
Results. Ex-ECG and MDCT were rated as positive in 419 (61%) and 274 (40%) out of 681 patients, respectively. In univariate analysis, both ex-ECG and MDCT were predictors of all cardiac events (HR: 2.09 [1.5-2.8], P < .0001 and HR: 21.1 [14.6-30.5], P < .0001, respectively) and hard cardiac events (HR: 1.9 [1.1-3.2], P = .02 and HR: 6.8 [3.9-12.0], P < .0001, respectively), while in a multivariate analysis CAD 50% stenoses detected by MDCT was the only independent predictor of hard cardiac events. Stratifying our population on ex-ECG and MDCT findings, Kaplan-Meier curves showed that ex-ECG provides only a further risk stratification in the subset of patients with low to intermediate likelihood of CAD and positive MDCT.
Conclusions: MDCT may show a higher prognostic value as compared to ex-ECG in patients with suspected CAD, mainly in those with a low-to-intermediate pre-test likelihood of CAD. In this clinical setting, MDCT may be a better diagnostic tool and may play a key role for prognostic stratification in a combined anatomical and functional assessment workflow.
228
18F-FDG PET/CT evaluation of carotid plaque: Correlation to histological status
A. Artor Niccoli Asabella1; A. Di Palo1; A. Notaristefano1; C. Ferrari1; M. Fanelli1; G. Rubini1;
1Universitary PolIclinic of Bari—Nuclear Medicine—D.I.M., Bari, Italy
Purpose: Inflammation, plaque erosion and consequent embolism are the main cause of acute cardiovascular events which usually result from the sudden rupture of macrophage-rich atherosclerotic plaques. The interior of a plaque is an anaerobic area, so glucose is the major substrate for macrophages. The aim of this study was to evaluate a relationship between 18F-FDG uptake in PET/CT and histology in carotid artery plaques.
Materials and Methods: We studied 31 patients, with ultrasound diagnosis of carotid plaque with stenosis of although 70% and candidated to endoarterectomy, who performed 18F-FDG PET/CT. Plaques, removed during carotid endarterectomy, were histologically analyzed. Arterial 18F-FDG uptake in the neck was measured by drawing a region of interest (ROI) around the artery on every slice of the coregistered transaxial PET/CT images. On each image slice, the SUV max and SUV mean of 18F-FDG in the ROI (containing the arterial wall and the lumen) was calculated as the maximum pixel activity. We calculated also the Target Backround Ratio max (TBR max) as the SUV max normalized to venous SUV max (measured by drawing a ROI around the superior cava vein). We calculated also the Target Backround Ratio mean (TBR mean) as the SUV mean normalized to venous SUV mean.
Results: A statistically significant difference was observed in TBR mean value in relation with presence or absence of fibro-fatty infiltration (1.50 vs 1.25; t = 2.05, P = .05). A statistically significant difference was observed in TBR mean value in relation with value of BMI between 25 and 29 (1.47 vs 1.12; t = 2.57; P = .02). A statistically significant Pearson’s correlation was observed between SUV max of carotid plaque and SUV max of aortic arch (r = 0.793, P = 0) and between SUV mean of carotid plaque and SUV mean of aortic arch (r = 0.838, P = 0).
Conclusions: Our results find an association between plaque FDG uptake, evaluated in particular with TBR mean, and fibro-fatty infiltration and underline vascular inflammation, predominantly in the form of macrophages. We confirm the role of PET imaging has as a biomarker of the metabolic activity of atherosclerosis. 18F-FDG PET/CT is able to identify symptomatic lesions and should help the identification of patients at high risk of cardiovascular events.
229
The relationship between serum PAPP-A concentration with plaque morphology and coronary artery perfusion
V. Valtteri Uusitalo1; A. Saraste2; S. Wittfoot3; S. Kajander1; H. Ukkonen2; M. Pietila2; J. Airaksinen2; K. Pettersson3; J. Knuuti1
1Turku PET Centre, University of Turku & Turku University Hospital, Turku, Finland; 2Turku University Hospital, Department of Internal Medicine, Division of Cardiology, Turku, Finland; 3Department of Biotechnology, Turku, Finland
Purpose: Pregnancy-associated plasma protein-A (PAPP-A) is a metalloproteinase that is highly expressed in atherosclerotic plaques. Elevated circulating PAPP-A level in acute coronary syndromes or stable coronary artery disease (CAD) has been proposed as a biomarker of risk for future cardiac events. We wanted to study the relationship between circulating PAPP-A level and atherosclerotic plaque morphology or myocardial blood flow as assessed by computed tomography angiography (CTA) and positron emission tomography (PET).
Methods: 76 patients with intermediate likelihood of CAD (age 63 ± 7 years) underwent coronary CTA and myocardial perfusion PET with O15 water using hybrid scanner. Blood sample was obtained for measurement of serum PAPP-A concentration with immunofluorometric assay. All patients underwent invasive coronary angiography (ICA) to detect haemodynamically significant CAD defined as stenosis >70% or FFR <0.80. Coronary arteries were divided to 17 segments and plaques in these segments labeled as soft (non-calcified), mixed or calcified plaques by CTA. For summed stenosis score (SSS) stenoses were scored as 1 (<30%), 2 (30-49%), 3 (50-69%) and 4 (>70%). Coronary calcification was quantified by Agatston coronary calcium score (CCS).
Results: PAPP-A concentration was comparable in patients with and without haemodynamically significant CAD by ICA (1.52 ± 3.38 vs 0.95 ± 0.66 mIU/L, P = .82). PAPP-A concentration was not associated with global coronary flow reserve by PET (r = −0.09, P = .52), SSS by CTA (r = 0.09, P = .46) or CCS (r = 0.12, P = .31). There were also no correlations between the number of mixed or calcified plaques and PAPP-A (r = 0.07, P = .48 and r = 0.08, P = .57). However, in a subgroup of patients without haemodynamically significant coronary stenosis (n = 46), patients with soft plaque (n = 15) had greater PAPP-A concentration than patients without (n = 31) soft plaques (1.12 ± 0.58 vs 0.88 ± 0.70 mIU/L, P = .045).
Conclusions: PAPP-A concentration was comparable in patients with and without flow-limiting coronary artery stenosis. However, PAPP-A concentration was higher in patients with non-calcified plaques as detected by CTA. In addition to soft plaque phenotype by CTA, elevated PAPP-A could be useful risk marker of coronary events in patients with non-obstructive CAD.
230
Significance and outcomes of strongly positive stress test in the setting of low risk myocardial single photon emission computed tomography scans; highlights from Egyptian population
M. Mohamed Mandour Ali1; A.H. Allam1
1Al-Azhar University, Department of Cardiology, Cairo, Egypt
Background: Stress test and myocardial SPECT studies are very widely utilized tools in CAD evaluation. We thought to investigate for cardiac outcomes of positive stress test in the setting of negative SPECT study.
Methods: 415 consecutive patients were enrolled, 202 (48.7%) patients had a negative stress test and perfusion scan (group I) and 213 (51.3%) patients had positive stress test and negative perfusion scan (group II). Significantly positive stress test was defined as >1 mm of horizontal ST depression 80 ms. after J point. Patients with prior PCI/CABG, pre-excitation syndromes, pacemakers, baseline/rate dependent LBBB and/or positive SPECT scans were excluded. Coronary calcium score was done in all patients. 246 patients underwent either coronary angiography or CT angiography based on the clinical decision of the referring MD. “117 in group I and 129 in group II”.
Results: Mean interventricular septal (IVS) thickness (mm) was 1.21 ± 0.15 and 1.29 ± 0.1 in groups I and II (P value < .05). Coronary stenosis (>50%) was seen in 3 (1.5%) and 5 (2.3%) patients in groups I and II (P value = .5). At one year, 1 (0.5%) and 3 (1.4%) hard cardiac events (cardiac death, STEMI/NSTEMI) happened in groups I and II respectively (P value = .5). At 2 years 3 (1.5%) and 6 (2.8%) hard events happened in groups I and II respectively (P value = .5).
Conclusion: Positive stress test in the setting of negative SPECT study neither correlates with significant coronary stenosis nor hard cardiac event rate at one and two years of follow up.
231
Risk stratification and prognostication of acute coronary syndrome patients by combined MPI SPECT and TIMI risk scores
P.S. Shanmuga Sundaram Palaniswamy1; S. Padma1
1Amrita Institute of Medical Sciences, Cochin, India
Aim: Risk stratification of ACS pts (unstable angina & Non ST MI) is very useful in assessment of myocardium at jeopardy and to optimize pt management. Our retrospective study aims to correlate stress MPI findings, TIMI risk scores and their prognostic implications.
Methods: 110 pts (M:F = 83:27, age range 47 ± 9 years) proven/suspected MI undergoing risk stratification MPI during 2009-2010 were analyzed. Pts with previous revascularization and normal MPI were excluded. A TIMI risk score 0-7 were assigned, one point for each variable i.e. age > 65 years, >3 CAD risk factors, stenosis > 50%, last 1 week aspirin use, recent angina, elevated cardiac enzymes, ST in rest images. Segment with near normal tracer uptake, good wall thickening but significant hypokinesia in gated study said to be hibernating. 1 year follow-up data obtained.
Results: MPI studies were interpreted visually and with a 20 segment model. 72 pts had Transmural MI and 38 (35%) had NSTMI. TMI pts were excluded for further analysis. Images were evaluated for perfusion defects (reversible, irreversible), wall thickening/motion and other findings like TID, lung uptake. Pts were risk categorized using TIMI score as low (0-2 score), intermediate (3-4) and high (5-7) i.e. 11:4:23 pts.
High risk 23/38 (60%) pts showed 6.2 ± 2.2 myocardial segments at risk (ischemia ± hibernation) when compared to 2.0 ± 1.1 segments in low risk (P < .01).
11/23 (48%) high risk pts showed LAD territory perfusion abnormalities. 9/23 (39%) high risk pts showed other non perfusion high risk MPI findings (TID, lung uptake). As high as 80% of high risk pts (18/23) had revascularization during the follow-up period. Good correlation was observed in high risk pts between MPI findings and TIMI score (r = 0.8).
Out of 11 low risk pts, only 1 had LAD perfusion defects and 5/11 pts (45%) had insignificant CAD or normal angiogram. None of low risk pts had any revascularization and any cardiac hard events during 1 year followup.
Conclusion: Stress MPI and TIMI scoring together helps to risk stratify ACS pts. Low risk pts were found to have less cardiac events. MPI, TIMI correlated moderate/high risk pts need to undergo revascularization.
232
Ischemic ST-segment depression only during recovery after ETT: Correlation with stress gated-perfusion SPECT data
A.F. Falcao1; W.C. Challela1; J.C.M. Meneghetti1; J.R. Ramirez1; R.K. Kallil1; L.A. Azouri1; S. Salvador Borges-Neto2
1Heart Institute (InCor)—University of Sao Paulo Faculty of Medicine Clinics Hospital (HC-FMUSP), Sao Paulo, Brazil; 2Duke University, Durham, United States of America
Purpose: The diagnostic and prognostic value of ST-segment depression (↓ST) occurring during the recovery period is less well defined as compared with that appearing during exercise testing (ET). Only few studies have investigated the clinical significance of this finding.
Objective: The aim of this study was to compare ↓ST only in recovery with the gated-SPECT imaging incidence of the severity and extent of ischemic changes.
Methods: Seventy patients (pts) with ↓ST only during recovery, who underwent gated-SPECT associated with ET and Bruce protocol, were analyzed. Mean age was 60.1 ± 9.8 years, 56 (78%) male, with previous myocardial infarction in 27.5%, coronary artery bypass graft in 21%, and percutaneous coronary intervention in 34%. Qualitative analysis of imaging used 5-point score (0-normal; 4-no uptake) for perfusion (17 myocardial segments), and 6-point score (0-normal; 5-diskinesia) for motility. Left ventricular ejection fraction (LVEF) was assessed after ET. ↓ST, blood pressure (BP), heart rate (HR), time of tolerance to exercise (TTE), functional capacity (MET), appearance time to ↓ST (AT↓ST), and presence of arrhythmias were evaluated during ET.
Results: Severe and extensive perfusion abnormalities was found in 57 pts (81.5%), 47% with transient defect and 11.4% associate with persistent defect; wall motion abnormalities seen in 23 pts (33%); mean LVEF was 58% ± 11%, with a mean of 10.6 ± 3 MET of functional capacity. A borderline significant relationship were found between AT↓ST vs TTE (P = .09) as well as between an abnormal perfusion vs MET (P = .09).
Conclusion: This study suggests that ↓ST occurring solely during recovery after ET is a relevant finding due to the high prevalence of severe and extensive myocardial ischemia in the gated-SPECT. A larger prospective study evaluating this relationship, the prognostic value and the ability to risk stratify patients with those ischemic parameters developed only after exercise stress is warranted.
233
Can lower heart rate response to adenosine stress myocardial perfusion imaging predict future cardiovascular events?
S. Satoko Yamasaki1; A. Goda1; S. Taniai1; A. Nagae2; K. Shimoyama3; T. Nishimura4; K. Sakata1; T. Satoh1; H. Yoshino1
1Kyorin University, Tokyo, Japan; 2Jukoukai Hospital, Saitama, Japan; 3Minamidai Hospital, Tokyo, Japan; 4Towers Clinic for Internal Medicine, Tokyo, Japan
Background: Myocardial perfusion imaging (MPI) using adenosine widely applies for detection of coronary ischemia as well as exercise MPI. However, little is known about heart rate response (HRR) to adenosine. The objectives of this study are to determine which factors affect to HRR to adenosine and whether HRR has an incremental prognostic value to MPI.
Methods: A total of 1,247 consecutive patients (male/female 795/452, age 71 ± 11 years) underwent adenosine MPI. An HRR < 10% (change from baseline) was considered lower HRR. The outcome of interest was cardiovascular death and events (heart failure worsening and acute coronary syndrome).
Results: A total of 22 cardiovascular deaths and 40 cardiovascular events occurred over 368 ± 250 days of follow-up. The patients with lower HRR (n = 819) were characterized by more male (66.8% vs 58.6%, P = .011), higher presence of hypertension (75.8% vs 68.3%, P = .015), CKD (16.9% vs 10.7%, P = .040), and lower resting LVEF (62.3 ± 16.4% vs 66.2 ± 15.3, P < .001) than those with higher HRR (n = 428). However, summed difference score was not different between lower HRR and higher HRR group (1.09 ± 3.65 vs 1.14 ± 3.75, P = .816). Univariate Cox proportional hazards analysis identified age, lower HRR (hazard ratio, 2.88; 95% CI 1.21 to 6.87; P = .017), resting LVEF, exercise LVEF and presence of CKD, as independent prognosis indexes of events. Kaplan-Meier survival analysis revealed that patients with lower HRR had increased cardiovascular events compared with patients that had higher HRR (χ2 = 7.77, P = .005). In multivariate analysis, resting LVEF (hazard ratio, 0.96; 95% CI 0.95 to 0.98; P < .001), presence of CKD (hazard ratio, 2.75; 95% CI 1.41 to 5.40; P = .003) and age (hazard ratio, 1.04; 95% CI 1.01 to 1.08; P = .015) predicted cardiovascular events, but lower HRR (hazard ratio, 2.12; 95% CI 0.88 to 5.09; P = .094) did not.
Conclusions: Lower HRR to adenosine is associated with gender, presence of HT, CKD, and lower EF, but not with presence of myocardial ischemia. Predictive value of lower HRR in cardiovascular events does not go beyond the presence of CKD and resting LVEF.
234
Cost savings associated with the use of selective stress-only and CZT SPECT myocardial perfusion imaging
M. Milena Henzlova1; T. Naib1; G. Greco1; P. Vaishnava1; J. Berman1; D. Ascheim1; W.L. Duvall1
1Mount Sinai School of Medicine, New York, United States of America
Purpose: Selective stress-only myocardial perfusion imaging (MPI) and high efficiency cadmium zinc telluride (CZT) camera technology both shorten test time and tracer dose. The cost savings of either strategy has not been established.
Methods: Two Tc-99m SPECT imaging strategies at a tertiary medical center were modeled using either a CZT or conventional attenuation correction equipped Anger camera: stress-first and rest-stress. Fixed costs (purchase price), annual operating costs (maintenance) and variable costs per study (personnel time and supplies) were calculated assuming one SPECT camera was used with a daily capacity of 10 studies. Overhead (rent, utilities, administrative costs) was not included as it was considered identical among all strategies.
Results: Purchase costs of the CZT camera exceed that of a conventional camera (28% higher annuitized 10 year capital cost) but yearly maintenance was 9% lower. Yearly variable costs were 5% less with a CZT camera compared to conventional camera by decreasing personnel time. A stress-first strategy results in a 24% annual savings with both cameras based on decreased personnel time and isotope cost. The proportion of normal stress studies and imaging volume determined whether the CZT camera overcame the higher initial up-front costs.
Conclusions: Cost savings can be seen with selective stress-only imaging and new CZT camera technology compared to traditional rest-stress imaging and conventional SPECT cameras.
235
How often did we underestimate extent of ischemia by gated SPECT myocardial perfusion imaging in patients with severe coronary artery disease?
S. Shigeru Fukuzawa1; J. Sugioka1; A. Ikeda1; S. Okino1; J. Maekawa1; S. Ichikawa1; N. Kuroiwa1; S. Okamoto1; M. Inagaki1
1Funabashi Municipal Medical Center, Funabashi, Japan
Background: Since left main alone or in combination with triple vessel coronary artery disease (CAD) are categorised as representing potentially life-threatening variants of CAD, a screening test with high sensitivity, low negative likelihood ratio or higher discriminatory capacity would be desirable for risk stratification. There have been limited data regarding the value of gated single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) for the detection of triple vessel or left main coronary artery disease in clinical practice.
Methods and Results: We studied 72 patients with angiographic triple vessel/left main CAD and no prior myocardial infarction or coronary revascularization who underwent gated exercise or adenosine stress SPECT MPI by one-day stress and rest protocol. The extent and severity of perfusion abnormalities were assessed using a 4-point system and 17-segment model. By perfusion assessment alone, high-risk disease with moderate to severe defects (>10% myocardium at stress) was identified in only 53% of patients visually. However, by combining visual perfusion data and nonperfusion variables, especially low ejection fraction, 69%, and transient ischemic dilation, 85% of patients were identified as high risk.
Conclusion: The findings of this study demonstrate that assessment of perfusion data alone by visual SPECT MPI analysis underestimates the magnitude of triple vessel or left main CAD. The combination of perfusion and nonperfusion abnormalities on gated MPI identifies high risk in most patients with triple vessel or left main CAD. This limitation can be overcome, to a certain extent, by incorporating other imaging findings as well as clinical and stress testing parameters that help identify individuals at an increased risk of adverse cardiac events and hence those with severe and extensive coronary disease.
236
Left ventricular hypertrophy influences the association between ST segment changes and ischemia in stress myocardial perfusion SPECT
F. Mut1; M. Kapitan2; A. Damian2; M. Lujambio2; R. Ferrando2
1Nuclear Medicine, Spanish Association, Montevideo, Uruguay; 2University Clinical Hospital, Montevideo, Uruguay
Purpose: Specificity of ST segment changes on exercise testing (ET) for diagnosis of myocardial ischemia and coronary artery disease (CAD) in patients with left ventricular hypertrophy (LVH) remains controversial. The aim of this study was to determine whether the presence of LVH influences the association between ST segment changes and ischemia in SPECT myocardial perfusion studies (MPS).
Methods: Retrospective analysis of 175 consecutive patients (37-83 years, mean 61.7 years, 50.3% females) evaluated stress/rest MPS with 99mTc-sestamibi who presented exercise-induced horizontal or downsloping ST depression ≥1 mm in two or more consecutive leads, either with normal baseline ECG or with LVH pattern. We excluded patients with LBBB, pacemaker, WPW, and those receiving digitalics. Patients were assigned to two groups: GI) without LVH (n = 121) and GII) with LVH (n = 54). MPS images were assessed by two independent observers, blinded to ET results, and summed difference scores (SDS) were calculated. Relationships between changes in ST segment [segment depression (ΔST) and recovery time (RT)] and SDS were evaluated by Pearson correlation coefficient (PC), t test, Chi2, and ANOVA, considering alpha = 0.05.
Results: Differences were not significant between groups I and II regarding age (P = .50), sex (P = .48), BMI (P = .60), diabetes (P = .22), smoking (P = .77), dyslipidemia (P = .52), and presence of CAD (P = .68). As expected, hypertension was more frequent in GII (P = .001). RT was longer in GII (P = .019), while ΔST and SDS did not differ between groups (P = .09 and P = .38 respectively). In GI, both ΔST and RT were positively correlated with SDS (PC = 0.43, P < .001 and PC = 0.25, P = .005, respectively). ΔST correlated with SDS in GII (PC = 0.28, P = .043) but RT did not (PC = 0.02, P = .86). ΔST ≥2 mm was associated with higher SDS in GI (P < .001, t test) but not in GII (P = .98). SDS was higher in patients with ΔST ≤ 2 mm than ΔST < 2 mm in GI (P < .001, ANOVA, Bonferroni correction) but not in GII.
Conclusions: In patients without LVH, both ΔST and RT are associated with greater extent/severity of ischemia in MPS. RT is longer in patients with LVH, but is not significantly associated with the degree of ischemia. ΔST has limited correlation with ischemia in the presence of LVH, thus supporting the lower specificity of this sign for the diagnosis of CAD.
237
Cardiac CT for the evaluation of patients prior to non coronary cardiac surgery
F.J. Guerrero Marquez1; N. Nieves Romero Rodriguez1; J.L. Martos Maine1; M.P. Serrano Gotarredona1; S. Navarro Herrero1; J.M. Borrego1; A. Martinez Martinez1
1Virgen del Rocio University Hospital, Seville, Spain
Cardiac CT has an important place in the coronary study and its main value lies in its high negative predictive value. This justifies its role in coronary assessment prior to valve replacement surgery instead of coronary angiography.
Method: From December 2008 to February 2012 we included all patients awaiting valve replacement intervention and/or intervention on ascending aorta or tumor resection, with indication of prior coronary evaluation. This was performed by coronary CT Toshiba Aquilion 64 using standard protocol. We excluded patients with previous ischemic disease and those with renal failure and/or diabetes for more than 15 years of evolution and those patients who underwent coronary angiography due to lack of availability of TAC prior to the date of surgery (25 patients). We collected all clinical and echocardiographic data and they were followed after surgery and 6 months afterwards.
Results: A total of 1025 adult patients were operated, from whom 256 were finally evaluated by Cardiac CT; 142 were male with a mean age of 68,7 years old (SD 8.9). In 3 patients the presence of significants lesions and in 12 patients a calcium score >500 made necessary an invasive angiography, with the demonstration of significant lesions in 6 of them. In the rest of patients cardiac CT ruled out the presence of significant lesions, with no complications related to the test. During the postoperative follow-up we did not detect any acute coronary syndrome and 9 patients died from non-ischemic causes.
Conclusions: Coronary CT is a safe and effective technique for coronary assessment prior to valve replacement surgery, although the patient selection is crucial to indicate the test in an appropriate way.
238
Transient ischemic dilation in SPECT myocardial perfusion imaging for prediction of severe coronary artery disease in diabetic patients
R. Assante1; W. Acampa1; S. Daniele1; E. Zampella1; C. Nappi1; M. Tuccillo1; M. Plaitano1; P. Perrone-Filardi1; M. Petretta1; A. Alberto Cuocolo1
1University Federico II, Napoli, Italy
Transient ischemic dilation (TID) of the left ventricle during stress myocardial perfusion SPECT (MPS) has been shown to be a useful marker of severe coronary artery disease (CAD). However, investigations in diabetic patients with available coronary angiographic data are still limited. We evaluated the incremental diagnostic value of TID in identifying the presence of angiographically severe CAD in diabetic patients.
Methods: TID ratio values were automatically derived from rest-stress MPS in 242 diabetic patients with available coronary angiography data. A cutoff of >1.19 was considered to represent TID. Severe CAD (>70% stenosis in the proximal left anterior descending artery or the left main artery, or >90% stenosis in two or three vessels) was identified in 69 (29%) patients.
Results: At multivariate analysis, the best independent predictors of severe CAD were summed stress score and TID (both P < .001). At incremental analysis, the addition of TID improved the power of a model including clinical data and summed stress score, increasing the global chi-square value from 14.3 to 28.2 (P < .01). The best cut-off of summed stress score for identifying patients with severe CAD was >7. When the TID ratio was considered in patients with summed stress score between 3 and 7, the sensitivity for diagnosing severe CAD significantly improved from 71% to 77% (P < .05). In the overall study population, the net reclassification improvement by adding TID to a model including clinical data and summed stress score in the prediction of severe CAD was 0.40 (P < .005).
Conclusions: TID ratios obtained from rest-stress MPS provide incremental diagnostic information to standard perfusion analysis for the identification of severe and extensive CAD in diabetic patients.
239
Usefulness of spect myocardial perfusion in asymptomatic patients with multiple vascular risk factors
V.D. Victor Daniel Martire1; E.R. Pis Diez1; M.V. Martire1
1CESALP. Fundación Horacio Corrada, La Plata, Buenos Aires, Argentina
Objective: To determine the incidence and magnitude of ischemia through myocardial perfusion with SPECT as a tool for initial detection of asymptomatic patients (P) with multiple vascular risk factors (RF).
Method: Since the incorporation of rotating gamma camera SPECT, 8965 P have been consecutively studied (1999 to 2011) among which 1611 P (18%) showed that the indication of SPECT functional imaging study matches the objectivebefore mentioned for this study: mean age 58 ± 11 years old, 984 men, hypertension: 709 P (44%), Dyslipidemia: 918 P (57%), Diabetes mellitus (type 2): 177 P (11%), tobacco 515 P (32%), abnormal ECG 451 P (28%), overweight/obesity: 724 P (45%), other RF: 514 P (32%). (MS-ACCESS™ database, Graph-Pad v5.01™). All the P were studied with Sestamibi-99Tc SPECT, PEG-12 derivatives, according to conventional protocols.
Result: 1-PEG: 78% of P reached target maximum heart rate: negative PEG: 1031 P (64%). Markedly positive: 129 P (8%). Doubtful: 451 P (28%).
2-Perfusion: 1030 P (64%) evidenced normal SPECT. 581 P (36%) evidenced abnormal SPECT, among which 275 P (17% /out of 1611) showed low-intermediate ischemic risk, and 306 P (19%/out of 1611) evidenced high-risk spect results (defined by the extension and magnitude of ischemia on the analysis of 17 segments). As additional datum in the ischemic high-risk group (306 P), anatomic information of the coronary arteries was obtained in 208 of them (68%), resulting in indication for revascularization in 172 P (83%).
Conclusion: The myocardial perfusion study is a very useful diagnostic tool for the detection of asymptomatic patients with multiple high-risk factors initially considered to be of apparent low clinical risk, discriminating sub groups with significant ischemic volume and worse prognosis.
240
Myocardial perfusion imaging in the evaluation of patients with high risk for cardiovascular events but no cardiac symptoms and atypical cardiac symptoms
P. Paola Smanio1; L. Machado1; J.V. Holtz1; J. Silva1; C. Marques1; L. Ueda1; P. Cestari1; J.I. Franca1
1Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
Background: The incidence of coronary artery disease (CAD) in the world is increasing, being also an important cause of mortality in South America. Is there already robust evidence about the importance of myocardial perfusion imaging (MPI) in the diagnostic evaluation of symptomatic patients (p). However, the use of MPI in the assessment of asymptomatic or with atypical symptoms p is not well defined.
Purposes: The primary objective was to evaluate the prevalence of perfusion abnormalities in a high risk for CAD group of asymptomatic or with atypical symptoms p, trying to identify clinical predictors of risk in this group. The secondary objective was to determine the association of ischemia on the MPI and presence of major cardiac events in a follow up period of 12-24 months.
Methods: It was an observational and retrospective study including 503 p that performed stress MPI between 07/2010 and 06/2011. From the total, 280 p (55.6%) male, 83.9% hypertensive, 72.4% dyslipidemia, 32.4% with diabetes, 49% had known CAD, 281 p (55.8%) were asymptomatic, and 222 p (44.2%) had atypical symptoms. It was considered atypical symptoms presence of atypical chest pain (112 p, 22.2%) and dyspnea (110 p, 21.8%). The sestamibi-Tc-99m gated SPECT was performed by standard technique. It was considered normal MPI if there was no perfusion defect after stress phase and suggestive of ischemia if presence of reversible perfusion defect. It was considered major cardiac events presence of nonfatal myocardial infarction and cardiac death . Statistical analysis was performed using Fisher’s exact test and logistic regression analysisbeing considered significant P values ≤ .05.
Results: MPI suggestive of ischemia was observed in 112 p (22.2%) and there was no statistically significant difference between the group of completely asymptomatic, with atypical chest pain and dyspnea (P = .701). The clinical characteristics that were associated with the presence of any perfusion defect on MPI were male gender (P = .007) and the presence of known CAD (P < .05). On logistic regression analysis it were observed that presence of known CAD and abnormal stress test were predictors of ischemia on MPI (P < .05). In the 12-24 months follow up it was observed that presence of ischemia was associated with higher rates of nonfatal MI (P = .009).
Conclusions: The obtained results may suggest high prevalence of ischemia in the studied group. The presence of ischemia on MPI was not statistically different in asymptomatic in comparison with atypical symptoms p. Presence of ischemia on MPI was associated with nonfatal MI after 12-24 months.
241
Rest-dypiridamol 99mTcMIBI lower limb muscle perfusion scintigraphy and myocardial perfusion scintigraphy in non diabetic and diabetic patients (one-day protocol)
D. Pop Gjorceva1; M. Vavlukis2; V. Majstorov1; N. Ristevska1; M. Zdraveska Kocovska1; I. Ahmeti3; S, Stojanoski1; M, Zdravkovska1
1Institute of Pathophysiology and Nuclear Medicine, Skopje, Former Yugoslav Republic; 2University Clinic of Cardiology, Medical Faculty, Skopje, Macedonia, The Former Yugoslav Republic of; 3University Clinic of Endocrinology, Diabetes and Metabolic Disorders, Skopje, Macedonia, Republic of the Former Yugoslav
Purpose of the Study: To establish one-day rest-Dypiridamol 99mTcMIBI protocol for lower limb muscle perfusion scintigraphy (LLMPS), as part of myocardial perfusion scintigraphy (MPS) for simultaneous evaluation of coronary and peripheral artery disease (CAD/PAD), in nondiabetic (NDpts) and diabetic patients (Dpts), as well as to evaluate diagnostic capabilities of various parameters of LLMPS in assessment of PAD in estimated groups.
Patients and methods: 24 pts, 13 Dpts (54%) and 11 NDpts (56%) were included in the study. No significant difference was found in gender distribution, BMI and presence of risk factors for PAD and CAD among the groups, except for presence of diabetes and age (Dpts 56 ± 6 vs NDpts 63 ± 10, P < .05). At rest, LLMPS was performed as “dynamic phase of the calves” (0-7 minutes p.i.) followed with acquisition of whole body scan (WBS-PA) and MPS at rest. At stress, LLMPS (WBS-PA) was performed immediately after Dypiridamol/99mTcMIBI application, followed by MPS.
Results: Dpts showed prolonged parameter of early arterial phase at rest (Tmax 92/93 ± 19/19 vs 110/114 ± 24/24 seconds in NDpts, P < .05) and lower percentage of 1st minute-accumulation of 99mTcMIBI in the two calves (84% vs 88% in NDpts, n.s.). 3/11 NDpts (27%) and 7/13 Dpts (54%) showed pathological values of index of asymmetry (left/right thigh and left/right calf, at rest and stress). Perfusion reserve (PR) of thighs (LT, RT) and calves (LC, RC) calculated as “(ROI Stress − ROI Rest) × 100%/ROI Rest”, noncorrected and corrected for rest-stress doses of 99mTcMIBI and background activity at stress-WBS were significantly lower in Dpts compared with NDpts: LT-143 ± 35% or 23 ± 23% (Dpts) vs 183 ± 40% or 46 ± 27% (NDpts), P < 0.01/P < 0.05; RT-142 ± 29% or 21 ± 17% (Dpts) vs 177 ± 35% or 42 ± 23% (NDpts), P < 0.01/P < 0.05; LC-140 ± 23% or 20 ± 12% (Dpts) vs 173 ± 37% or 39 ± 22% (NDpts), P < 0.01/P < 0.01; RC-140 ± 23% or 23 ± 17% (Dpts) vs 173 ± 26% or 40 ± 22 (NDpts), P < 0.001/< 0.05). Identically, significantly lower perfusion reserve in Dpts was obtained comparing the ∆ values of stress-rest ratio of: LT/L-knee, RT/R-knee, LC/L-ankle and RC/R-ankle. PR estimated as percentage of counts over ROI of thighs and calves at rest and stress as a part of whole body counts, although lower in Dpts did not show significant difference among the groups.
Conclusion: LLMPS performed simultaneously with Dypiridamol 99mTcMIBI MPS seems to be useful procedure in assessing PAD along with CAD. Preliminary data of our study (small number of pts) suggest the respectable role of LLMPS in estimation of tissue perfusion by measuring the PR in lower limb muscles in patients with risk factor for PAD, especially Dpts.
242
Prognostic value of stress myocardial perfusion imaging in female patients with low to intermediate risk for coronary artery disease
A. Andrea Peter1; S. Lucic1; R. Jung2; M. Lucic1; S. Tadic2; S. Stojsic2; M. Stefanovic2; J. Stojiljkovic2; J. Kmezic Grujin2
1Institute of Oncology of Vojvodina, Sremska Kamenica, Serbia; 2Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia
Introduction: Stress myocardial perfusion imaging (MPI) is one of the major diagnostic tools in the evaluation of the presence and severity of myocardial ischemia in patients with suspected coronary artery disease (CAD).
Aim of the Study: To determine the impact of stress MPI in the detection of perfusion abnormalities, their severity and to determine the prognostic value of this diagnostic modality.
Material and Methods: In the period from June 2007 to October 2012. a total number of 222 female patients with suspected CAD and had a low to intermediate pre test likelihood underwent a two-day protocol, dipyridamole stress/rest Tc-99m-MIBI myocardial perfusion imaging (MPI). After that they were followed up for the occurrence of cardiac death or myocardial infarction over a mean follow up period of 44.77 ± 16.11 months.
Results: Average age in the group of examined women was 61.93 ± 8.83 years. Risk factors for coronary artery disease were present in all of them and 203 women (91.44%) had arterial hypertension, 20 had diabetes (9.01%), 130 had hyperlipoproteinemia (58.56%), 54 were obese (24.32%), 10 were smokers (4.50%) and 11 had very positive family history for coronary artery disease (4.95%). In the group of women normal MPI had 85.14%, ischemia was found in 6.31%, discrete ischemia that was considered as nonsignificant had 6.75%, borderline perfusion defects had 1.80% and perfusion defects considered as normal for LBBB perfusion pattern had 3.60%. Average period of follow up was 44.77 ± 16.11, with a minimum of 12 and a maximum period of 64 months.
The values of SDS ≤3 were considered normal, in the group with ischemia the values of SDS were ≥7, in the group with discrete perfusion defects it was between 3 and 5, in the group with borderline perfusion defects between 5 and 7 and in the group with LBBB it was between 3 and 5. The results of stress MPI and consequent follow up showed us that the majority of the women are at low risk of nonfatal myocardial infarction and for cardiac death.
Conclusion: Stress MPI identifies successfully patients with hemodynamically significant ischemia and gives important prognostic information toward the identification of female patients under risk for major fatal cardiovascular incidents.
243
Early detection of atherosclerosis in asymptomatic patients with type 1 diabetes (concordance between SPECT, calcium score and carotid ecography)
M. Mila Lopez1; E. Aguilera2; S. Serrano3; V. Vallejos Arroyo1; J. Reverter2; N. Alonso2; E. Bernal3; S. Pellitero2; B. Soldevila2; M. Fraile1
1Germans Trias i Pujol University Hospital, Nuclear Medicine Department, Badalona, Spain; 2Germans Trias i Pujol University Hospital, Endocrinology Department, Badalona, Spain; 3Germans Trias i Pujol University Hospital, Department of Cardiology-IGTP, Badalona, Spain
Type 1 diabetes mellitus (T1D) is associated with an increase risk of cardiovascular disease compared to the non-diabetic population, although there is not enough data on the prevention and screening on these patients.
Aim of Study: To evaluate the presence of early atherosclerosis in asymptomatic T1D patients with an evolution of more than 10 years and without history of ischemic or macrovascular heart disease, compared with non diabetic age and sex matched controls.
Patients and Methods: 150 T1D patients consecutively recruited from our outpatient clinic were studied (58% males; age: 38.6 ± 8.1 years, T1D lasting: 20.4 ± 8.1 years, BMI: 25.1 ± 3.6 kg/m2, HbA1c: 83 ± 2.3%, total cholesterol: 182.7 ± 25.1 mg/dL, 52% non-smokers, 26% retinopathy, 9% microalbuminuria) along with 55 non-diabetic controls age and sex matched were studied. Carotid US scan was performed to determine the mean cIMT (common carotid, bifurcation and right and left internal) and the presence of atheroma plaques. ECG-gated Multidetector CT scans were done for calcium analysis and quantification. In T1D patients a two days stress-rest myocardial perfusion SPECT protocol was performed.
Results: In T1D patients mean cIMT value was significantly greater than in control subjects (0.56 ± 0.14 vs 0.48 ± 0.14 mm, P = .004). Patients with atheroma plaques (16/150) presented significantly higher HbA1c (8.6% ± 0.6% vs 8.3% ± 2.4%), and a greater mean cIMT values (0.74 ± 0.14 vs 0.52 ± 0.12 mm) than patients without plaques. Patients with a Calcium Score >0 (27/150) were significantly older, had higher HbA1c levels (8.5% ± 0.8% vs 8.2% ± 2.5%), longer evolution of the disease (24.7 ± 5.8 vs 19.5 ± 7.6 years) and a greater mean cIMT (0.68 ± 0.18 vs 0.52 ± 0.11 mm) than patients with score 0. In the control group, the rate of subjects with plaques (4/50:8%) and score >0 (4/50:8%) was lower than in T1D patients. 126 patients out of 150 were evaluated with myocardial perfusion SPECT. 16/126 T1D patients showed an abnormal SPECT (8 patients presented a typical pattern of ischaemia and 8 a depression of systolic function suggesting diffuse myocardial ischaemia). However, there was a low concordance between calcium score, carotid US and SPECT (only 2 patients with abnormal SPECT presented plaques and an score >0).
Conclusion: A small percentage of our T1D patients with more than 10 years of disease evolution presented data suggestive of atherosclerosis. However, such data did not correlate with myocardial perfusion SPECT, suggesting that SPECT can predict the appearance of ischaemic heart disease in T1D patients without macrovascular disease. Indeed, this might indicate the presence of microvascular pathology.
244
Cardiovascular disease in women: Myocardial perfusion SPECT in the prognostic assessment of diabetic women
V. Pubul1; M. Miguel Garrido1; M. Pombo1; S. Argibay1; S. Nieves1; E. Pereira1; A. Martinez1; J. Cortes1; R. Gonzalez-Juanatey1; A. Ruibal1;
1Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
Purpose: The aim of this study is to determine the value of SPECT as ischemia detection test performed for diagnostic purposes in diabetic women (DM), and to evaluate whether there are differences in cardiovascular risk profile and the prediction of adverse events compared with nondiabetic women (NDM).
Methods: Of 1028 women attending our unit to perform a myocardial perfusion SPECT for diagnostic purposes, we selected 196 consecutive diabetic women. All patients underwent a two days protocol test, performing gated acquisition at rest or effort when the images were considered normal. Ejection fraction, diastolic and systolic volumes indexed for body surface area were calculated. Cardiovascular risk factors recorded were: age, smoking, diabetes, hypertension, hypercholesterolemia, peripheral arterial disease and body mass index. Positive SPECT criteria included the visualization of both reversible and non-reversible significant perfusion defects. In the posterior follow-up, we considered as events the presence of acute coronary syndrome, revascularization surgery, development of cardiac insufficiency or cardiac death in the twelve months after the SPECT. The average time of follow-up was 2.5 ± 2 years.
Results: Diabetic women had a higher proportion of all risk factors studied, (hypertension 82% DM vs 62% NDM; hypercholesterolemia 72% DM vs 57% NDM; peripheral arterial disease 3% vs 0.3% body mass index 31 vs 28 P < .001), except smoking.
There was no significant differences in SPECT results between diabetic and non diabetic women. Significant differences were found in EF calculated by gated, being lower in diabetic patients (63.9 ± 13 vs 66.4 ± 10.3 P 0.007).
Diabetic women presented a higher proportion of adverse events on the follow up (13% vs 8%, P < 0.03). On the other hand, a positive result on SPECT was associated with a greater number of adverse events in both diabetic and in nondiabetic (Events in positive SPECT 34% DM and 29% NDM vs Events in negative SPECT 8% DM and 5% NDM, P 0.0001).
Conclusions: We observed a higher proportion of positive SPECT in diabetic women, although the presence of diabetes itself is not significantly related to the results of SPECT. Diabetic women had a higher proportion of adverse coronary events during follow-up, possibly related to the presence of higher atherogenic risk profile associated with diabetes, as well as lower values of left ventricular ejection fraction. The positivity of SPECT in these patients remains useful to discriminate risk subgroups.
245
Relationship between patients risk profile, myocardial and leg muscle perfusion obtained by rest-dypiridamol 99mTc MIBI scintigraphy
M. Vavlukis1; D. Pop Gjorcheva2; V. Majstorov2; N. Kostova1; M. Zdraveska Kocovska2; S. Stojanoski2; M. Zdravkovska2; I. Pejovska1; N. Nevena Ristevska2
1University Clinic of Cardiology, Medical Faculty, Skopje, Macedonia, Former Yugoslav Republic; 2Institute of Pathophysiology and Nuclear Medicine, Skopje, Former Yugoslav Republic
Aim of the Study: To evaluate relationship between cardiovascular risk profile, leg muscle perfusion and myocardial perfusion in cardiovascular high risk patients.
Material and Methods: 24 pts with high cardiovascular risk profile underwent one-day protocol of rest-dypiridamol 99mTcMIBI Leg Muscle Perfusion (LMP) Scintigraphy and Myocardial Perfusion Scintigraphy. Comparative analysis was performed as comparison between diabetic and nondiabetic pts and their clinical, hemodynamic, myocardial and leg muscle perfusion parameters as a response to dipyridamol stress.
Results: Out of 24 pts included in the study, 17 (70.8%) were female and 7 (29.2%) male. They were divided in diabetic and non diabetic group (D and ND). No significant differences in diabetes distribution between genders (58.8% females and 42.8% males had diabetes; P = ns) was found. Diabetic patients were significantly older 63.6 vs 56.1; P = .034. Except for presence of diabetes, two groups (D and ND) were similarly burdened with risk factors (HTA, HLP, LVH, obesity, cigarette smoking, except for PVD that was as expected, more often present in D pts (OR 6.87, P = .030). Hemodynamic response to dipyridamol revealed no significant difference in heart rate response to dipiridamol, and significant decrease of systolic BP (P = .033). Significant positive correlations were found for age and presence of PVD (r = 0.442; P = .030 and r = 0.472, P = .020 respectively). As for the hemodynamic and symptom response to dipyridamol, significant negative correlation was found for D group and systolic BP (more pronounced drop in SBP), and more often were asymptomatic (45.8% vs 33.3%, Fishers exact test P = .030, OR 6.875, Mantel-Haenszel P = .041). 4 (36%) ND and 7 (54%) D pts showed pathological values of index of asymmetry (left/right thigh and left/right calf, at rest and stress), OR 1.5, P = ns, as a parameter of pathological leg muscle perfusion. 2 (8.3%) of ND and 4 (16.7%) of D pts had pathological myocardial perfusion, with OR 2.0, P = ns. 50% of pts had normal myocardial and leg muscle perfusion, while only 4 (16%) pts. had abnormal both myocardial and LMP. Patients with pathological myocardial perfusion had OR 4.0, P = ns for presence of impaired LMP. Using diabetes as cofounder, we found no differences.
Conclusion: According to our data in high risk profile patients, myocardial perfusion was not significantly different, but leg muscle perfusion was significantly different in D vs ND pts. In diabetic patients we can expect more significant drop in SBP, and absence of dipyridamol induced symptoms, that can be due to increased vascular stiffness and autonomic dysfunction.
246
Myocardial perfusion scintigraphy in the diagnosis of coronary artery disease in asymptomatic hemodialysis patients
A. Sellem1; J. Souli1; W. Ajmi1; Y. Mahjoub1; H. Hammami1;
1Military Hospital of Tunis, University of Tunis Elmanar, Tunis, Tunisia
Background: The hemodialysis population is characterized by a high prevalence of ‘asymptomatic’ coronary artery disease (CAD), which could be detected by nuclear cardiac imaging.
Aim: We investigated whether the absence of cardiac symptoms may affect the diagnostic potential of gated myocardial perfusion scintigraphy for detecting myocardial ischemia in hemodialysis patients.
Methods: Ninety-four patients in hemodialysis for in average 3 years (1 week-25 years) undergone stress-rest gated myocardial perfusion scintigraphy. Depending on the presence or not of cardiac symptoms we divided our patients into two groups. The first group (A) included 45 patients with cardiac symptoms, the second (B) included 49 asymptomatic patients.
Results: The mean age of our ninety-four patients (66 men, 28 women) was 60 years (range, 24-82 years).
A gated myocardial perfusion scintigraphy revealed perfusion defects in 31 patients (68.88%) from group A, and 32 (65.3%) from group B, without statistically significant difference (P = .88).
Conclusions: Our results show that myocardial perfusion defects are frequent even in non-symptomatic dialysis patients. This suggests that ischemic heart disease could be more frequent than estimated by clinical symptoms alone. Myocardial perfusion scintigraphy is a useful non-invasive procedure in cardiological evaluation of dialysis patients.
247
Correlation between septal thickness and cardiac outcomes among patients with chronic kidney disease with negative myocardial SPECT studies
M. Mohamed Mandour Ali1; A.A. Sadek1; A.H. Allam1
1Al-Azhar University, Department of Cardiology, Cairo, Egypt
Background: Chronic kidney disease (CKD) is a well-known independent predictor of cardiac events. We thought to investigate for the correlation between increased septal thickness and cardiac outcomes among patients with CKD.
Methods: LV dimensions were assessed by echocardiography in 188 patients with CKD and negative myocardial SPECT (to exclude significant CAD). 66 (35.1%) had septal thickness >130 mm (group I), 81 (43.1%) were 110-130 mm (group II) and 41 (21.8%) were <0.05 and 17 (25.7%); 8 (9.8%) and 1 (2.4%) at 2 years in groups I, II and III respectively (P values < .005). Hard events (cardiac death, STEMI/NSTEMI) were 4 (6.1%), 0% and 0% (P value < .05) at one year; and 7 (10.6%), 3 (3.7%) and 1 (2.4%) at 2 years (P value < .05). Thickness cut-off value ≥130 mm correlated with significantly increased cardiac event rate.
Conclusion: Increased septal thickness is an independent predictor of soft and hard cardiac events at one and two years of follow up among patients with CKD and negative SPECT scans.
248
Estimated glomerular filtration rate as a predictor of cardiovascular events in patients with renal dysfunction and without coronary artery disease
T. Tatsuhiko Furuhashi1; M. Moroi2; M. Minakawa1; H. Masai1; T. Kunimasa1; H. Fukuda1; K. Sugi1;
1Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan; 2National Center for Global Health and Medicine, Cardiology Division, Tokyo, Japan
Objectives: Patients with normal stress myocardial perfusion imaging (MPI) have been generally warranted excellent prognosis for cardiovascular events which is less than 1%/year. Chronic kidney disease (CKD) is an established risk factor for cardiovascular events and estimated glomerular filtration rate (eGFR) varies widely among patients with CKD. In CKD patients, eGFR is a poorly established predictor of cardiovascular events. This study evaluates the prognostic value of eGFR in CKD patients with no undergoing hemodialysis and with no evidence of coronary artery disease (CAD) assessed by stress MPI.
Methods: Eighty-two CKD patients with no CAD (no previous CAD and normal stress MPI which was summed stress score <4) and no undergoing hemodialysis (49 males and mean age was 73 years) were followed up for mean 22 months. CKD was characterized by an eGFR of less than 60 mL/minute/1.73 m² and/or persistent proteinuria. Cardiovascular events included hard cardiovascular events (cardiac death, non-fatal myocardial infarction and unstable angina) and congestive heart failure requiring hospitalization.
Results: Total cardiovascular events were observed in 27 patients (33%). Univariate Cox regression analysis identified diabetes, anemia, eGFR and summed stress score of stress MPI as significant predictors of cardiovascular events. Multivariate Cox regression analysis revealed that only eGFR (hazard ratio = 0.97; P = .003) was an independent significant risk factor for total cardiovascular events. Hard cardiovascular events were observed in 7 patients (9%) and only eGFR could be a significant predictor for hard cardiovascular events (hazard ratio = 0.95; P = .035).
Conclusions: Even in CKD patients who have non-previous CAD and normal stress MPI, we cannot warrant excellent cardiovascular prognosis. Lower eGFR can be a powerful predictor of cardiovascular events. Nevertheless, CAD is undetected by stress MPI and clinical history, patients with low eGFR require careful and continuous follow-up to prevent cardiovascular events.
249
Gender differences and prognostic value in the exercise capacity and gated SPECT in patients with suspected coronary artery disease (CAD)
V. Pubul1; M. Miguel Garrido1; S. Argibay1; M. Pombo1; R. Agra1; S. Raposeiras1; C. Pena1; E. Abu1; R. Gonzalez-Juanatey1; A. Ruibal1
1Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
Purpose: The exercise EKG has a lower sensitivity and specificity for detection of obstructive CAD in women compared with men. The clinical limitations of the exercise-electrocardiography test included a lower percentage of women reaching target heart rate than men and higher false positive rate in women. Our objective was to examine gender differences in the exercise capacity and prognostic value of gated SPECT in patients with suspected CAD.
Methods: We selected 1959 consecutive patients, 931 men and 1028 women with suspicion of CAD, were submitted to the realization of a myocardial perfusion SPECT for diagnostic purpose, with a two-day stress/rest protocol study. We consider a positive result in the stress test by obtaining a clinical response or/and a significant alteration of the EKG. Positive SPECT criteria included the visualization of both reversible and non-reversible significant perfusion defects. In the posterior follow-up, we considered as events the presence of acute coronary syndrome, revascularization surgery, development of cardiac insufficiency or cardiac death in the twelve months after the SPECT. The average time of follow-up was 2.5 ± 2 years.
Results: Patients obtained a high proportion of test that surpassed the 80% of the calculated target heart rate (CTHR), and there were no differences between sexes (69%♀ vs 68%♂; P .5). The stress test results showed no differences between women and men (22% vs 26%; P .7). The SPECT, however, showed a higher percentage of positive results in men than women (36% vs 14%; P < .001). Positive/negative results in the stress test were related to the number of events in the follow-up (Registered events in 18% of patients with positive stress test vs events in 9% patients with negative stress test; P < .001). The SPECT showed significant relation with the outcome in both sexes (Events in 34% patients with SPECT+ vs 6% patients with SPECT−).
Conclusions: In our experience, there was no difference between women and men achieving target objectives in the stress test. The result of the stress test was related with events in both men and women. The SPECT was more positive in men, and a positive result was associated with more number of events.
250
Value of myocardial perfusion imaging in the assessment of ischemia in asymptomatic renal disease patients before dialysis
P. Paola Smanio1; A. Cordeiro1; M.A. Oliveira1; L. Machado1; J.I. Franca1; P. Cestari1; A. Thom1
1Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
Background: It is already known that cardiovascular disease (CVD) is the leading cause of mortality in renal disease (RD) patients (p). Studies suggest that early detection of ischemia followed by appropriate clinical management, improve survival. The diagnostic value of myocardial perfusion imaging (MPI) in the evaluation of ischemia is already known. Unfortunately, it is not yet established that RD patients should perform an early systematic investigation of ischemia and which group of RD p should be evaluated.
Purposes: To determine the value of myocardial perfusion imaging in asymptomatic RD patients before start dialysis and also try to determine a clinical predictor of perfusion abnormalities.
Methods: We prospectively evaluated with dipyridamole MPI, 123 asymptomatic consecutive patients been followed in the renal failure group in our institution between 08/2009 and 12/2011. None had known CAD, 80 male with the mean age of 60.9 years, 97.2% were hypertensive, 45% diabetic, 70% with dyslipidemia, 12.5% and 35.6% of smokers and ex-smokers. The MPI was performed by the standard dipyridamole gated SPECT technique. It was considered ischemia and fibrosis if there were reversible and fixed decreased uptake of sestamibi-99mTc after pharmacological stress, respectively. The statistical analysis was performed by Fisher’s exact test, with significance level of P ≤ .05.
Results: Perfusion abnormalities were found in 57 p (46%). Thirty-four p (28%) had MPI suggestive of ischemia and 23 p (19%) had MPI suggestive of fibrosis, respectively. The only CVD risk factor associated with ischemia was diabetes (P = 0.007). Gender (P = 0.142), hypertension (P = 0.451), dyslipidemia (P = 0.093) and smoking (P = 0.279) were not associated with ischemia.
Conclusion: Our results may suggest that dipyridamole MPI was very important to identify perfusion abnormalities. It was found a high prevalence of ischemia and fibrosis in patients with RD before dialysis even without any cardiac symptom. Diabetes was the only CVD risk factor associated with ischemia in the evaluated group.
251
EANM/ECNC expert statement on reporting nuclear cardiology
E. Tragardh1; B. Hesse2; L. Edenbrandt1; J. Knuuti3; P.A. Kaufmann4; A. Flotats5
1Skane University Hospital, Clinical Physiology and Nuclear Medicine Unit, Malmo, Sweden; 2Rigshospitalet—Copenhagen University Hospital, Clinical Physiology, Nuclear Medicine & PET, Copenhagen, Denmark; 3Turku PET Centre, University of Turku & Turku University Hospital, Turku, Finland; 4University Hospital Zurich, Cardiac Imaging, Zurich, Switzerland; 5Nuclear Medicine Department, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
The report of an imaging procedure is a critical component of an examination, since it is often the only communication from the interpreting physician to the referring physician. In addition the report may become legal evidence. Few recommendations/guidelines are available, therefore a European expert statement on how to report nuclear cardiology (myocardial perfusion, blood pool, viability, innervation, and hybrid imaging) is currently in preparation and will be published in spring 2013. Sections will cover demographics, study indications, stress testing data and image acquisition, image interpretation, conclusion of the report, etc. An important limitation for guidelines on reporting imaging studies is lack of evidence regarding different ways of writing a report on clinical outcome. The current expert statement combines existing evidence with expert consensus, previously published recommendations as well as current clinical practices. It is hoped this expert statement can improve the clinical value of nuclear cardiology for physicians and patients, and eventually improve clinical outcome.
252
Comparative analysis of ischemia in the myocardial perfusion scintigraphy in women before and after menopause
P. Paola Smanio1; D. Santos1; W. Sierraalta1; L. Machado1; M. Oliveira1; P. Cestari1; J. Franca1
1Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
Background: Despite of all efforts to reduce cardiovascular mortality in recent decades, cardiovascular disease remains the leading cause of death in females. It is already known that in postmenopausal women, the traditional risk factors for coronary artery disease (CAD) are more common than in men, however, is not yet fully established whether there are differences in the prevalence of ischemia in pre and postmenopausal women with multiple risk factors for CAD.
Purposes: To compare the prevalence of ischemia in myocardial perfusion imaging (MPI) in pre and postmenopausal women, analyzing also the menopause as an independent predictor of ischemia in women with multiple risk factors for CAD.
Methods: We evaluated retrospectively 500 MPI with sestamibi-Tc-99m of pre and postmenopausal women with high probability of CAD due to presence of multiple risk factors. The MPI was performed by standard technique and 1 day (rest/stress) protocol. It was considered suggestive of ischemia if presence of reversible perfusion defect after stress phase in at least 3 of 17 analyzed myocardial segments. We also evaluated whether menopause or some other risk factors were independent predictors of ischemia in MPS. Statistical analyses were performed using Fisher exact test and multivariate analysis and it was considered significant a P values ≤ .05.
Results: Of the total, 55.9% were in the postmenopausal period, 83.3% were hypertensive, 28.9% diabetic, 61.2% with dyslipidemia, 32.1% were smokers, 25% obese and 34.3% had known CAD. It was observed that postmenopausal women had more hypertension, diabetes, dyslipidemia, lower functional capacity at exercise stress test and a higher prevalence of stress tests suggestive of ischemia (all P < .05). The same was not observed for the presence of ischemia on MPI (P = NS). The only variable associated with ischemia on MPI was presence of previous CAD (P = .001).
Conclusion: The obtained results may suggest that in the studied group of women with high probability of CAD, menopause was not a predictor of ischemia in MPS. This information reinforces the idea that investigation of CAD in high risk for CAD population should begin already in premenopausal especially in patients with known CAD.
253
Relation between atherosclerosis and left ventricular hypertrophy and function in patients with chronic kidney disease
M. Ghaleb1; Y. Baghdady1; E. Baligh1; D. Roshd2; H. Saleh1; D. Osama1;
1Cairo University, Kasr Al-Ainy Hospital-Faculty of Medicine, Department of Cardiology, Cairo, Egypt; 2Cairo University, Kasr Al-Ainy Hospital-Faculty of Medicine, Department of Nephrology, Cairo, Egypt
Background: Patients with chronic kidney disease (CKD) have an increased risk of cardiovascular disease and mortality. Chronic kidney disease is associated with a variety of cardiac alterations including left ventricular hypertrophy, left ventricular dilation, and reduction in left ventricular systolic and diastolic function. In this study, we aimed to investigate the relation between atherosclerosis and left ventricular hypertrophy (LVH) and left ventricular function in patients with CKD.
Methods: This is a prospective study involving 50 CKD patients without overt cardiovascular disease (20 on hemodialysis and 30 not on dialysis). The study was conducted in the period extending from May 2011 through February 2012 in Kasr El-Aini hospital (Cairo University). All patients underwent carotid and femoral ultrasonography and echocardiography and biochemical analysis (creatinine, urea, albumin, haemoglobin, fasting glucose and lipid profile).
Results: Atherosclerotic patients had higher left ventricular mass index (LVMI) than non atherosclerotic patients (151.05 ± 38.68 vs 114.49 ± 42.23 g/m2, P = .001) and atherosclerotic patients had significantly higher prevalence of LVH than non atherosclerotic patients (91.3% vs 48.1%, P = .001). Atherosclerotic patients with CKD had higher prevalence of left ventricular systolic and diastolic dysfunction than non atherosclerotic patients with CKD but did not reach to statistically significant. LVH was detected in 68% of patients with CKD (63.30% in non dialysis patients, 75% in hemodialysis patients). Left ventricular systolic dysfunction was detected in 30% of patients with CKD (30% in both hemodialysis and non dialysis patients). Left ventricular diastolic dysfunction was detected in 66% of patients with CKD (70% in non dialysis patients, 60% in hemodialysis patients).
Conclusions: Prevalence of atherosclerosis is more evident in CKD patients with LVH. Left ventricular systolic and diastolic dysfunctions are prevalent in patients with CKD especially in the presence of atherosclerosis.
254
Chronic kidney disease can be considered as a risk factor for atherosclerosis
M. Ghaleb1; Y. Baghdady1; E. Baligh1; D. Roshd2; H. Saleh1; D. Osama1
1Cairo University, Kasr Al-Ainy Hospital-Faculty of Medicine, Department of Cardiology, Cairo, Egypt; 2Cairo University, Kasr Al-Ainy Hospital-Faculty of Medicine, Department of Nephrology, Cairo, Egypt, Cairo, Egypt
Background: Cardiovascular complications are the main cause of death in patients with chronic kidney disease (CKD). As a marker of atherosclerosis, increased carotid intima-media thickness (CIMT) has been widely accepted as a strong predictor of cardiovascular disease (CVD) and mortality in patients with CKD. In this study, we aimed to investigate the prevalence of atherosclerosis in patients with CKD on hemodialysis and not on dialysis.
Methods: This is a prospective, case-control study involving 50 CKD patients without cardiovascular disease (20 on hemodialysis and 30 not on dialysis) and 20 age and sex-matched healthy controls. The study was conducted in the period extending from May 2011 through February 2012 in Kasr El-Aini hospital (Cairo University). All patients and controls underwent carotid ultrasonography and biochemical analysis (creatinine, urea, albumin, haemoglobin, fasting glucose and lipid profile).
Results: Prevalence of atherosclerosis was 46% in all patients with CKD and there was no significant difference between patients on hemodialysis and patients not on dialysis regarding the prevalence of atherosclerosis (35% vs 53.3%, P = .203). Patients on hemodialysis had significantly higher common carotid artery intima media thickness (CCA IMT) than controls (0.68 ± 0.13 vs 0.5 ± 0.07; mean ± SD, P = .001) and patients not on dialysis had significantly higher CCAIMT than controls (0.79 ± 0.18 vs 0.5 ± 0.07; mean ± SD, P < .001). Patients not on dialysis had significantly higher CCA IMT than patients on hemodialysis (0.79 ± 0.18 vs 0.68 ± 0.13; mean ± SD, P = .024). We applied multivariate logistic regression analysis to predict atherosclerosis, variables that we have made in this analysis were: age, diabetes mellitus, duration of CKD, duration of smoking and dyslipidemia. The most significant predictor was age.
Conclusions: Atherosclerosis is prevalent in patients with CKD before and after starting hemodialysis treatment and chronic kidney disease can be considered as a risk factor for atherosclerosis.
255
Patterns of stress imaging testing after revascularization and impact on repeat revascularization
A.N Anastasia N. Kitsiou1; S. Karas1
1Sismanoglio Hospital, Athens, Greece
Introduction: The use of stress imaging testing after revascularization in patients without anginal symptoms is controversial. We examined the timing and the type of stress imaging testing after revascularization in asymptomatic patients followed at the outpatient Cardiology Clinic. All patients remained angina-free during the follow-up period.
Methods and Results: The patient population consisted of 72 patients (mean age 63 ± 9 years, 53 males) who had undergone percutaneous coronary intervention PCI (n = 55) or coronary artery bypass grafting CABG (n = 17), 8 months to 4 years before the last stress imaging test. The first stress imaging test after revascularization was single photon emission tomography (SPECT) with either Thallium-201 or Tc-99m tetrofosmin, for the majority of the patients (n = 63), whereas for the rest of the patients (n = 9) it was dobutamine stress echocardiography (DSE). Among all the patients, 34 (47%) had a total of 3 stress imaging tests in the follow-up period, 28 (39%) had a total of 2 stress imaging tests and 10 (14%) had one. The total number of SPECT studies was 139 (83%) and the total number of DSE was 29 (17%) during the follow-up period. In 28 (39%) of the patients, repeat stress imaging testing led to repeat revascularization, based on the presence of significant ischemia (more than 2 segments in the 17-segment model, visual image analysis).
Conclusions: In this patient population, repeat stress imaging testing was performed as a routine after revascularization, despite the fact that it is considered inappropriate according to the current guidelines. Repeat stress imaging testing demonstrated significant ischemia in a substantial number of asymptomatic patients after revascularization.
256
Exercise performance and myocardial perfusion SPECT in patients with young myocardial infarction
\E. Emre Entok1; O. Akcay1; I. Ak Sivrikoz1; A. Birdane1
1Eskisehir Osmangazi University, Eskisehir, Turkey
Aim: There has been rise of coronary artery disease (CAD) with age group of less than 40 years. It is unclear and in lately various studies focused on various etiologic aspects of CAD, but could not determine the significance of marker. We evaluated exercise capacity and other exercise parameters in young patients with abnormal myocardial perfusion SPECT.
Methods: Sixty nine patients with scintigraphically abnormal coronary arteries were evaluated in two groups according to the presence (n = 26; 11 females, 15 males; mean age 36 ± 3 years) or absence (n = 43; 19 females, 24 males; mean age 38 ± 5 years) of myocardial infarction. All the patients underwent exercise treadmill testing with the modified Bruce protocol, whereby the following variables were determined: workload achieved in metabolic equivalents, total exercise time, percentage of target heart rate achieved, double product, heart rate recovery, chronotropic response and incompetence. The relationships between exercise parameters and myocardial perfusion SPECT and clinical variables were evaluated.
Results: Smoking was the most prevalent risk factor. Family history and metabolic disease were seen in 32% patient. Ten patients had presence of more than one risk factors. Excessive alcohol intake seen in 65% patient. There was significant difference in lipid profile, fibrinogen levels and CRP among the patients with myocardial infraction. The maximum workload achieved was significantly lower and the double product was significantly higher in patients with myocardial infarction. Hypertensive and hyperglycemic subjects had significantly lower maximum workload and exercise time.
Conclusion: Smoking and family history is associated with early development of clinical atherosclerosis. In addition young patients CRP increased significant with myocardial infarction. In patients with abnormal myocardial perfusion SPECT and myocardial infarction is associated with decreased exercise capacity. SPECT results define adverse cardiac events.
257
Myocardial perfusion scintigraphy in patients with myocardial bridging over the left anterior descending artery
A. Teresinska1; J. Wnuk1; A. Dabrowski1; A. Mierzejewska1; A. Czerwiec1
1Institute of Cardiology, Warsaw, Poland
Introduction: A myocardial bridge (MB) is a muscle atypically overlying the intramyocardial segment of an epicardial coronary artery. MBs are characterized by systolic compression of the tunneled segment and stay clinically silent in the majority of cases. Some MBs can cause ischemia and associated symptoms—probably in a mechanism of delayed diastolic relaxation.
Purpose: To investigate the incidence and the characteristics of myocardial perfusion abnormalities in patients with chest pain, revealing isolated MB over LAD (LAD-IMB) in coronary angiography (no significant atherosclerotic changes in LAD or other main coronary artery).
Methods: 75 pts were selected retrospectively from the population of patients after coronary angiography revealing LAD-IMB, without previous infarction or PCI (49 males, 51 ± 12 years). The patients were divided into 3 groups: I—27 pts with MB causing ≥70% constriction of LAD lumen, II—23 pts with <70% constriction, III—25 pts with the constriction not defined. Perfusion of the LV was evaluated by using Tc-99m-MIBI SPECT studies and 17-segment model with 5-grade score of MIBI uptake in each segment (0-normal, 4-no uptake). Summed stress score (SSS), rest score (SRS) and difference score (SDS) were used to measure perfusion deficits—globally in the LV and in LAD territory.
Results:
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1.
Significant perfusion deficit (SSS ≥ 4) was detected in 45 (60%) pts, with at least moderate deficit (SSS ≥ 9) in 25 (33%) pts.
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2.
Global perfusion deficit had ischemic character (av.SSS = 6.3 vs av.SRS = 3.1, P = 0,00004). Also deficit in LAD territory was ischemic (av.SSS = 3.3 vs av.SRS = 1.4, P = 0,000004).
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3.
There were no differences between groups I and II:
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(a)
in frequency of significant perfusion deficits in pts (20/27 = 74% vs 13/23 = 57%).
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(b)
in average global values of SSS, SRS and SDS (6.8 vs 6.7, 2.5 vs 3.7, and 4.3 vs 2.9) as well as in average values of SSS, SRS and SDS for LAD territory (3.5 vs 3.8, 1.1 vs 1.8, and 2.3 vs 2.0).
-
(a)
-
4.
For 50 pts from groups I and II, no linear relationship between LAD constriction by MB and global perfusion deficits SSS, SRS and SDS was found (r = −0.01, −0.11 and 0.09); similarly, no relationship between LAD constriction and SSS, SRS and SDS in LAD territory was found (r = −0.11, −0.19 and −0.01).
Conclusion: Functional assessment of LAD-IMBs with myocardial perfusion scintigraphy is of high clinical importance, as independently of LAD lumen constriction diagnosed in coronary angiography, significant ischemic perfusion defects are often (in our population in 60% of pts) and in more than half of those cases stress perfusion defects are at least moderate.
258
Peri-infarct ischemia assessed by cardiovascular magnetic resonance imaging: Validation versus quantitative perfusion single photon emission computed tomography imaging
E. Gerbaud1; H. Cochet2; E. Bullier\3; C. Ragot1; H. Douard1; Y. Pucheu1; F. Laurent2; P. Coste1; L. Bordenave3; M. Montaudon2
1CHU de Bordeaux—Service de Cardiologie, Pessac, France; 2CHU de Bordeaux—Unité d’imagerie Thoracique et Cardiovasculaire, Pessac, France; 3CHU de Bordeaux—Département de Médecine Nucléaire, Pessac, France
Objectives: To evaluate stress adenosine cardiovascular magnetic resonance (CMR) evaluation of peri-infarct ischemia using quantitative perfusion single photon emission computed tomography (SPECT) imaging as a reference.
Methods: Forty patients presenting with a peri-infarct ischemia on a routine stress 99mTc-SPECT imaging were recruited. Within 8 days of SPECT study, myocardial perfusion was evaluated using stress adenosine CMR and peri-infarct ischemia quantified by the percentage of myocardium with stress-induced perfusion defect adjacent to and larger than the scar. This parameter was compared to both, the percent myocardium of summed difference score (SD%) and ischemic total perfusion deficit (ischemic TPD) assessed using SPECT. The diagnostic performance of CMR to detect a significant coronary artery stenosis (i.e. ≥75%) was determined.
Results: In addition to peri-infarct ischemia, reversible perfusion abnormalities were detected in a remote zone in 7 patients on SPECT imaging. In the 33 patients presenting only with peri-infarct ischemia on SPECT imaging, the agreement between CMR peri-infarct ischemia percentage and both, SD% and ischemic TPD was excellent (ICC = 0.969 and ICC = 0.877, respectively). Using a cut-off value of 8.1%, the area under the curve of peri-infarct ischemia to detect a significant stenosis in the distribution of an infarct-related artery was 0.856 (95% CI: 0.680–0.939).
Conclusion: CMR imaging can be an alternative to SPECT for detection and quantification of peri-infarct ischemia.
Moderated Posters
Left ventricular function and new insights
Tuesday 7 May, 2013, 14:00–18:00 Poster Area
259
Value of QRS width and left ventricle dyssynchrony of myocardial perfusion imaging in predicting cardiac events
A. Alejandro Solodky1; T. Bental1; A. Gutstein1; I. Mats1; D. Belzer1; Y. Hasid1; A. Battler1; N. Zafrir1
1Rabin Medical Center, Petah Tikva, Israel
Purpose: Recently, phase analysis software has been developed to assess mechanical left ventricular (LV) dyssynchrony from myocardial perfusion imaging (MPI). Prolonged QRS duration is a known index of poor prognosis. Our aim is to examine the relation of LV dyssynchrony detected by phase analysis and QRS width related with heart failure (HF) hospitalization and cardiac mortality.
Methods: During 2010, in 405 consecutive patients who referred to Tc sestamibi GSPECT MPI, we selected 143 with LVEF < 50%. Phase analysis software was applied. In the phase analysis, LV dyssynchrony was measured by phase standard deviation (PSD). Patient’s characteristics, risk factors of CAD, MPI, phase analysis results, LVEF and QRS width were analyzed. The patients were followed-up for cardiac events (HF hospitalizations and cardiac mortality) for 437 ± 75 days.
Results: Table.
Bivariate logistic regression analysis (QRS width and PSD) was used because of the low number of events, and showed for QRS width R = 1.013, CI 95% = 0.99-1.03 and P = .089 and for PSD R = 1.033, CI 95% = 1.01-1.06 and P = 0 .012.
Conclusion: In addition to LVEF as a predictor of events, PSD of phase analysis was identified to be an independent predictor for heart failure hospitalization and cardiac mortality.
.
Events N = 20 | No events N = 123 | P value | |
|---|---|---|---|
Age (years) | 71 ± 12 | 66.3 ± 12 | .1 |
Diabetes Mellitus | 12 (60%) | 43 (35%) | .059 |
Infarct Size (1–5) | 3.2 ± 2 | 2.25 ± 1.7 | .04 |
QRS Width | 129.8 ± 40 | 105.52 ± 31 | .01 |
LVEF | 26.15 ± 10 | 38.29 ± 10 | .0001 |
PSD | 57.18 ± 24 | 39.59 ± 20 | .002 |
260
Use of radionuclide ventriculography in the diagnosis of cardiotoxicity in patients with breast cancer treated with herceptin and its relationship with other clinical and hemodynamic parameters
M. Garrido1; V. Pubul1; M. Pombo1; S. Argibay1; S. Nieves1; J. Lopez-Urdaneta1; A. Bejarano1; J. Cortes1; A. Sanchez-Salmon1; A. Ruibal1
1Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
Objective: To assess the prevalence of cardiotoxicity measured by radionuclide ventriculography in women with breast cancer treated with Herceptin, and the possible relationship of the changes in LVEF with the presence of cardiovascular risk factors or other hemodynamic parameters (diastolic function and ventricular volumes).
Material: We selected 131 patients diagnosed with infiltrating ductal breast carcinoma HER2 positive, with a test for estimating baseline LVEF prior to the administration of Herceptin and at least one or more test at least three months from the start of the treatment.
All patients had a baseline EF value greater than 50% and heart rate values during acquisition between 50 and 100 bpm.
Hemodynamic parameters calculated by ventriculography included: ejection fraction (LVEF), peak filling rate (PFR), time of diastole until PFR (TPFR), end-systolic volume (ESV), end-diastolic volume (EDV).
It was considered a significant drop in LVEF to get a value of EF below 50% during treatment or a fall of more than 10% compared to baseline.
Results: 48 patients (36.6%) made significant drops in LVEF during treatment.
In a study of lineal correlation between hemodynamic parameters and the decrease of EF, it appears to establish a slight connection between the initial values of EF (Pearson −0.1843, P .002), PFR (Pearson −0.1396, P .044) and EDV (Pearson −0.196, P .016).
However, initial EF value was not associated with a significant decrease in EF during treatment (initial FE significant decrease in patients with 63.7 ± 7.7 vs 62.8 ± 5.7 in patients without significant decrease; P .458). Diastolic function parameters did not show this relationship (initial PFR: 3.1 ± 0.67 vs 2.9 ± 0.6, P .139—Initial TPFR: 133.1 ± 28.9 vs 148.1 ± 76.5). In terms of volumes, only the highest values of EDV showed relation with a significant decrease in EF (110.3 ± 19.7 vs 100.4 ± 19.3, P .006).
Conclusions: Cardiotoxicity during treatment with Herceptin in the treatment of breast cancer is a common adverse event—reaching in our study a prevalence of 36%.
The diagnosis of cardiotoxicity conditioned a change in therapy and in subsequent management of the patient.
The patient’s hemodynamic status at the beginning of the treatment was weakly related to the presence or absence of cardiotoxicity, so we considerextremely important the regular monitoring of LVEF during treatment of patients with breast cancer.
261
Comparison of parametric modeling of gated SPECT in normals and patients with LBBB using gaussian and first harmonic Fourier fitting
C.L. Christopher L Hansen1; K.B. Reist1
1Thomas Jefferson University, Philadelphia, United States of America
Purpose: Parametric modeling of gated SPECT using the first harmonic of the Fourier transform (cosine) has been proposed as a way to identify patients most likely to benefit from biventricular pacing. We have previously shown that parametric modeling of the LV using a Gaussian fit is more accurate than cosine fit in both radionuclide ventriculography and in gated SPECT. The purpose of the present study was to compare the accuracy of fit and differences in parameters patients with low probability of coronary disease (nls) and patients with left bundle branch block (LBBB) and normal ejection fraction (EF).
Methods: We retrospectively identified 55 nls and 51 patients (pts) with LBBB without gating artifact. Sequential radial plots were fitted to both a Gaussian and cosine functions using a modification of the Levenberg-Marquardt algorithm. Output of the Gaussian function was amplitude, mean and standard deviation (SD); output of the cosine function was amplitude and phase. The mean and SD of a volume-weighted bullseye for each parameter were calculated. Accuracy of each fit was measured by calculating the root mean square (RMS) of the difference between the fit and the measured curves.
Results: The RMS error of the Gaussian fit was significantly lower in both nls (10.3 ± 1.3% vs 11.3 ± 1.6%, P < .001) and LBBB (8.4 ± 0.9% vs 9.3 ± 1%, P < .001). There was very high correlation between the amplitude of the Gaussian and Cosine fits (r = 0.968, P < .001). As we found previously, there was very strong correlation be the cosine phase and Gaussian mean (r = 0.945 nls, r = 0.914 LBBB, both P < .001) and the SDs of the mean and phase (r = 0.876 nls, 0.853 LBBB, both P < .001). The mean of the Gaussian SD, another measure of variability, correlated with both the SDs of the Gaussian mean (r = 0.666 nls, 0.737 LBBB, both P < .001) and phase (r = 0.853 nls, 0.876 LBBB, both P < .001). Both Gaussian and cosine showed differences between nls and LBBB by significant differences in SDs of the Gaussian mean (0.53 ± 0.22 nls vs 0.68 ± 0.22 LBBB, P = .001) and SD of phase (0.89 ± 0.45 nls vs 1.14 ± 0.44 LBBB, P = .004). There was a trend towards a difference in the mean of the Gaussian SD (1.37 ± 0.23 nls, 1.44 ± 0.18 LBBB, P = .10).
Conclusions: Gaussian provides a more accurate parametric fit to gated SPECT images than does cosine. The SD of the mean of the Gaussian is at least as powerful as cosine fit in identifying phase differences in nls and pts with LBBB. The Gaussian SD, another measure of variability, may prove additionally useful in identifying pts likely to benefit from biventricular pacing.
262
Prognostic value of the left ventricular dyssynchrony determined by gated SPECT in patients with nonischemic dilated cardiomyopathy
S. Salvador Hernandez Sandoval1; E. Alexanderson Rosas1; H.J. Hernandez Perales1; M. Jimenez Santos1; C.A. Guizar Sanchez1
1Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
Objective: To correlate the left ventricular dyssynchrony, determined by gated SPECT, with the morbidity and mortality in a 5-year period in patients that have been diagnosed with nonischemic dilated cardiomyopathy.
Methods: This is a retrospective and transversal study. It includes patients with dilated cardiomyopathy that were treated between 2006 and 2008. They all received a gated SPECT study without evidence of coronary disease. Also, they all had an ejection fraction of less than 40% and they were all monitored for 5 years. From the gated SPECT analysis we obtained the indexes of left ventricular synchrony: standard deviation and bandwidth. We registered the end-diastolic and end-systolic volumes and the ejection fraction. We divided the patients into two groups according to the cutting points of 44° for standard deviation and 135° for bandwidth. It’s been demonstrated that these values indicate significant asynchrony and predict a response to the cardiac resynchronization therapy. The gated SPECT analysis was performed using the Emory Cardiac Toolbox software. We evaluated the mortality from cardiovascular causes and the existence of at least 1 hospitalization due to decompensated heart failure during a period of 5 years.
Results: We included 32 patients, of which 20 were male and 13 were female. The median of the ejection fraction was 27.5 ± 9%. The median for the end-diastolic volume was 237 ± 69 mL, and the median for the end-systolic volume was 174 ± 64 mL. The mortality was 34.3% during the 5-year period. We found correlation between the asynchrony defined by the bandwidth (bigger than 135°) and the mortality, with a relative risk of 3.43, P = 0.027; as well as correlation with the hospitalization, with a relative risk of 3.86, P = .050. We didn’t find correlation between the standard deviation and the mortality (P = .266) nor with the ejection fraction (correlation coefficient was −0.659 with P = .000). There was also no correlation between mortality and the end-diastolic volume (0.447 with P = .010) nor with the end-systolic volume (0.601 with P = .000). The bandwidth was correlated with the ejection fraction (−0.716 with P = .000), the end-diastolic volume (0.442 with P = .011) and the end-systolic volume (0.609 with P = .000).
Conclusions: The parameters of the left ventricular dyssynchrony are obtained with the conventional gated SPECT study and can provide prognostic information in addition of the other variables that have been already studied, such as ventricular volumes and ejection fraction.
263
Poststress LVEF changes in patients with normal perfusion and function on gated MPI SPECT
A. Amelia Jimenez-Heffernan1; A. Ortega-Carpio2; E. Sanchez De Mora1; J. Lopez-Martin1; C. Salgado1; C. Ramos1; C. Sanchez-Gonzalez3; R. Lopez-Aguilar3
1Hospital Juan Ramón Jiménez, Department of Diagnostic Imaging, Huelva, Spain; 2Centro de Salud El Torrejon, Huelva, Spain; 3Hospital Juan Ramon Jimenez, Department of Cardiology, Huelva, Spain
Purpose: Users of standard Anger camera technology for gated MPI SPECT can achieve the ASNC’ goal of reducing total radiation exposure to ≤9 mSv in 50% of studies by 2014 by means of fast reconstruction algorithms coupled with dose reduction; and/or particularly with stress-only imaging in appropriately selected patients. Poststress LVEF (PSEF) reduction has been associated with ischemia and has shown prognostic value. We aim to evaluate the changes between poststress and resting LVEF (RTEF) in patients with no significant perfusion defects and PSEF ≥ 50%, changes that would not be observed with stress-only imaging.
Methods: A 7-year database of 2069 consecutive patients undergoing 2-day stress-rest 99mTc MPI was screened for studies with normal/near normal perfusion (SSN ≤ 4), PSEF ≥ 50% and at least one year of follow-up, retrieving 829 patients. In 148 cases follow-up was not possible, so the study group comprised 681 patients (56.4 % female, age: 64.5 ± 10.7 years, weight: 78 ± 14.7 kg). Mean poststress acquisition time was 88 ± 33 minutes (r: 30-210). LVEF was calculated from well validated commercial software.
Patients were divided into three groups according to whether PSEF in relation to RTEF was ≥5% higher (group A), between 4% and −4% (group B) or ≥5% lower (≤−5%) (group C). Groups A, B and C comprised 158, 365 and 158 patients respectively. Follow-up was obtained by revision of electronic medical records. Mean follow-up was 3.5 years. Percutaneous or surgical revascularization, non-fatal myocardial infarction and cardiac death made up the primary end-point.
Results: The end-point was met by 9 (5.6%), 36 (9.9%) and 19 (12%) patients from groups A, B and C respectively. Chi-square test showed no significant differences between groups although a lineal association was suggested (P = .054) with a growing event rate as PSEF goes from increasing to decreasing in relation to RTEF. Kaplan Meier survival analysis showed no significant differences in the event rate between the three groups. Mean HR at poststress acquisition was 68.9 ± 13.9 bpm, significantly higher than at rest: 66.6 ± 12.2 bpm but we don′t expect this to have an influence on our final results.
Conclusion: In patients with normal perfusion failure to increase or an actual decrease in PSEF in relation to RTEF is not significantly associated with a higher event rate, so stress-only imaging should be safe enough. Nevertheless, if performing stress-rest studies a PSEF reduction ≥5% should be carefully interpreted as 12% of such patients in our study had cardiac events during follow-up.
264
Prognostic value of gated-SPECT left ventricular shape index in post-MI patients
E. Alexanderson Rosas1; C. Sierra-Fernandez1; E.A. Penarrieta-Daher1; L.E. Juarez-Orozco1; L.V. Torres-Araujo1; A. Jordan-Rios1; S. Hernandez-Sandoval1; C.A. Guizar-Sanchez1; A. Meave1; M. Jimenez-Santos1
1Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico City, Mexico
Ischemic heart disease is one of the major causes of mortality and morbidity worldwide. The objective of this study is to determine the prognostic value of Telesystolic Left Ventricular Shape Index (TS LVSI) in post-MI patients.
Methods: In this historic cohort study 51 post-MI patients (46 males and 5 females, mean of age 62 years old) with 5-year follow up were included. One-day rest-stress gated SPECT sestamibi protocol was performed in all patients 6 to 12 months post-MI. CSI Cedar-Sinai software was used to calculate all the gating and perfusion parameters as well as TS LVSI. SPSS Mac v.20 was used for statistical analysis.
Results: The prognostic analysis demonstrated a global mortality of 7.8% when TS LVSI was ≥0.54, while there were no mortality cases at a TS LVSI ≤ 0.53 (P < .01). Assessing NYHA Class deterioration, 21.6% of TS LVSI ≥ 0.54 patients had a decrease in functional class when compared with 3.9% of those who had a TS LVSI ≤ 0.53 (P < .001). Overall, we found a mortality RR of 19 (CI 95% 1.8-33.4 P = .04) and a NYHA Class deterioration RR of 12.03 (CI 95% 3.0-48.09 P < .01) for a TS LVSI ≥ 0.54. Table 1 compares TS LVSI with LVEF, SRS, SSS and SDS.
Conclusion: TS LVSI is a good prognostic parameter and allows better determination of patients with risk of cardiac death or NYHA class deterioration than LVEF, degree of ischemia and MI extension, when taking 0.54 as a cutoff value. These risks increase proportionally with this index, reaching a mortality of 100% when ≥0.70.
265
Diastolic function and ventricular synchrony in low cardiovascular risk population: An assessment with 13N-Ammonia PET/CT scanning
E. Erick Alexanderson Rosas1; L.E. Juarez-Orozco2; R.H.J.A. Slart3; E.A. Penarrieta-Daher1; L.V. Torres-Araujo1; R.A. Tio3; A. Meave1; R.A. Dierckx3
1Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico City, Mexico; 2Unidad PET/CT Ciclotrón UNAM, Mexico City, Mexico; 3University of Groningen, University Medical Center Groningen, Groningen, Netherlands
Introduction: Cardiovascular PET/CT scanning has developed, beyond doubt as an important adjuvant for diagnostic, prognostic and therapeutic evaluation in cardiac disease. Nevertheless, little is known about the significance and potential utility of the diastolic function and phase synchrony parameters obtained by PET/CT reconstruction algorithms due to lack of normal and low risk population studies.
Methods: We performed and analyzed eighteen 13N-Ammonia 2-phase perfusion PET/CT scans with a “list mode” acquisition for static, dynamic and gated images in low cardiovascular risk patients according to the cardiovascular risk Framingham score. Furthermore we obtained the determination of peak filling rate (PFR) and time to peak filling (TTPF) for diastolic function evaluation; histogram bandwidth (HB), standard deviation (SD) and entropy (E) were obtained for phase synchrony assessment. Resting shape index (SI) and left ventricle ejection fraction (LVEF) was included from the gated acquisition.
Results: We included 6 male and 12 female patients with a mean age of 56 ± 10 years. Findings are depicted in Table 1.
Conclusions: PET/CT perfusion scans provide quantitative assessment of diastolic function and ventricle synchrony. We found that diastolic function parameters are close to the ones reported in SPECT scanning but not the synchrony ones, this could be related to the automatic border delimitation in the basal portion of the heart. Further research for normal measurements is needed.
266
Left ventricle ejection fraction: Correlation with infarct size and myocardial perfusion reserve post-MI
R.H.J.A. Slart1; L.E. Juarez-Orozco2; E. Erick Alexanderson Rosas3; R.A. Tio1; R.A. Dierckx1; E.A. Penarrieta-Daher3; J. Glauche1; L.V. Torres-Araujo1
1University of Groningen, University Medical Center Groningen, Groningen, Netherlands; 2Unidad PET/CT Ciclotrón UNAM, Mexico City, Mexico; 3Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico City, Mexico
Introduction: Left ventricular function after myocardial infarction is considered to be determined by the size of the infarction and residual function of the spared myocardium. Myocardial perfusion reserve assessed by 13N-ammonia PET has been shown to be a strong predictor in patients with ischemic heart failure. Unknown is the value of MPR in the spared myocardium in relation with infarct size and LVEF. In the present study, the interrelationship between MPR, LVEF and infarct size was acquainted.
Methods: In this study, 102 patients with a prior history of myocardial infarction were included. All underwent rest—dypiridamole stress 13N-ammonia and gated FDG PET for evaluation of myocardial perfusion reserve and viability. FDG polar maps were used to determine the size of the infarction. The LVEF was obtained by gated FDG PET or another available method within 3 months of the PET scan. The segmental MPR was obtained by dividing stress and rest myocardial perfusion in the spared myocardium.
Results: Mean age of the subjects was 69 ± 12 years (men 78%), global MPR was 1.65 ± 0.51. Mean LVEF was 36 ± 9.8%, mean infarct size 23.6 ± 14.6%. Fifty patients had dyslipidemia, 41 hypertension, 13 diabetes, 45 were smokers, and 35 a positive family history for cardiovascular disease. Linear regression model was applied for the analysis considering the LVEF as an independent variable. All risk factors, infarct size and MPR were entered as variable. The infarct size (P < .001) and MPR (P = .008) reached statistical significance. Of all risk factors only diabetes mellitus (P = .030) showed a significant correlation with LVEF.
Conclusions: In patients with a prior history of myocardial infarction, LVEF is not just related to infarct size but also to MPR in the spared myocardium.
Poster Session 4
Left ventricular function and new insights
Tuesday 7 May, 2013, 14:00–18:00 Poster Area
268
Improving diagnostic yield of exercise ECG for obstructive coronary artery disease: Integration with clinical and bio-humoral markers
C. Caselli1; V. Lorenzoni1; G. Todiere2; M. Marinelli1; M. Pietila3; D. Giannessi1; J. Knuuti3; D. Neglia2; D. Rovai1
1Institute of Clinical Physiology of CNR, Pisa, Italy; 2Gabriele Monasterio Foundation-CNR Region Toscana, Pisa, Italy; 3Turku University Hospital, Turku, Finland
Purpose: Exercise ECG is used in patients with suspected coronary artery disease (CAD) to select candidates for stress imaging testing or coronary angiography. The diagnostic accuracy of exercise ECG can be improved by integrating clinical variables into predictive models of CAD. We hypothesized that the diagnostic accuracy could be improved by including bio-humoral markers in predictive models based on clinical data and exercise ECG.
Materials and Methods: A cohort of 428 patients with angina-like chest pain or equivalent symptoms, enrolled in the EVINCI study, underwent clinical examination, exercise ECG test, bio-humoral characterization and coronary arteriography. In every patient 36 biomarkers linked to the atherosclerotic process were evaluated, and the integrated Duke clinical score (with exercise ECG results) was calculated. Independent markers of CAD were identified by logistic regression analysis. Severe obstructive CAD, i.e. >70% coronary stenosis in at least one vessel at coronary arteriography, or 30-70% stenosis with reduced fractional flow reserve, was the diagnostic endpoint. The diagnostic accuracy of the integrated models was evaluated by ROC curves analysis.
Results: The prevalence of severe obstructive CAD was 27%. The integrated clinical model showed a predictive accuracy of 66.7%. At multivariate analysis, HDL-cholesterol, AST, HOMA Index, IL-6, and Osteopontin were independent predictors of CAD. Adding these variables to the clinical model, the diagnostic accuracy increased up to 74.0% (P = .001).
Conclusions: Five bio-humoral markers linked to the atherosclerotic process are independently associated with obstructive CAD. Adding these markers into predictive models significantly improves the diagnostic accuracy of clinical evaluation and exercise ECG for obstructive CAD.
ROC curves
269
Left atrial appendage volume is increased in more than half of patients with cryptogenic stroke
M. Taina1; R. Vanninen1; M. Hedman2; P. Jakala3; P. Sipola1
1Kuopio University Hospital, Department of Radiology, Kuopio, Finland; 2Kuopio University Hospital, Heart Center, Kuopio, Finland; 3Neuron Institute, Kuopio, Finland
Background: Ischemic stroke without a well-defined etiology is labelled as cryptogenic, and it accounts for 30-40% of strokes in modern stroke registries. Enlarged left atrial appendage (LAA) is the most typical origin for intracardiac thrombus formation, when associated to atrial fibrillation (AF). We studied whether increased LAA volume detected with cardiac computed tomography (cCT) constitutes a risk factor in cryptogenic stroke patients.
Methods: Consecutive stroke or TIA patients with cryptogenic etiology for stroke after profound clinical, radiological and cardiological investigations were selected for the study. The 1993 TOAST criteria modified by 2010 European Association of Echocardiography (EAE) recommendations for defining cardiac sources of embolism were used for classification. Eighty-two patients (57 males; mean age 58 years) were identified. Forty control subjects without cardiovascular diseases, matched for age and gender, were selected for pair-wise comparisons (21 males; mean age 54 years). LAA volume adjusted for body surface area was measured three dimensionally by tracing the borders of LAA on electrocardiogram gated CT slices.
Results: In control subjects LAA volume was 3.4 ± 1.1 mL/m2 (range 1.3=6.0 mL/m2). The upper limit for normal LAA volume was defined as mean + 2 SD in control subjects (5.6 mL/m2). In matched pair-wise comparisons LAA volume was 67% larger in cryptogenic stroke/TIA patients than in control subjects (5.7 ± 2.0 mL/m2 vs 3.4 ± 1.1 mL/m2; P < .001). Of the all patients with cryptogenic stroke/TIA 45 (55 %) had enlarged LAA.
Conclusions: LAA is significantly enlarged in more than half of patients with cryptogenic stroke. LAA thrombosis may contribute in the pathogenesis of stroke in patients considered to have cryptogenic stroke after conventional evaluation and thus do not have AF or any other previously known risk factor for stroke.
270
Prevalence and prognostic value of positive myocardial perfusion SPECT in relation to the workload achieved during exercise testing
V. Pubul1; S. Nieves1; M. Miguel Garrido1; S. Argibay1; R. Vidal1; M. Vega1; A. Martinez1; J. Lopez-Urdaneta1; R. Gonzalez-Juanatey1; A. Ruibal1
1Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
Purpose: To evaluate the prevalence of ischemia determined by SPECT in relation to the workload achieved during exercise testing in patients with suspected or known coronary artery disease, and determine the frequency of adverse events in these groups.
Methods: We selected 2206 consecutive patients who underwent myocardial perfusion SPECT for diagnosis/prognosis purpose, with a two-day stress/rest protocol study, reaching over 80% of the maximum age-predicted heart rate and >5 metabolic equivalents (METs) during exercise testing. Finally, we studied 1771 patients with follow-up, which were grouped according to the workload achieved (5-7 METs n = 186, 7-9 METs n = 756, and >10 METs n = 824), analyzing its relationship with perfusion defects and adverse events. Age, diabetes, smoking, hypertension, dyslipidemia, body mass index, and peripheral arterial disease were variables to study. At follow-up we assessed the occurrence of adverse events such as: Coronary Revascularization, Acute Myocardial Infarction, Hospitalization for Cardiac Causes and Heart-Related Deaths. The average time of follow-up was 2.5 ± 2 years.
Results: Patients who achieved >10 METS, were mostly young (mean 57 years), males (71%) and a had smaller proportion of cardiovascular risk factors such as Diabetes (17%) and obesity (12%) compared to the other two groups.
The exercise test had more positive results in the groups of lower workloads than the group of >10 METS (5-7 METS: 32%, 7-9: METS 32% and >10 METS 27%; P < .05). The groups of low workload were also associated with a higher percentage of positivity in the SPECT (5-7 METS: 46%; 7-9 METS: 37% and >10 METS: 35%; P < .05).
Regardless the workload, a positive result in the SPECT in each of the three groups was related to a high prevalence of adverse events (Events in patients with positive SPECT: 5-7 METS: 44%; 7-9 METS: 31%, and ≥10 METS: 19%), compared to patients with negative SPECT.
Conclusions: Patients who achieved a lower workload had a more atherogenic risk profile and a higher prevalence of inducible ischemia. A positive result on SPECT is correlated with a higher percentage of adverse events in the three groups. In our population the results of myocardial perfusion SPECT is useful to discriminate patients with a higher likelihood of future events even among those who reach high workloads.
271
Radiation dose and downstream testing from coronary CT angiography compared to stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department
M. Milena Henzlova1; J. Savino1; E.J. Levine1; L.B. Croft1; A.J. Einstein1; L. Hermann1; W.L. Duvall1
1Mount Sinai School of Medicine, New York, United States of America
Purpose: While recent coronary CT angiography (CTA) studies have suggested lower radiation dose and faster study time than stress testing and myocardial perfusion imaging (MPI), this comparison has been to older Na-I SPECT cameras using traditional rest-stress protocols. We compared CTA to stress testing with modern SPECT MPI using high-efficiency CZT (cadmium-zinc-telluride) cameras and newer stress-first protocols in an emergency department (ED) Chest Pain Unit (CPU) population.
Methods: In a retrospective, non-randomized study all patients who underwent CTA or stress testing [exercise treadmill testing (ETT) or Tc-99m sestamibi SPECT MPI] as part of their ED CPU assessment in 2010-2011 driven by ED attending preference and equipment availability were evaluated for their radiation exposure and subsequent diagnostic testing (within 3 months of ED visit). CTA was performed on a 64-slice scanner and MPI was performed on either a CZT or Na-I SPECT camera. Effective dose from CTA was estimated from scanner-reported dose-length product using a published scanner-specific conversion factor and from MPI from recorded administered activity using separate conversion factors for stress and rest imaging provided in ICRP Publication 80.
Results: Over the 2 year period, 1,458 patients underwent testing in the ED with 192 CTA’s and 1,266 stress tests (327 ETT’s and 939 MPI’s). The CTA patients were a lower risk cohort based on age, cardiac risk factors, and known heart disease. In the MPI group, 708 (75%) underwent stress-only imaging, 184 (20%) rest-stress, and 47 (5%) stress-rest with 853 (91%) imaged on a CZT camera. There were significantly more follow-up studies in the CTA group than in the stress testing group (13.5% vs 6.6%, P = .001), with no significant difference in the proportion of subsequent angiograms (8.3% vs 6.2%, P = .32), but more follow-up functional studies (5.2% vs 0.5%, P < .0001). There was a non-significant trend towards more revascularization in those patients undergoing invasive angiography in the CTA group than in the stress testing group (59% vs 40%, P = .16). The mean effective dose of 13.5 ± 9.2 mSv for the CTA group was significantly higher (P < .0001) than 5.0 ± 4.1 mSv for the stress-testing group and 6.4 ± 3.3 mSv for CZT SPECT MPI studies.
Conclusions: Stress testing including ETT, CZT SPECT MPI, and stress-only imaging protocols had a significantly lower patient radiation dose and less follow-up diagnostic testing than CTA. As previously published, stress-only imaging can be completed within 90 minutes which compares favorably with the 1 hour length of a CTA.
272
Automated quantitative computed tomography coronary angiography (CTA) correlates of myocardial ischemia on gated myocardial perfusion SPECT
M.A. Michiel De Graaf1; H.M. El-Nagger1; A. Broersen2; J. Dijkstra2; L.J. Kroft3; I. Al-Younis4; J.H. Reiber2; J.J. Bax1; V. Delgado1; A.J. Scholte1
1Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands; 2Leiden University Medical Center, Department of Radiology, Division of Image Processing, Leiden, Netherlands; 3Leiden University Medical Center, Department of Radiology, Leiden, Netherlands; 4Leiden University Medical Center, Department of Nuclear Medicine, Leiden, Netherlands
Purpose: CTA plaque characteristics are associated with myocardial ischemia. The current study aimed to evaluate the correlation of quantitatively assessed CTA (QCT) plaque characteristics and the presence of myocardial ischemia on gated myocardial perfusion single-photon emission computed tomography (SPECT).
Methods: Patients with suspected CAD who had undergone multi-detector row CTA and gated myocardial perfusion SPECT within 6 months were included. CTA datasets were visually assessed to determine plaque type and stenosis degree. Consecutively, QCT was performed per coronary lesion to assess plaque length, plaque burden and percentage lumen area stenosis. Subsequently, the presence of myocardial ischemia was assessed using the summed difference score (SDS ≥ 2) on SPECT. Using nested multivariate models, the independent correlation of the QCT parameters and myocardial ischemia was assessed.
Results: A total of 40 patients (mean age 58.2 ± 10.9 years, 27 men) were included. 25 (62.5%) patients showed myocardial ischemia in 37 vascular territories. Multivariate analyses demonstrated that independent of baseline variables and visual assessed significant stenosis, both quantitative significant stenosis and quantitative assessed lesion length were significantly correlated with myocardial ischemia (OR 7.72 [2.41-24.07], P < .001 and OR 1.07 [1.00-1.45], P = .032, respectively). As depicted in Figure 1, both quantitative parameters have incremental value over relevant clinical risk factors in the association with myocardial ischemia.
Figure of the abstract 272
Conclusions: Coronary lesion length and quantitative assessed significant stenosis are significantly correlated with myocardial ischemia on gated myocardial perfusion SPECT independent of clinical risk factors and visual assessed stenosis.
273
Predictive variables for hard cardiac events and coronary revascularization in patients with normal left ventricular myocardial perfusion and systolic function
J.G. Jorge Guillermo Romero Farina1; S. Aguade-Bruix1; G. Cuberas-Borros1; G. De Leon1; J. Pinar1; J. Castell-Conesa1; D. Garcia-Dorado1; J. Candell-Riera1
1Hospital Universitari Vall d’Hebron, Barcelona, Spain
Purpose: To investigate the impact of clinical variables to predict hard events (HE) and coronary revascularization (CR) in patients with normal stress-rest gated SPECT.
Methods: Two thousand and four patients (63.5 ± 12.5 years, male: 41.6%) with a normal myocardial perfusion and left ventricular ejection fraction (LVEF) >50% on gated SPECT were followed for HE (cardiovascular death or acute myocardial infarction) and CR. Multivariate Cox regression analysis and Kaplan-Meier curves analysis were used to evaluated and predict HE and CR.
Results: During a follow-up of 4.3 ± 2.4 years, 33 patients (1.6%) (0.4%/year) had HE and 50 patients (2.5%) (0.6%/year) underwent CR. In univariate analysis, age ≥ 65 years, insulin-dependent diabetes mellitus (IDDM), left bundle branch block (LBBB), and pharmacologic stress were associated with HE. Independent predictors of HE were age ≥ 65 years (P < .001; HR: 6.9), IDDM (P = .014; HR: 3.4), and LBBB (P = .002; HR: 4.6). In univariate analysis, male, known coronary artery disease (CAD), LBBB, and a positive stress test were associated with CR. Independent predictors of CR were known CAD (P = .016; HR:2.1), and a positive stress test (P = .006; HR: 2.3).
Conclusions: Age ≥ 65 years, IDDM, and LBBB are HE independent predictors in patients with normal myocardial perfusion and normal LVEF on gated SPECT. The presence of a known CAD or a positive stress test significantly increases the probability of CR during follow-up.
274
Prognostic value of myocardial perfusion imaging in non-stenotic coronary lesion
A. Kisko1; M. Vereb2; J. Kmec3; J. Cencarik3; P. Gazdic3; J. Stasko3
1Cardiology Clinic, Reiman University Hospital, Sekcov Polyclinic, Presov, Slovak Republic; 2Sekcov Polyclinic, Nuclear Medicine, Presov, Slovak Republic; 3Cardiology Clinic, Reiman University Hospital, Presov, Slovak Republic
Coronary angiography has diagnostic limitation in identifying non-stenotic coronary lesion (NSCL) responsible for ischemia. Myocardial perfusion defects in patients (pts) with NSCL have often been unreasonably considered by invasive cardiologists as being “false positive”. We evaluated a prognostic value of gated SPECT MPI in unselected group of the pts with NSCL over a 24 month period of follow-up.
170 pts (115 males, 67.6%; age 42-68 years; mean age 56.4 ± 9.2 years) with NSCL (stenosis of 50% or less of LAD and 70% or less of any other coronary artery or its major branches) were enrolled into the study. Retrospective analysis of 86 pts with NSCL and subsequent positive MPS performed within 6 months from the time of coronary angiography (study group) and 84 pts with normal scan results (control group) was performed. Follow-up period was for 24 months from the time of MPI or up to the time of major coronary event (MCE)—first occurrence of cardiac death or myocardial infarction.
Over a two-year follow-up, approximately 11% of the pts in study group had MCE as compared to 3.2% in the control group (P < .01). Abnormal MPI, EF <35% and high levels of hs-CRP were independent predictors for MCE in the study group. In multivariate analysis only an abnormal MPI remained to be an independent predictor regardless of size or severity of perfusion abnormalities (P < .005).
Pts with NSCL on coronary angiography and myocardial perfusion defects have relatively high event rate (11%) of MCE over a period of 24 months from the time of MPI. So, we highly recommend gated SPECT MPI to be obligatory performed in all cases of NSCL to avoid life-threatening coronary complications in forthcoming future.
275
Left bundle branch block: Influence of septal perfusion defects and septal dyskinesia in phase analysis of gated-SPECT MPI
R. Cardenas Perilla1; S. Santiago Aguade-Bruix1; G. Romero-Farina1; M.N. Pizzi1; G. De Leon1; J. Candell-Riera1; J. Castell-Conesa1
1Hospital Vall d’Hebron, Barcelona, Spain
Introduction: Quantitative phase analysis (PhA) parameters of myocardial perfusion gated SPECT (gated SPECT MPI) shows abnormal values in all of patients with left bundle branch block (LBBB), but relationship between septal abnormalities in perfusion and motion was not investigated.
Objective: To compare rest PhA gated-SPECT MPI in patients with LBBB, with and without septal defects, and with and without septal dyskinesia.
Methods: 95 patients with LBBB (age: 71 ± 10, 67 females) and without MI, dilated cardiomyopathy, ischemia or pacemaker were evaluated by rest gated-SPECT MPI. PhA was performed with Synctool (ECT, Emory, USA) to obtain phase peak (PhP), standard deviation (SD), bandwidth (BD), skewness and kurtosis of phase histogram. Heart rate, QRS interval, left ventricular volumes, ejection fraction and perfusion defect scores (SSS, SRS, SDS) were considered.
Results: Significant differences in phase SD (19.7 ± 8.6 vs 28.2 ± 12.5, P = .001) and histogram bandwidth (60.2 ± 23.5 vs 90.7 ± 49.9, P = .002) were observed between 21 patients with septal dyskinesia and 74 patients without septal dyskinesia.
No significant differences in PhA parameters were observed between 56 patients with septal perfusion defects and 39 patients without septal defects (SSS: 1.6 ± 2.1 vs 4.3 ± 2.9, P < .001; SRS: 1 ± 1.5 vs 2.3 ± 2.3, P = .002; SDS: 1.2 ± 1.7 vs 2.3 ± 1.9, P < .001), and between 35 patients with septal perfusion defects and without septal dyskinesia and 21 patients without septal perfusion defects and without septal dyskinesia.
Conclusions: Septal dyskinesia, but not abnormal septal perfusion, significantly influences PhA parameters of myocardial perfusion gated SPECT.
276
Estimation of at risk and salvaged myocardium by gated SPECT performed one month after acute myocardial infarction
J.G. Jorge Guillermo Romero Farina1; S. Aguade-Bruix1; N. Pizzi1; V. Pineda1; J. Figueras1; G. Cuberas-Borros1; G. De Leon1; C. Castell-Conesa1; D. Garcia-Dorado1; J. Candell-Riera1
1Hospital Universitari Vall d’Hebron, Barcelona, Spain
Purpose: To determine the value of late (one month) myocardial perfusion gated SPECT (gSPECT) to estimate at risk and salvaged myocardium in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI).
Materials and Methods: Forty patients (mean age 61.5 years, 8 women) with a first AMI were included in the study. They underwent two gSPECTs: the first (gSPECT-1) was performed with IV dose of 99mTc-tetrofosmine prior to PCI, and the second (gSPECT-2) was performed during the 4th or 5th week following AMI. In gSPECT-1 myocardium at risk was quantified by measuring the perfusion defect, and salvaged myocardium by subtracting the area of necrosis in gSPECT-2 from the myocardium at risk area. In gSPECT-2, myocardium at risk was estimated by analyzing discordance between the areas of left ventricular wall motion and perfusion.
Results: A significant improvement in perfusion, wall motion, thickening and left ventricular ejection fraction (P < .001) was observed between gSPECT-1 and gSPECT-2. In gSPECT-2 the mean value of the area with abnormal wall motion was significantly greater (35.5 vs 23.1 cm2, P = .007) than the mean area with altered perfusion (mismatch pattern wall motion-perfusion). The extent of myocardium at risk estimated from this discordance area correlated well with myocardium at risk measured in gSPECT-1 and with salvaged myocardium between gSPECT-1 and gSPECT-2 (Pearson’s correlation coefficient: 0.78 and 0.6 respectively). The degree of concordance for correct classification of patients with salvaged myocardium >50% was 83%.
Conclusions: Myocardial perfusion gSPECT performed one month after early PCI in a first AMI provides useful information on at risk and salvaged myocardium areas.
277
Usefulness of gated myocardial perfusion SPECT to qualify patients for cardiac resynchronization therapy and identify responders through prediction of left ventricular remodeling
M. Kostkiewicz1; W. Szot2; A. Lesniak-Sobelga1; T. Miszalski-Jamka2; P. Podolec1
1Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Department of Cardiovascular Diseases, Krakow, Poland; 2John Paul II Hospital, Krakow, Poland
Cardiac resynchronization therapy (CRT) has been accepted as a treatment for heart failure patients refractory to conventional therapy. However, 20-40% of the patients selected for CRT based on conventional criteria—e.g. per the NewYork Heart Association (NYHA), class III or IV severity, depressed LV ejection fraction (LVEF) (≤35%), prolonged QRS duration (≥120 ms) and sinus rhythm do not respond to CRT. Phase analysis enables gated SPECT to assess LV dyssynchrony and has the potential for comprehensive assessment of additional multiple parameters, such as myocardial scar burden and location and site of latest activation, that influence response to CRT. LV dyssynchrony measured by gated SPECT phase analysis has been shown to correlate with that measured by 2D echocardiography, yet is more likely to obtain reproducible results.
Aim of the study was to examine the relationship between mechanical dyssynchrony assessed by and the outcome of patients after CRT therapy.
Material and Methods: We studied 29 NYHA class III-IV heart failure patients with ejection fraction (EF) ≤35% and QRS duration ≥120 ms referred for CRT. Established optimal cutoff values for the prediction of response to CRT, i.e. 135° for phase histogram bandwidth (PHB) and 43° for phase standard deviation (PSD), were used. We repeated the SPECT studies for all patients after 6 months. All images were analyzed by a reader unfamiliar with the patient’s history. Quantitative variables were expressed as mean ± standard deviation; categorical variables were expressed as frequencies and percentages.
Results: SPECT identified severe LV dyssynchrony in 21 patients with a mean PHD of 225.2° ± 36.7° and a mean PSD of 68.7° ± 11.3°. Normal LV synchronicity or mild LV dyssynchrony was found in 8 patients with a mean PHD of 83.9° ± 32.8° and a PSD of 28.7° ± 13.1°. In the post-therapy study LV mechanical dyssynchrony parameters were shown to predict good responses to CRT. Based on an improvement rate of ≥1 NYHA class at 6 months follow-up, 19 patients were classified as responders, the other 2 as non-responders. At 6 month follow-up both PSD (56.3 ± 19.9° vs 37.1 ± 14.4°, P < .01) and PHB (175 ± 63° vs 117 ± 51°, P < .01) were still significantly higher in responders compared to non-responders.
Conclusion: SPECT with phase analysis has a potential for assessing LV dyssynchrony. This method is feasible, accurate and capable of gathering information of dyssynchrony equally with information about perfusion. SPECT can be a viable clinical approach to consistent prediction of CRT response in HF patients.
278
Does severity of systolic LV dysfunction predict the presence of LV dyssynchrony in heart failure patients with narrow QRS complex?
L. Ramaiah1; V.S. Hejjaji1; J. Selvakumar1; G.R.K. Amancharla1; G. Nair1
1Narayana Hrudayalaya Institute of Medical Sciences, Bangalore, India
Cardiac resynchronization therapy (CRT) has been shown to be an efficient method of treating patients with severe heart failure. Current selection criteria for CRT includes wide QRS (>120 ms), left ventricular ejection fraction (LVEF) of ≤35% and NYHA symptom class III/IV. Around 30% of patients do not experience benefits when current selection criteria are applied. There has been a substantial interest towards detection of mechanical dyssynchrony, as it predicts the response to CRT. Heart failure patients with narrow QRS (≤120 ms) have also been shown to manifest mechanical dyssynchrony.
Purpose: To evaluate the relationship between left intraventricular dyssynchrony and severity of systolic left ventricular (LV) dysfunction in heart failure patients with narrow QRS using equilibrium gated radionuclide ventriculography (ERNV).
Methods: 40 patients (age 53 ± 26 years, 29 males and 11 females) with QRS duration ≤120 ms, NYHA symptom class III/IV and LVEF ≤35% despite maximal pharmacological therapy, were enrolled in the study. Patients underwent resting ERNV according to standard guidelines. First harmonic phase analysis was performed on scintigraphic data using XT-ERNA software. A cosine curve fitted within the cardiac cycle from 0° to 360° was obtained. It was characterized by a phase angle and amplitude. Phase angle was converted to milliseconds by the formula: [phase angle/360°] × RR interval (milliseconds). Earliest phase angle referred to the time of onset of ventricular contraction, mean phase angle referred the mean time of onset of ventricular contraction and the standard deviation was related to synchrony of contraction. Standard deviation of LV phase was used to define dyssynchrony.
Results: Left intraventricular dyssynchrony was detected in 65% (26/40) of patients. Phase analysis result was stratified according to the LVEF obtained by ERNV. Left intraventricular dyssynchrony was observed in all patients with LVEF below 20%. When severity of LV dysfunction was correlated with left intraventricular dyssynchrony, it was found that the prevalence of left intraventricular dyssynchrony increased with fall in LVEF (Pearson correlation coefficient r = −0.28, P = .07).
Conclusions: Fourier phase analysis on ERNV is an effective and operator independent method with least inter observer variability for detecting LV dyssynchrony. A significant proportion of heart failure patients with narrow QRS manifest LV dyssynchrony. Heart failure patients with severe systolic LV dysfunction and left intraventricular dyssynchrony could be considered as potential candidates for CRT.
279
Phase analysis in cardiac gated-SPECT: New possibilities to evaluate left ventricular dyssynchrony
N. Nuno Cabanelas1; M.J. Vidigal Ferreira2; L. Santos3; J. Correia2; M.J. Cunha2; A. Albuquerque2; A.P. Moreira2; G. Costa2; \L.A. Providencia2
1Hospital de Santarém, Santarém, Portugal; 2University Hospitals of Coimbra, Coimbra, Portuga; 3Hospital Sao Teotonio, Viseu, Portugal
Introduction: QRS width is, in present, the preferred marker of left ventricular dyssynchrony, and the most used one when cardiac resynchronization therapy is hypothesized for patients with low ejection fraction. However, the actual rate of non-responders suggests that a better marker is needed.
Aims: In heart failure patients referred for cardiac SPECT, it’s intended to evaluate the relation between mechanical dyssynchrony (phase standard deviation, SD, from phase histogram, FH), electrical dyssynchrony (QRS width), left ventricular ejection fraction (LVEF), presence of perfusion defects and prognostic end-points.
Methods: Patients referred for cardiac SPECT, between 2007 and 2008, for investigation of heart failure and in whom phase analysis was possible to obtain using Emory Cardiac Toolbox, were retrospectively studied (n = 41). According to previous studies a SD above 43º is considered suggestive of dyssynchrony. Then 2 groups were established: A, patients with SD < 43: n = 23; and B, patients with SD³43: n = 18. They had been followed for 21.8 ± 9.9 months. The groups were compared in terms of LVEF, QRS width, presence of ischemia, presence of necrosis, hospitalization due to heart failure, acute coronary events incidence, CRT implantation and mortality.
Results: There was not significant difference in QRS > 120 ms prevalence (30% vs 44%, P = .48), but patients from group B had higher prevalence of EF < 35% (26% vs 78%, P = .013). SPECT perfusion images suggested ischaemia and necrosis in similar proportions (ischaemia: 65% vs 61%, necrosis: 26% vs 33%). SD value had a negative correlation with left ventricle EF (Pearson coefficient: r = −0.59), but not with QRS width (r = 0.09). There were no deaths in both groups. Patients from group B, showed a tendency for more CRT implantations (0% vs 22%, P = .058), they had higher all-cause hospitalizations incidence (24% vs 72%, P = .016). Incidences of acute coronary events were similar (5% vs 8%) and although a higher incidence of admissions was observed in group B no statistical difference was found (4% vs 11%).
Conclusion: Standard deviation from phase histogram appears to be a marker of dyssynchrony with high discriminative power. In this study, it showed a good correlation with left ventricle EF and was related to higher incidence of some important end-points. Using gated SPECT, it becomes possible to identify ischaemia or necrosis and to quantify left ventricular dyssynchrony with a single exam.
280
Phase analysis of gated myocardial perfusion single-photon emission computed in left bundle branch block patients for the assessment of left ventricular synchrony
E.N. Aramayo G.,1; M. Daicz1; J.F. Casuscelli1; H.G. Marrero1; C.M. Claudia Mariana Cortes1; M.A. Embon1
1Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
Purpose: The aim of this study was to evaluate the left ventricular (LV) synchrony assessed by gated myocardial perfusion single-photon emission computed tomography (GSPECT) in left bundle branch block (LBBB) patients, and to compare them with normal subjects.
Methods: Rest GSPECT was performed in 48 consecutive patients with LBBB. The parameters of LV synchrony (histogram peak, histogram bandwidth (HB), phase Standard Deviation (SD), histogram skewness, and histogram kurtosis were obtained by phase analysis of rest GSPECT and were compared with our database of 130 normal subjects. Univariate analysis was performed including clinical, electrocardiographic and scintigraphic variables as well as LV function in LBBB patients. For logistic regression model significant dyssynchrony was defined as Phase SD ≥ 43°.
Results: The LBBB patients were older than normal subjects (65 ± 13 vs 57 ± 10 years, P < 0.002) and 27 were men. Among coronary risk factors, 29 presented hypertension, 28 hyperlipidemia, 6 diabetes mellitus, and 5 were active smokers. Twelve patients showed history of coronary artery disease (5 with myocardial infarction, 9 had previous revascularization). Seventy percent of patients had LV ejection fraction (LVEF) > 50% and 23% had end systolic volume (ESV) > 70 mL.
Comparison between phase analysis parameters of the LBBB patients and normal subjects showed higher SD (30 ± 21 vs 12 ± 5; P < 0.001) and HB (98 ± 65 vs 40 ± 15; P < 0.001). This difference remained regardless of sex (men < 0.001, women P < 0.001) and radiotracer dose (high dose < 0.001 and low dose P < 0.001).
In the LBBB patients, SD and HB phase analysis parameters were not statistically different according to sex and dose.
The LBBB patients whose LVEF ≤ 50%, ESV ≥ 70 mL, QRS duration ≥ 160 ms. or have a presence of abnormal rest perfusion defects, had SD and HB statistically higher (all P < .01). In a logistic regression model the independent predictors were ESV ≥ 70 mL or LVEF ≤ 35%.
Conclusion: In our population, the phase analysis parameters in rest GSPECT clearly differentiate patients with LBBB from normal subjects according to LV synchrony.
In patients with LBBB whose LVEF < 50%, ESV > 70 mL QRS > 160 ms or have abnormal perfusion are associated with higher LV dyssynchrony. ESV ≥ 70 mL or LVEF ≤ 35% were independent predictors of LV dyssynchrony in LBBB patients.
281
The predictors of cardiovascular events in hemodialysis patients who underwent stress myocardial perfusion imaging
T. Tatsuhiko Furuhashi1; M. Moroi2; N. Joki3; H. Hase1; M. Minakawa1; H. Masai1; T. Kunimasa1; H. Fukuda1; K. Sugi1
1Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan; 2National Center for Global Health and Medicine, Cardiology Division, Tokyo, Japan; 3Toho University, Ohashi Medical Center, Department of Nephrology, Tokyo, Japan
Objectives: Patients who have normal stress myocardial perfusion imaging (MPI) are generally warranted excellent cardiovascular prognosis. Patients with chronic kidney disease (CKD) who underwent hemodialysis have shown poor prognosis for cardiovascular events. This study evaluates the prognostic factor in CKD patients with hemodialysis who underwent stress MPI.
Methods: Eighty-four hemodialysis patients (mean age = 69, male = 57, previous coronary artery disease = 27, hemodialysis duration = 36 months) underwent stress MPI and followed up for 25 months. Cardiovascular events were cardiac death, non-fatal myocardial infarction and unstable angina requiring hospitalization.
Results: Cardiovascular events were observed in 16 patients (19%). Univariate Cox regression analysis revealed that peripheral artery disease and parameters of stress MPI were significant predictors of cardiovascular events. Multivariate Cox regression analysis revealed that only peripheral artery disease (hazard ratio = 6.41; P = .002) and summed stress score (SSS) > 3 of stress MPI (hazard ratio = 7.82; P = .009) were independent and significant predictors for total cardiovascular events. As shown in Kaplan-Meier survival curves in Figure, patients with normal stress MPI (SSS ≤ 3) had better prognosis of cardiovascular events than in patients with abnormal stress MPI (SSS > 3). However in patients with normal stress MPI, cardiovascular events were observed in 10 of 72 patients (14%).
Conclusions: In hemodialysis patients, both peripheral artery disease and stress MPI can be powerful cardiovascular predictors. Normal stress MPI cannot mean excellent prognosis for cardiovascular events in hemodialysis patients.
Kaplan-Meier event-free survival curves
282
The variation of left ventricular mechanical dyssynchrony in patients with coronary artery disease
N. Takahashi1; M. Ishikawa1; A. Kikuchi1; E. Yamamoto1; K. Amitani1; T. Uchida1; N. Sato1; K. Munakata1; S. Kumita2; K. Mizuno3
1Nippon Medical School Musashikosugi Hospital, Department of Cardiology, Kawasaki, Japan; 2Nippon Medical School Hospital, Department of Radiology, Tokyo, Japan; 3Nippon Medical School, Department of Cardiology, Tokyo, Japan
Background: Left ventricular Mechanical dyssynchrony (LVMD) has been demonstrated to be present in patients with severe heart failure including myocardial infarction (MI) and cardiomyopathy. However, LVMD has not been fully clarified in stable angina pectoris (AP).
Objectives: The aim of this study was to assess the variation of LVMD before and after stress in stable AP.
Methods: A total of 200 patients (age 69 ± 11, 137 men) with suspected coronary artery disease underwent stress/rest gated myocardial perfusion SPECT (GMPS). For the evaluation of LVMD, histogram bandwidth (HBW) at stress and rest were determined by GMPS using phase analysis. End-systolic volume (ESV) at stress divided by ESV at rest was calculated as a parameter of transient ischemic dilatation (TID) ratio in all patients. ΔHBW (HBW at stress—HBW at rest) was compared among three groups: 103-normal subjects group (NG); [summed stress score (SSS) < 4 and LV ejection fraction ≥ 50%], 53-ischemic group (IG); [SSS ≥ 4 and summed difference score (SDS) ≥ 2 and summed rest score (SRS) < 3], and 44-prior MI group (pMIG); SSS ≥ 4 and SDS ≤ 1.
Results: The measured ΔHBW in NG, IG, and pMIG are summarized in the figure (NG; 2.3 ± 27.8°, IG; 18.0 ± 48.2°, pMIG; 5.9 ± 37.8°, P < .05 ANOVA). There were significant positive correlation between ΔHBW and TID ratio in IG (r = 0.39, P < .01).
Conclusions: The variation of LVMD before and after stress in stable AP was demonstrated to be greater enhancement than those in normal subjects. The variation of LVMD was associated with TID ratio in stable AP.
Variation of LVMD
283
Comparison of adjunctive balloon postdilatation and intravascular ultrasound guidance during percutaneous coronary intervention
J.B. Jae Bin Seo1; H.S. Kim2
1Boramae Hospital, Seoul, Republic of Korea; 2Seoul National University Hospital, Seoul, Republic of Korea
Background: Intravascular ultrasound (IVUS) is helpful during percutaneous coronary intervention (PCI), because we can confirm the good apposition or optimal expansion of stents. In this study, we compared adjunctive balloon postdilatation and IVUS-guidance during PCI.
Methods and Results: For this study, we have divided PCI lesions for 3 years into two groups; adjunctive balloon postdilatation after stenting vs IVUS during PCI with or without postdilatation. Among total 302 lesions (279 patients) which underwent PCI with TAXUS stent, 60 lesions underwent PCI during which adjunctive balloon postdilatation was done without IVUS, whereas 242 lesions did underwent PCI with IVUS. Baseline clinical features are similar between two groups. The actual rate of adjunctive balloon postdilatation was 100% in the postdilatation group whereas 75.6% in the IVUS-guidance group. We analyzed serial angiographic data, pre-PCI, immediate post-PCI, and follow-up at 6-9 months. The minimal lumen diameter at pre-PCI and the immediate post-PCI was significantly wider in IVUS-guidance group than in postdilatation one (0.72 vs 0.84 mm, P = .013; 2.36 vs 2.51 mm, P = .006). But the difference disappeared at follow-up period (1.98 vs 1.93 mm, P = .327). The late loss was higher in IVUS-guidance group (0.41 vs 0.57 mm, P = .029). Target lesion revascularization at 1 year was not different between the two groups.
Conclusions: PCI with adjunctive balloon postdilatation was comparable to PCI under IVUS-guidance in terms of angiographic and clinical outcome.
284
Necrosis and myocardial viability: Could gated SPECT helps cardiac magnetic resonance?
M.N. Pizzi1; G. Cuberas-Borros2; S. Aguade-Bruix3; V. Pineda4; G. Romero-Farina2; J. Castell-Conesa3; J. Pinar5; J. Candell-Riera5
1Universitary Hospital Vall d’Hebron, Cardiology Department, Nuclear Cardiology and Cardiac CT Unit, Barcelona, Spain; 2Hospital Vall d’Hebron, Cardiology Department, Epidemiology Unit, Barcelona, Spain; 3Universitary Hospital Vall d’Hebron, Nuclear Medicine Department, Barcelona, Spain; 4Universitary Hospital Vall d’Hebron, Radiology Department, Barcelona, Spain; 5Universitary Hospital Vall d’Hebron, Cardiology Department, Barcelona, Spain
Introduction and Objectives: Cardiac Magnetic Resonance (CMR) is considered one of the gold standards to determine necrosis transmurality and extension, but does it has the same accuracy defining viability? The aim of this study was to compare the concordance between necrosis delimitation in CMR images and viability criteria of 99mTc-tetrofosmine in gated SPECT, in patients with chronic myocardial infarction (MI).
Methods: CMR and gated SPECT were performed in 104 patients (mean age: 61 ± 12 years, 87.5% men) with previous MI. Left ventricular (LV) volumes and ejection fraction (EF) and classic late gadolinium enhancement (LGE) viability criteria (<75% transmurality) were correlated with volumes, EF and viability criteria (uptake > 50%) of the gated SPECT in the 17 segments of the LV. Motion, thickening and ischemia in gated SPECT were analyzed in non-viable and LGE doubtful segments (50-75% of transmurality).
Results: A good correlation was observed between both techniques for volumes, EF (P < .05) and estimated necrotic mass-necrosis extension (P < .01). Eighty two (31%) of the 264 segments with LGE > 75% had SPECT tracer uptake > 50%. From those 106 doubtful segments in CMR, 68 (64%) had SPECT tracer uptake > 50%, 41 (38.7%) a preserved motion, 46 (43.4%) a conserved systolic thickening and 17 (16%) evidence of ischemia in SPECT.
Conclusions: A third of CMR non viable segments show > 50% tracer uptake on myocardial SPECT. Gated-SPECT can help CMR in the evaluation of doubtful segments with the evaluation of tracer uptake, motion and thickening analysis and the presence of ischemia.
285
Late tetrofosmin-Tc-99m lung/heart ratio during exercise gated cardiac SPECT: Correlations with left ventricle myocardial perfusion defects and post-stress ejection fraction
T. Vieira1; A. Oliveira1; P. Oliveira1; V. Alves1; T. Faria1; M.B. Perez1; E. Martins2; J.G. Pereira1
1Sao Joao Hospital, Department of Nuclear Medicine, Porto, Portugal; 2Sao Joao Hospital, Department of Cardiology, Porto, Portugal
Purpose: It has long been reported that the Tl-201 lung/heart ratio (LHR) is a reliable marker of coronary artery disease and of left ventricular dysfunction (LVD). Subsequent experience suggests that sestamibi-Tc-99m LHR has a comparable role. Given the similar biodistributions of tetrofosmin and sestamibi, it is plausible to think that the same would also apply to tetrofosmin-Tc-99m LHR. Indeed, recently published literature proposes that early (4-6 minutes after radiotracer injection) post-stress tetrofosmin-Tc-99m LHR appears to be a useful index of myocardial perfusion defects (MPD) and LVD. We aimed to evaluate the correlations of late post-stress tetrofosmin-Tc-99m pulmonary lung uptake with post-stress left ventricle ejection fraction (LVEF) and MPD, obtained during exercise gated cardiac SPECT (GSPECT).
Methods: Our study included 105 consecutive patients addressed for myocardial perfusion scintigraphy (MPS) with cardiac stress induced by the Bruce protocol. The stress imaging was performed by GSPECT, 30-60 minutes after tetrofosmin-Tc-99m administration. QGS/QPS® was the software used for left ventricle (LV) perfusion and function assessment. Subsequently, we summed all LV coronal slices from SPECT acquisition to improve count statistics for the purpose of LHR calculation. We manually generated ROIs in the LV and in the left lung of the resulting summed images. The LHR was then calculated as the simple ratio of the average pixel counts in the lung and LV ROIs.
Results: Twenty-one patients (20%) were female. Mean age was 57 years-old. Forty-five patients (42.9%) had an abnormal MPS and 16 patients (15.2%) had a LVEF < 45%. There was a positive correlation of tetrofosmin-Tc-99m LHR with MPD severity (r = 0.59) and extent (r = 0.55), and a negative correlation with LVEF (r = −0.57).
Conclusions: Late tetrofosmin-Tc-99m LHR obtained from exercise GSPECT appears to be a useful marker of LV MPD and post-stress LVD.
286
Correlation of carotid intima media thickness and carotid plaque prevalence with coronary artery disease
A. Anand Jeevarethinam1; S. Venuraju1; A. Lahiri1
1Wellington Hospital, Clinical Imaging and Research Centre, London, United Kingdom
Objectives: Our aim was to evaluate the correlation between CIMT, carotid plaque prevalence and severity of coronary artery plaque burden as well coronary plaque sub-type.
Methods: One hundred and fifty patients (n = 150) with no history of CAD, who underwent both US carotid Doppler and clinically indicated CT coronary angiogram (CTCA) between May 2009 and May 2011 were included in the analysis. CIMT was measured in the far wall of the common CCA 1 cm proximal to the carotid bulb using automated edge detection software. The entire carotid system was surveyed bilaterally for presence of plaque. CTCA was performed by a Dual Source CT scanner.
Results: The average age was 56.34 ± 10.4 years and BMI 27.2 ± 6.7. There were 106 (68.7%) males, 23 (15%) cigarette smokers, 70 (45%) with hypertension, 95 (62%) with hyperlipidemia, 107 (69%) patients had family h/o IHD and 20 (13%) with diabetes. A total of 101 (67.3%) patients were found to have coronary plaque. The mean CIMT was higher in patients with CAD than in those without CAD (0.76 vs 0.66 mm, P < .003). The prevalence of carotid plaque in CAD patients was 45.5%.
CIMT measurement correlated well with prevalence of any coronary plaque (P = .002), whereas presence of carotid plaque was a good predictor of obstructive (>50% stenosis) coronary plaque (P = .01). In a multi-variate analysis of, age (P .048), hyperlipidaemia (P .027), systolic blood pressure (P .043) and IMT (P .04) were predictors of any coronary plaque. Calcified plaque (P = .04) and mixed plaque (P = .003) correlate well with presence of carotid plaque but not CIMT.
Conclusion: Presence of a carotid plaque was a good predictor of prevalence of significant coronary stenosis whereas CIMT was a strong predictor for presence of any coronary plaque but not of severity of plaque burden.
Carotid plaque correlation with CAD
287
Left ventricular geometry indexes evaluated by preoperative gated-SPECT in severe CAD and their correlation to hospitalization post CABG: A five year follow up
M. Jimenez-Santos1; L.E. Rodriguez-Castellanos1; S. Hernandez-Sandoval1; L.E. Juarez-Orozco2; E.A. Penarrieta-Daher1; L.V. Araujo-Torres1; C.A. Guizar-Sanchez1; E. Erick Alexanderson Rosas1
1Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico City, Mexico; 2Unidad PET/CT Ciclotrón UNAM, Mexico city, Mexico
Background: Left ventricular geometry indexes approaching to sphericity have been studied with gated-SPECT in hospital heart failure patients. In the other hand, these indexes have also been used as measures of ventricular remodeling and myocardial viability.
Methods: In this longitudinal retrospective study 60 patients were included from 2005 to 2007 and were followed for 5 years.
We correlated abnormal pre-procedure left ventricular geometry indexes (shape index (SI), eccentricity index (EI) as well as end-diastolic (EDV) and end-systolic left ventricular volumes (ESV)) by gated-SPECT in patients with severe CAD to number of hospitalization rates due to heart failure, heart failure progression or postoperative death in a 5 year follow-up CABG.
Results: The hospitalization rate was 16%; SI at rest was 0.717 vs 0.581 (P = .0001) and at stress was 0.544 vs 0.637 (P = .021) (hospitalization); EI was not significantly different in all the cases. The rate of cardiac death was 23%; there were non statistically significant differences of the evaluated parameters between the groups. The rest SI was different, in NYHA I was 0.542; NYHA II was 0.637 and NYHA III 0.81 with P value = .0001; the stress SI was not statistically different between the groups.
Conclusion: in this study we demonstrate that the SI at rest was statistically different between the NYHA groups for MACE prognosis and hospitalization. Preoperative gated-SPECT can discriminate patients with higher probability of developing heart failure, although it was not observed in the other values evaluated in this study.
Characteristic | Number |
|---|---|
Males | 80% |
Age (mean) | 57 ± 9.43 |
DM (%) | 48 |
Obesity (%) | 21.7 |
Smoking (%) | 65 |
Hypertension (%) | 70 |
Dyslipidemia (%) | 51 |
Renal Failure (%) | 17 |
Previous MI (%) | 95 |
LVEF (mean) | 33.6 ± 8.2 |
288
The use of leukocyte scintigraphy and FDG-PET in search for a primary focus in infective endocarditis; experiences from a single tertiary heart centre
C.H.B. Jespersen1; K. Iversen1; P. Hasbak2; A. Loft2; H. Bundgaard1; N. Ihlemann1
1Rigshospitalet—Copenhagen University Hospital, Heart Centre, Department of Cardiology, Copenhagen, Denmark; 2Rigshospitalet—Copenhagen University Hospital, Clinical Physiology, Nuclear Medicine & PET, Copenhagen, Denmark
Purpose: In 50% of patients with infective endocarditis (IE) extracardiac infectious foci are present. Finding these foci is essential but the optimal strategy has yet to be established. The purpose of this study was to assess the diagnostic value of leukocyte scintigraphy (LS) and 18F-fluorodeoxyglucose (FDG) PET/CT scans in discovering extra cardiac foci of infection in patients with IE.
Methods: Patients admitted at a tertiary referral centre from January 1, 2010 to December 31, 2011 with the diagnosis IE were studied. Records were reviewed for information on use of LS and FDG-PET scans; C-reactive protein (CRP) and leukocyte levels; and bacterial aetiology.
Experienced cardiologists reviewed all journals with positive findings on LS or FDG-PET to decide if the focus was unknown, and if the finding changed the clinical course for the patient.
Results: A total of 165 patients were admitted. LS was performed in 95 of the cases, and FDG-PET in 29. There were no demographic baseline differences between the groups in which LS was performed and was not performed.
In total, 14 (14.7%) of the LS showed pathological leukocyte accumulation, and 18 (62.1%) of the FDG-PET scans showed pathological FDG uptake. CRP-levels [mg/L] were higher if an infectious focus was found both with LS (65.36 vs 38.84, P = .137) and FDG-PET scans (45.33 vs 34.36, P = .589), but they were not significant. In patients with positive LS scans the examinations were performed earlier [days] from initiation of antibiotic treatment as compared with patients with negative LS outcome (12.6 vs 16.7, P = .540).
Journal review showed that 8 of the 14 pathological LS turned out to be clinically insignificant or false positives, and two had inconclusive results. The final four patients all had ostitis, and they all had clinical signs of the final diagnosis before LS was performed. Only in two of the 95 cases, LS resulted in altered treatment.
There was a low level of agreement between the outcomes of patients who had both LS and FDG-PET done (κ = 0.099, 95% CI [−0.040; 0.238]). Of the 26 patients who had both LS and FDG-PET performed, only two patients had a positive finding in both LS and FDG-PET, and in these cases the foci found with the two modalities were different.
Conclusions: This study suggests that the value of LS in the search for extracardiac foci of infection in IE is low. Also, there was no agreement between foci found with LS and FDG-PET scans.
Performing LS early in the time course of antibiotic treatment and choosing patients with elevated CRP-levels might result in higher rates of LS with clinically useful results.
289
Evaluation of left ventricular synchrony parameters in normal subjects by gated myocardial perfusion single photon emission computed tomography phase analysis
E.N. Aramayo G.1; C.M. Cortes1; M. Daicz1; J.F. Casuscelli1; H.G. Marrero1; M.A. Embon1
1Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
The aim of our study was to generate reference values of phase analysis parameters by gated myocardial perfusion single photon emission computed tomography (GSPECT) in normal subjects according to sex and sestamibi dose.
Method: Prospectively and consecutively were obtained phase analysis LV synchrony parameters: peak, standard deviation (SD), histogram bandwidth (HB), histogram skewness (HS) and histogram kurtosis (HK), assessed by stress and rest GSPECT. We selected normal subjects defined as low pre test of coronary artery disease, without myocardiopathy and with normal electrocardiogram, stress test, myocardial perfusion and ejection fraction (EF). We compared these parameters in relation to sex, sestamibi dose (according to one or two days protocol).
Results: One hundred and thirty subjects were enrolled, 84 men, average age of 56 ± 10 years, 42% hypertensive, 42% hyperlipidemic and 11% smokers. 92% underwent physical stress test and 17% two days GSPECT protocol. Phase analysis parameters of stress vs rest were not statistically different neither in SD (12 ± 5 vs 12 ± 5) nor HB (38 ± 14 vs 40 ± 15).
Conclusion: In our population of normal subjects, SD and HB phase analysis parameters of LV synchrony are similar in rest and stress images. Some phase analysis parameters are different according to sex and sestamibi dose. These differences should be taken into account to assess other populations.
Rest | Male n = 76 | Female n = 43 | P | High dose n = 88 | Low dose n = 31 | P |
|---|---|---|---|---|---|---|
Peak | 138 (18) | 145 (15) | .072 | 137 (17) | 144 (17) | .4 |
SD | 14 (4) | 10 (4) | .11 | 12 (4) | 14 (6) | .003* |
HB | 45 (15) | 32 (11) | .01* | 38 (12) | 46 (21) | .0001* |
HS | 3.9 (0.8) | 4.9 (1.1) | .008* | 4.3 (0.9) | 4.4 (1.3) | .01* |
HK | 18 (9) | 28 (13) | .01* | 22 (9) | 24 (16) | .0001* |
Stress | Male n = 84 | Female n = 46 | P | High dose n = 52 | Low dose n = 78 | P |
|---|---|---|---|---|---|---|
Peak | 146 (20) | 145 (15) | .028* | 149 (17) | 144 (19) | .15 |
SD | 13 (5) | 9 (3) | .001* | 12 (5) | 12 (5) | .3 |
HB | 42 (14) | 31 (12) | .06 | 38 (16) | 38 (13) | .07 |
HS | 4.2 (1) | 5 (1) | .33 | 4.5 (0.9) | 4.6 (1.2) | .03* |
HK | 22 (12) | 29 (12) | .31 | 24 (11) | 25 (14) | .01* |
290
Value of strain imaging with low dose dobutamine stress in detection of myocardial viability in myocardial infarction patients: Comparison with myocardial perfusion imaging
A.M. Amal Hamdy1; M. Naeim1; S. Allam1; T. Ahmed1
1Al-Azhar University, Cairo, Egypt
Background: Detection of myocardial viability (MV) is an important element in management of patients (pts) after myocardial infarction (MI). The purpose of this study was to investigate the value of strain imaging (SI) with low dose dobutamine stress echo (LDDS) for detection of MV in pts with MI in comparison to myocardial perfusion imaging (MPI).
Methods: 39 MI pts were subjected to both MPI using technetium-99m Sestamibi with nitrate potentiation and SI during LDDS. Pts were classified according to results of MPI into groups of viable and nonviable myocardium in each of the three coronary territories. Wall motion score index (WMSI) was calculated at rest and with LDDS in 117 territories (39 LAD, 39 LCX and 39 RCA). Strain values were determined at rest and with LDDS in 12 segments per patient (total 468 segments). Post-systolic shortening (PSS) as a marker of MV was investigated.
Results: MPI identified MV in a total of 92 out of the 117 territories and in 339 out of the 468 segments. Detection of MV by reduction of WMSI in response to LDDS was concordant with MPI results in 82 (26 in LAD, 34 in LCX and 22 in RCA) out of the 92 territories identified as viable by MPI; and both techniques were matched in non-viability in eight territories (4 in LAD, 1 in LCX and 3 in RCA), Fisher exact P = .02. Positive predictive value (PPV) for LDDS-WMSI in viability detection was 82.8%, specificity was 32% and overall accuracy was 76.9%. Strain values were lower in nonviable compared to viable segments in LAD and LCX territories but the differences were significant (P < .05) in only few segments (mid anterior, basal and mid lateral segments). Strain values increased in response to LDDS in viable segments of LAD territory (P < .01), with no significant increase in nonviable segments. Responses of strain values to LDDS in segments of RCA and LCX territories were not conclusive. PSS was present in 98 out of the 339 (28.9%) segments identified as viable by MPI (40 in LAD, 29 in LCX and 29 in RCA territory), and in 52 out of 129 segments (40.3%) identified by MPI as nonviable. PPV of PSS as a marker of viability was 65.3%, its specificity was 59.7% and its accuracy was 37.4%.
Conclusion: Strain imaging might help in detection of myocardial viability; however, results of this study do not support its use as a single modality for viability assessment. PSS can be detected in non-viable as well as in viable and normal myocardium; thus, it can’t be relied upon as a marker of viability in patients with myocardial infarction.
291
Prognostic value of 18-FDG PET myocardial viability in ischemic left ventricular dysfunction
F. Rolfo1; G.L. Rosso2; L. Icardi1; E. Racca1; M. Feola2; A. Terulla3; S. Chauvie3; M. Bobbio1; A. Biggi3
1Cardiology, Santa Croce e Carle Hospital, Cuneo, Italy; 2Heart Failure Unit, SS. Trinità Hospital, Fossano, Italy; 3Nuclear Medicine, Santa Croce e Carle Hospital, Cuneo, Italy
Purpose: Patients with ischemic left ventricular (LV) dysfunction might benefit from revascularization assuming an high risk of death or clinical events. F-18-fluorodeoxyglucose (FDG) positron emission tomography (PET) is used to define viable myocardium that recovers after revascularization. Clinical outcome predicted by remaining viability and coronary revascularization is still discussed. The aim of this study was to determine whether the amount of viable myocardium or scar detected with FDG-PET scan might predict prognosis.
Methods: This observational study reports a single-center experience. Patients included had previous myocardial infarction and left ventricular ejection fraction (LVEF)
Results: A total of 144 patients (118 males, ages 64 ± 9 years) were studied. The LVEF was 31 ± 8 %; 71 (49.3%) suffered an anterior MI; 56 (39%) had three-vessel disease. 67 subjects (46.5%) were treated with coronary revascularization (90% coronary artery by-pass graft). Patients who underwent revascularization procedures had larger viable myocardium (2.2 ± 2.2 vs 1.2 ± 1.3 segments, P = .0027) but similar LVEF (30.2 ± 7.8% vs 30.4 ± 8.3%, P = .93), diabetes mellitus (33.9% vs 24.6%, P = .26) and non viable myocardium (4.3 ± 2.5 vs 4.8 ± 2.7 segments, P = .30). At 5 years follow-up, total mortality (32.8% vs 33.3%), cardiovascular death (45% vs 37%), MI (4% vs 6%) and HF (11.3% vs 15.8%) were not different in the two groups. At multivariate analysis, more than five non viable segments (P = .0037), diabetes mellitus (P = .0014) and age (P = .0011) were significant predictors of event free survival at 5 years (71.2% vs 43.5%). The amount of mismatch (more than two segments) demonstrated a trend towards an association with reduced risk: free survival 70.5% vs 57.3% (P = .068).
Conclusions: In patients with severe ischemic LV dysfunction, the amount of myocardial scar evaluated by FDG-PET is a useful tool to predict a mid-term worse clinical prognosis. Viability only demonstrated a trend towards an association with cardiovascular events risk reduction. A combination of FDG-PET and clinical parameters (diabetes, age) predicts survival.
292
Simultaneous evaluation of cardiac function, aorta, coronary, and AdamKiewicz Artery by 128 slice MDCT
H. Hiroyuki Fukuya1; M. Okada1; M. Su1
1Kobe Circulation Clinic, Kobe, Japan
Background: Identification of AdamKiewiczArtery (AKA) is necessary to avoid spiral cord ischemia after surgery of descending aortic aneurysm. Evaluation of coronary artery and cardiac function are also required for safe operation. However, CT angiography of coronary artery and AKA is performed independently, so high invasion of radiation and contrast is problem. In this study, to minimize invasion of contrast agent and radiation, we attempted simultaneous evaluation of cardiac function, aorta, coronary artery and AKA as “one stop shop” examination by high-speed helical MDCT.
Method: We performed MDCT in nine new patients (7 males, 71.7 ± 13.7 y.o.) of aortic disease (6 abdominal aneurysm and 3 dissections) by 128 slice MDCT. After CT coronary angiography (CTCA) by nitrate administration, we injected all remaining contrast and scanned whole aorta without ECG gating. Using reconstructed images of coronary artery, 4D cardiac motion, aorta, and AKA, we evaluated each images and success rate of AKA visualization.
Result: Contrast volume of CTCA was 61.6 ± 13.0 mL and additionally injected contrast volume was 33.3 ± 8.5 mL. Coronary arteries were clearly visualized in all patients and significant stenosis was found in three patients. LVEF was 52.4 ± 7.9%. CT value of ascending aorta and iliac artery was 283.8 ± 61.6 HU and 269.2 ± 35.6 HU. AKA was identified in eight of nine patients. The success rate of AKA identification was 88.9%.
Conclusion: High spatial resolution and rapid helical pitch of MDCT, and vasodilation by nitrate contributed successful combination scan. Full capitalizing on MDCT modality characteristics enables less invasive and high performance examination.
293
Anthracycline and trastuzumab toxicity characterized but not predicted with ERNA phase analysis
D. Daniel Zalkind1; A.C. Chen2; E.V. Vallejo3; L.J. Jimenez3; R.R. Russell1
1Yale-New Haven Medical Center, New Haven, United States of America; 2Columbia University Medical Center, New York, United States of America; 3Nuclear Cardiology Department at the Instituto Nacional de Cardiologia Ignacio Chavez, Chavez, Mexico
Purpose: Equilibrium Radionuclide Angiocardiography (ERNA) is used to assess left ventricular ejection fraction (LVEF) during anthracycline as well as trastuzumab chemotherapy. ERNA phase analysis of LV-RV delay has been used to evaluate cardiac dyssynchrony prior to implantation of biventricular pacemakers in patients with known left ventricular systolic dysfunction (LVSD). We proposed to use LV-RV delay to predict LVSD in chemotherapy patients.
Methods: Eighty-four consecutive patients (mean age 50.7 ± 10.2 years) with four or more ERNA studies from 2002 to 2012 who underwent anthracycline, trastuzumab or combination therapy were selected for this retrospective analysis. The cohort was divided into two groups based on the development of LVSD (group A) or preservation of normal LVEF (group B). Phase analysis was performed using the VentriQuant software package. Multiple phase analysis parameters including the LV-RV delay were analyzed. The original large cohort was subsequently divided by the LV-RV delay of 10 or above and below 10 (Group C and D respectively). Similar phase analysis was performed on these cohorts. ANOVA single-factor analysis with a P-value of .05 was used to compare the chemotherapy specific subgroups in Group C and D.
Results: Mean period of 295.3 and 643.8 days between the baseline LVEF and the last normal (pre-drop) in Group A and Group B, respectively. Mean period of 506.3 and 502.2 days between the baseline and last study in Group C and D respectively. ANOVA analysis of patients undergoing either anthracycline alone or combination therapy in Groups B and C was not statistically significant F(3,50) = 0.43 P = .74.
Conclusions: Although there is a trend toward significance, the LV-RV delay does not discriminate well between patient who develop cardiomyopathy and those who do not while receiving anthracycline, trastuzumab or combination therapy.
Group A (qualifying LVEF decline) | Group B (no LVEF decline) | |||
|---|---|---|---|---|
Baseline | Last normal | Baseline | Pre-drop | |
LVEF | 64.8 ± 5.7% | 62.2 ± 6.6% | 60.2 ± 4.5% | 59.1 ± 5.3% |
LV-RV delay | 10.47 ± 10.26 | 7.88 ± 9 | 4.33 ± 7.8 | 7.14 ± 10.2 |
Group C (LV-RV delay < 10) | Group D (LV-RV ≥ 10) | |||
LVEF baseline | 62.5 ± 5.3% | 63 ± 5.9% | ||
LVEF change% (drop to last) | 2.1 ± 6 | 7.8 ± 7.7 | ||
294
Post-stress and rest phase analysis differences in one-day and two days gated-SPECT MPI
S. Santiago Aguade-Bruix1; R. Cardenas Perilla1; M.N. Pizzi1; G. Romero-Farina1; J. Castell-Conesa1; J. Candell-Riera1
1Hospital Vall d’Hebron, Barcelona, Spain
Purpose: Phase analysis (PhA) of gated myocardial perfusion SPECT (gated-SPECT MPI) leads to quantitative parameters that reports the degree of synchronism of left ventricular myocardial contraction. The purpose of this study was to compare post-stress and rest PhA parameters obtained by gated-SPECT MPI performed with two acquisition protocols (stress-rest one day vs two-days).
Methods: PhA of stress-rest gated-SPECT-MPI were prospectively evaluated by means of PhA in 88 patients (age 65.4 ± 9.9, 66 males), 48 of them with one day protocol. The criteria for two-day protocol was weight >90 kg. All studies use 99mTc-tetrofosmin, 300 MBq for low dose and 880 MBq for high dose and a Infinia HK4 (GE) gamma camera for acquisition. For any patient post-stress gated-SPECT and rest were performed, and five phase analysisparameters were obtained: phase peak (PhP), standard deviation (SD), bandwidth (BD), skewness and kurtosis. Student’s t-test, Wilcoxon’s test, Mann-Whitney test and multivariate linear regression analysis were used.
Results: Table 1.
Significant differences between post-stress and rest values for ejection fraction (EF), PhP, DS and BD were obtained in all 88 patients. In 48 patients with one-day protocol significant differences were obtained for EF, PhP, DS, BD and Skewness. In patients with two days protocol significant difference was obtained only for EF. Multiple lineal regression analysis in patients with one-day protocol, adjusted by age, gender, and CAD, show the histogram bandwidth as the parameter with major relation with EF.
Conclusions: There are significant differences between post-stress and rest PhA parameters, mainly if they were obtained with one-day stress-rest protocol gated-SPECT MPI.
295
Assessment of myocardial damage and prediction of future cardiac function in patients with acute myocardial infarction using sestamibi early washout imaging
T. Tokuo Kasai1; R. Tanaka2; T. Nakamura2
1Jikei University Katsushika Medical Center, Tokyo, Japan; 2Kushiro Sanjikai Hospital, Kushiro, Japan
We examined the relationship between myocardial washout rate of sestamibi and the severity of the myocardial damage in patients with acute myocardial infarction (AMI).
Purpose: The aim of this study was to elucidate the usefulness of early phase of washout rate of sestamibi in predicting future cardiac function.
Method: Thirty-seven AMI patients were hospitalized and underwent successful PCI then enrolled in this study. Sestamibi SPECT was obtained in sub-acute phase and repeated 6 months later. Images were acquired at five minutes (0 h), 1 hour (1 h), and 6 hours (6 h) after sestamibi (740 MBq) injection. Washout rate was calculated as washout index (WI) between 0 h and 1 h, 1 h and 6 h, respectively. ECG gated acquisition was performed at 1 h and 6 months later (6 M). The relationships between washout rate of sestamibi and various parameters, such as perfusion defect, CPK, BNP, and LVEF were investigated.
Results: There were 17 patients whose WI showed 0 from 0 h to 1 h (group A) and 20 patients whose WI was accelerated (group B). There were significant differences in WI from 1 h to 6 h between group A and B (15.3 ± 5.8 vs 19.1 ± 3.7, P < .05). No significant difference was found in the number of perfusion defect segments (NPDS) on SPECT among 0 h, 1 h, and 6 M in group A. On the other hand, significant difference was found between 0 h and 1 h, 1 h and 6 M in group B (P < .01, P < .05, respectively). Both groupss A and B demonstrated significant difference in NPDS between 0 h and 6 h (P < .01 for each). Group B demonstrated much higher max CPK value than that in group A (4098 ± 1695 IU/l vs 1452 ± 1006 IU/l, P < .001). Although BNP in sub-acute phase was not different between group A and B (384 ± 413 pg/mL vs 319 ± 260 pg/mL) and decreased 6 months later similarly, BNP in group B remained much higher than that in group A in the chronic phase (181 ± 145 vs 98 ± 109 pg/mL, P < .05). LVEF improved from 55.4 ± 12.4% in sub acute phase to 62.7 ± 8.8% at 6 month later in group A. On the other hand, no improvement was found in group B (from 45.7 ± 12.1% to 48.0 ± 13.1%).
Conclusion: It is suggested that in patients with AMI, early myocardial washout rate derived from sestamibi SPECT associates with severity of myocardial damage and predict future cardiac dysfunction.
296
New results of nuclear cardiology methods monitoring the CRT-treatment of patients with heart failure
I. Balogh1; Z. Galler1; E. Marosi2; M. Dekany2; N. Nyolczas2
1Uzsoki Municipal Hospital, Nuclear Medicine Department, Budapest, Hungary; 2Military Hospital, Department of Cardiology, Budapest, Hungary
Objectives: Our aim was to investigate the importance of different nuclear cardiology methods predicting or/and measuring the efficacy of cardiac resynchronization therapy (CRT) in severe heart failure.
Methods: In 15 patients (pts) with severe heart failure (HF)—EF < 30%, QRS > 120 ms, in NYHA III-IV clinical stage—several kinds of nuclear cardiology procedures were performed. (In 11 pts ischemic heart disease (IHD), in 4 pts only hypertension was responsible for HF.) (1) Before CRT gated myocardial perfusion scintigraphy (GMPS) was performed in every case to distinguish the viable and necrotic myocardium, to analyze the dynamic systolic wall-thickening and to measure other functional parameters as well (Emory Cardiac Toolbox). (2) Before and 6 months after CRT all 15 pts had (a) planar MUGA and (b) SPECT MUGA (Interview XP, Cedars Sinai QGS) to analyze the left ventricular (LV) and right ventricular (RV) function, phase angle (phase histogram) and synchrony (S).
Results: GMPS showed small necrosis only in two cases (2/15), but intraventricular dyssynchrony, with wide phase angle was detected in every case. According to necrotic myocardium a separate peak appeared on the phase angle. We could detect on planar and SPECT MUGA—before CRT—low LVEF (10-28%) in every case (15/15), in 3/15 cases RVEF was decreased as well (20-38%). Inter and/or intraventricular mechanical dyssynchrony, wide phase angle was detected in every case. After CRT the clinical stage and LVEF improved significantly in every case, RVEF decreased in 1 case and improved in 2 cases. In 13/15 cases both S value (as improvement) and phase angle (as shortening) changed significantly.
Conclusions: For the prediction of effectiveness of CRT-therapy GMPS proved to be an excellent method distinguishing the necrotic myocardium—with separate peak and wide phase angle on “the dynamic systolic wall thickening picture” (nonresponder to CRT)—and viable but dyssynchronic myocardium (responder to CRT). Planar and SPECT MUGA proved to be reliable methods to measure the functional changes both the left and right ventricle i.e. the “response” to CRT.
297
99mTc-sestamibi myocardial regional washout rate intensely enhances the degree of the reperfusion injury in patients with acute myocardial infarction receiving percutaneous coronary intervention
K. Teramoto1; Y. Yoshihiro Akashi1; K. Ashikaga1; M. Manabe1; T. Harada1; F. Miyake1
1St. Marianna University School of Medicine, Kawasaki, Japan
Background: Myocardial scintigraphy is widely used to assess myocardium damaged by ischemia. Recently, the washout rate (WR) of 99mTc-sestamibi is used as a marker of damaged myocardium. However, its clinical significance has not been evaluated in details. In the present study, we evaluated the relationship between the regional 99mTc-sestamibi WR determined from myocardial scintigraphic images and cardiac enzymes in patients with acute myocardial infarction (AMI).
Methods: Seventy-two consecutive patients with AMI (mean age 65.7 ± 10.1 years) within 24 hours of onset who underwent primary percutaneous coronary intervention (PCI) treatment on admission were enrolled. A cardiac enzyme, MB isoenzyme of creatinine kinase (CK-MB), was measured every 3 hours after PCI. 99mTc-sestamibi single photon emission computed tomography (SPECT) images were acquired at 30 minutes (early) and 4 hours (delayed) after tracer injection at 2 weeks after AMI onset. The left ventricular myocardium was divided into three segments according to each coronary territory area, and the regional WR was calculated using the cardioBull software (FUJIFILM RI Pharma Co. Ltd., Tokyo, Japan). The left ventricular ejection fraction (LVEF) was determined by the quantitative gated SPECT.
Results: (1) 29 patients had the culprit lesion in the left anterior descending coronary artery (LAD), eight patients in the left circumflex coronary artery (LCx), and 35 patients in the right coronary artery (RCA). The primary PCI was performed 7.7 ± 7.5 hours after the onset of AMI. The peak CK-MB level was 296.1 ± 194.6 IU/L (15.6 ± 5.6 hours after the onset). The initial LVEF was 50.2 ± 11.2 %. (2) The regional WR of the culprit area was 32.4 ± 9.5% in LAD, 31.0 ± 13.6% in LCx, and 33.2 ± 6.5% in RCA.
(3) The sensitivity and specificity of the regional WR of the culprit area in all patients for detecting mild ischemia reperfusion injury group, defined as patients with the peak CK-MB level lower than 300 IU/L after PCI, were 71% (95% CI, 53.4-83.9%) and 85% (95% CI, 70.9-92.9%), respectively, when the cutoff value was set at 40% (AUC = 0.833).
Conclusion: These results suggest that the regional WR calculated from 99mTc-sestamibi SPECT images reflect the degree of myocardial injury after PCI.
298
Noncompaction of left ventricular myocardium: Clinical masks of the syndrome
O.V. Blagova1; A.V. Nedostup1; V.P. Sedov1; N.V. Gagarina1; E.A. Kogan1; Y.U.V. Frolova2; S.L. Dzemeshkevich2; E.A. Mershina3; A.G. Kupryanova4
1I.M. Sechenov I Moscow State Medical University, Moscow, Russian Federation; 2B.V. Petrovsky Russian Scientific Center of Surgery of the Russian Academy of Medical Sciences, Moscow, Russian Federation; 3Roszdrav Medical Rehabilitation Center, Moscow, Russian Federation; 4Institute of Transplantology and Artificial Organs, Moscow, Russian Federation
Objective: To study clinical manifestations of noncompaction of the myocardium (NCM), especially in combination with other heart diseases.
Methods: In 27 patients (15 men, 42.3 ± 12.9 years) blood sampling for cardiotropic viruses (PCR and IgG/IgM, ELISA) and anti-heart antibodies were performed, ECG, Holter monitoring, EchoCG (NCM was confirmed in 88.9%), and cardiac CT (n = 23, 78.3%) and MRI (n = 11, 100%), coronarography (n = 9), endomyocardial biopsy (n = 2), intraoperative biopsy (n = 1), explanted heart examination (n = 1), autopsy with viral PCR (n = 2). In 81.5% of patients NCM was confirmed by 2-3 methods.
Results: Heart failure was diagnosed in 92.6% of patients (I class [NYHA] in 8, II in 6, III in 7, and IV in 4), ventricular arrhythmias in 92.6%, atrial fibrillation in 33.3%, angina in 25.9%. The average left ventricle diastolic diameter was 6.4 ± 0.8 cm, EF was 31.3 ± 14.0%, systolic pulmonary artery pressure was 40.9 ± 13.8 mm Hg; intracardiac thrombosis was diagnosed in 22.2%. There were various clinical syndrome masks (diagnostic scenarios): (1) NCM detected during screening without clinical signs (3.7%); (2) NCM manifested in the form of «idiopathic» arrhythmias (11.1%); (3) NCM masking coronary heart disease (3.7%); (4) NCM in patients with acute or subacute myocarditis (11.1%); (5) NCM manifested as dilated cardiomyopathy (48.1%); and (6) NCM in patients with other primary cardiomyopathies (22.3%). Three pacemakers, nine ICDs, two CRT-D were implanted (55.6% of patients), two heart transplantations, and one reconstructive surgery were performed; 13 patients received antiviral/immunosuppressive therapy. The mortality was 14.8% (average follow-up was 14.1 months).
Conclusions. Diagnostics of NCM should implement at least two methods (EchoCG, CT, or MRI). Isolated NCM was found only in one third of adult patients, usually it was combined with various heart abnormalities (atrial and ventricular septal defect, pulmonary stenosis; 18.5%), other primary cardiomyopathies (ARVD, genetic myopathy; 7.4%), myocarditis (51.9%, including viral myocarditis in 40.7%), that was the main cause of «unexplained» aggravation of stable NCM requirings treatment. Signs of restrictive/hypertrophic cardiomyopathy in 14.8% of patients with NCM can be considered as a combination of cardiomyopathy or morphofunctional NCM variant. Morphological diagnostics is informative both regarding verification of primary cardiomyopathies (also NCM), and myocarditis. It is necessary to study a possible compensatory nature of NCM in patients with severe systolic dysfunction.
299
Determination of vascular reserve of cerebral arteries during cerebral digital angiography by introduction of sodium nitroprusside buccal polymeric films with controlled substance release
S. Kechyn1; I. Kechyn1; A. Materukhin2
1Zaporizhzhya State Medical University, Zaporizhzhya, Ukraine; 2Zaporizhzhya Clinical Hospital Endovascular Surgery Department, Zaporizhzhya, Ukraine
Introduction: Transmucosal administration of drugs can increase the absolute bioavailability of the active substance by reducing its hepatic biotransformation in the,it allows to reduce the dose, and therefore reduce the risk of the development of unwanted side reactions and toxic manifestations of active substances.
Methods and material research: A drug form for buccal application has been developed: sodium nitroprusside (“Niprutsel”) as buccal polymer films with controlled release of substances for 30-40 minutes at a dose of 5 mg. Angiography performed on complex «Arcogem» (General Electric). A total of 72 patients with transient ischemic attacks (TIA) due to atherosclerosis, and hypoplasia of the brachiocephalic arteries were studied.
Results: The result of the application of buccal polymeric form of “Niprutsel” has shown significant hypotensive reactions. Mean BP decreased by 15-23% during 3-40 minutes in patients with both types of crises. Among patients with TIA: within 10 minutes after the application of the drug increased blood flow volume compared to baseline against atherosclerotic remodulation of carotid and vertebral arteries by 34% (P < .02). In 81% of patients with pathological tortuosity sonnih arteries—by 29% (P < .05) in the carotid, and 20% in the vertebral arteries (P < .05) in 90% of patients. Among patients with hypoplastic vertebral artery Niprutsel increases blood flow in the affected artery by 31% (P < .05); intact by 35% (P < 002) in 83.3% of patients.
Conclusions: Conducting contrast cerebral angiography using transmucosal buccal dosage form of sodium nitroprusside is a new and safe method allowing to indentify patients with low-capacitance cerebrovascular reserve bed, who are prescribed to undergo a non constructive surgical intervention on brachiocephalic arteries.
301
Myocardial bridges (MB) and myocardial perfusional single photon emission computed tomography (SPECT) in a clinical setting
G. Guido Valle1; A. Facciorusso2; S. Michelini3; M. Totaro1; G. Di Stolfo2; S. Mastroianno2; G. De Luca2; M. Stanislao2
1Scientific Institute Casa Sollievo della Sofferenza, Department of Nuclear Medicine, San Giovanni Rotondo, Italy; 2Scientific Institute Casa Sollievo della Sofferenza, Department of Cardiology, San Giovanni Rotondo, Italy; 3Sapienza University of Rome, 2nd Faculty of Medicine, Rome, Italy
Background and Aim: MB is the anatomical condition characterized by the presence of an epicardial artery that goes intramurally through the myocardium beneath the muscle bridge. MB is largely undiagnosed in lifetime. Symptoms, when present, simulate those of coronary atherosclerosis and the diagnosis is usually performed by coronarography and/or by angio-CT in subjects referred for the suspicion of atherosclerotic coronary artery disease. MB can be detected as isolated findings but can also be observed in presence of a atherosclerotic coronary artery disease both of the same bridged artery (usually upstream of the MB) or of other coronary arteries. Myocardial perfusional studies by SPECT offers a unique, safe and reliable way to assess the effective myocardial perfusion downstream the bridge. Aim of our study has been a retrospective analysis of our series focused on myocardial perfusional abnormalities induced by MB.
Patients and Methods: Sixteen patients (15 M) with a previously coronarography demonstrated MB underwent myocardial perfusion stress/rest gated-SPECT studies. MB was localized at the second (intermediate) portion of the Left Descending Artery (LDA) in 12 cases, in the distal part of LDA in 3 cases and in the distal portion of the Left Circumflex Artery (LCA) in one case. In eight cases the MB was the only pathological finding at coronarography, in the other eight patients an angiographically significant coronary artery disease was present.
Results: None of the patients with MB in the distal portion of the LDA nor in that with the MB at the terminal portion of the LCA demonstrated perfusional abnormalities in the area supplied by the bridged coronary artery. In eight out of the 12 patients with MB at the LDA second segment the perfusional myocardial SPECT did not demonstrated perfusional derangements of the anterior wall nor of the apex. On the contrary the other four subjects demonstrated the presence of significant perfusional abnormalities in the myocardial area downstream the MB.
Discussion and Conclusions: Our series gives a further confirmation that MB is usually not associated to important ischemic phenomena. In our series the dynamic stenosis represented by MB is associated to a normal perfusional pattern in 75% of cases. However in a quarter of cases myocardial perfusional SPECT demonstrated inducible heart wall ischemia downstream the MB. The identification of the subjects with significant functional stenosis is critical because these patients will take the maximal advantage from a diastolic time lengthening pharmacological therapy.
302
In-hospital outcomes of biventricular assist devices for high-risk percutaneous coronary intervention
V. Ganyukov1; M. Maxim Sinkov1; V. Popov1; D. Shukevich1; L. Barbarash1
1Research Institute for Complex Issues of Cardiov. Dis.-Siberian Branch RAMS Institution Scientific, Kemerovo, Russian Federation
Background: Revascularization by coronary artery bypass grafting (CABG) is contraindicated in some patients with severe multivessel coronary arterial disease (CAD). Percutaneous coronary intervention (PCI) in this patient group also carries the risk of adverse outcomes in case of low left ventricular (LV) function, a technically difficult procedure, or when a large area of viable myocardium is supplied by target vessels. Currently, evidence for intraaortic balloon pump (IABP) application in PCI is still pending due to the lack of adequate circulatory support and the need for a certain level of LV function. Perhaps, biventricular assist devices supported by extracorporeal membrane oxygenation (ECMO) can provide effective hemodynamic support for high-risk PCI patients with multivessel CAD who have contraindications for CABG.
Methods: Eight patients with CAD contraindication for CABG were included in the study. The average age was 62.8 ± 6.1 years, EuroScore 10.6 ± 2.4. Half of the patients (n = 4) had severe comorbidities,six patients had non-STEMI. All patients underwent the high-risk PCI facilitated by ECMO. Six patients had left main coronary artery (LMCA) stenosis (>70%), all of them presented multivessel CAD (SYNTAX score 32.4 ± 5.4).
The hemodynamic support in all patients was provided with venoarterial biventricular assist devices with perfusion index of 2.4-2.7 L/(minutes m2). Primary end-point of the study was death, myocardial infarction (MI), stroke, target vessel revascularization (TVR), bleeding and stent thrombosis.
Results: The average number of implanted stents per patents was 3:1. The average implanted stent length was 54.8 ± 16.2 mm. Seven patients underwent bifurcation stenting, two patients underwent chronic total occlusion revascularization and six subjects—unprotected LMCA intervention. Angiographic success without associated in-hospital major clinical complications (e.g., death, MI, stroke, TVR, bleeding, and stent thrombosis) was achieved in all cases. Complete revascularization was performed in 75% (n = 6) of all the patients.
Conclusions: Biventricular assist devices for the high-risk PCI facilitated by ECMO ensure to perform successful myocardial revascularization in patients ineligible for CABG.
Oral Abstract Session
Novel cardiovascular molecular imaging probes
Wednesday 8 May, 2013, 08:30–10:00 Room 4 – A05
313
Peptide receptor radionuclide therapy decreases inflammation in atherosclerotic plaques, as quantified by 68Ga-DOTATATE PET/CT
I. Imke Schatka1; T. Wollenweber1; C. Haense1; F. Brunz1; K.F. Gratz1; F.M. Bengel1
1Hannover Medical School, Department of Nuclear Medicine, Hannover, Germany
Purpose: DOTATATE is a somatostatin receptor (SSTR) ligand which is used with different radiolabels, for molecular imaging and targeted therapy of tumors. SSTR subtype II is also expressed on activated macrophages, which are an integral part of inflamed atherosclerotic plaques. We speculated that peptide receptor radionuclide therapy (PRRT) has beneficial effects on atherosclerotic plaque by reducing inflammation. This hypothesis was tested in patients receiving serial DOTATATE-based imaging and therapy for neuroendocrine tumors.
Methods: Out of a total group of 165 patients undergoing PRRT for various tumors, we retrospectively identified 11 patients (60 ± 13 years; 9 m, 2f) which had 3 successive 68Ga-DOTATATE PET/CT scans, with no therapy between scans 1 and 2 (median time between scans 347d [range 99-945]), and their first PRRT with the beta-emitter Lu-177 DOTATATE between scans 2 and 3 (median time between scan 2 and PRRT 28d [14-89], between PRRT and scan 3 105d [76-131]. Focal vessel wall DOTATATE uptake was measured in six arterial segments of PET images (carotids; aortic arch; ascending, descending, abdominal aorta; iliac arteries) as target-to-background ratio (TBR). CT images were used to detect calcified plaque (CP). Overall vessel uptake (OVU) was determined as the sum of TBR in all vascular segments of a patient.
Results: Focal 68Ga-DOTATATE vessel wall uptake was detectable in all patients. OVU of the first scan correlated with age (r = 0.76; P < .01), with the number of CP (r = 0.84; P < .001) and was higher in subjects with hypercholesterolemia (P = .04). No significant difference was found between scans 1 and 2 (43 ± 23 vs 41 ± 26; P = .80), confirming reproducibility in the absence of treatment. Following PRRT, there was a significant reduction in OVU of scan 3 (30 ± 19; P = .001 vs scan 1 and P = .004 vs scan 2). In each patient the number of CPs was stable in all scans.
Conclusion: Our results support feasibility and reproducibility of 68Ga-DOTATATE PET/CT for imaging atherosclerotic plaque inflammation via SSTR expression. In patients receiving SSTR-targeted PRRT for neuroendocrine tumors, a reduction of plaque inflammation was indicated after therapy. This initial observation may serve as a stimulus for further exploration of radionuclide-based anti-atherosclerotic molecular interventions.
314
RAGE imaging documents the beneficial effect of glucose control on atherosclerotic progression in apoE null mice both with and without diabetes
Y. Yared Tekabe1; M. Kollaros1; L. Johnson1
1Columbia University Medical Center, New York, United States of America
Purpose: Receptor for Advanced Glycation Endproducts (RAGE) binds AGEs and other inflammatory ligands and is expressed in atherosclerotic plaques in diabetic and non-diabetic subjects. The higher expression in diabetes mellitus (DM) corresponds with accelerated course of the disease. We have previously shown that RAGE expression in aortic atheroma can be imaged in vivo in apoE null mice using Tc-99m-anti-RAGE F(ab’)2 and SPECT/CT imaging and that uptake is greater in diabetic compared to non-diabetic mice. The purpose of this study was to show that control of blood glucose levels in diabetic mice would lead to reduced RAGE expression and reduced atherosclerosis compared to uncontrolled diabetics and that this difference can be detected on in-vivo SPECT imaging.
Methods: Thirty apoE null mice (6 weeks) were given STZ, and after 6 weeks 15 began treatment with 2 insulin implants (LinBits for mice) with weekly monitoring of blood glucose and additional implants for blood glucose > 200 mg/dL. At end of 15 weeks, all mice were injected with Tc-99m-anti-RAGE F(ab’)2 (15.14 ± 1.23 MBq) and CT contrast agent (eXIA 160XL) and underwent SPECT/CT imaging (Bioscan nano-SPECT/CT). Animals were sacrificed, the proximal aorta removed and counted to calculate the percentage of injected dose per gram (%ID/g) RAGE uptake, followed by histological and immunohistochemical characterization. ROIs were drawn over uptake of radiotracer in the aorta and neck vessels using the contrast angiogram to identify vessels and quantified in mCi using InVivoScope software.
Results: Radiotracer uptake in the proximal aorta, arch, and neck vessels was visibly less in the treated compared to non-treated and supported by the quantitative results for %ID: 0.45 ± 0.34 × 10−4 vs 0.78 ± 0.28 × 10−4 (P = 0.007). The mean blood glucose levels for the duration in treated mice were 144 ± 14 mg/dL and for the controls 348 ± 60 mg/dL. RAGE uptake correlated with quantitative RAGE staining in the atheroma and there was a significant correlation between %ID from scans vs %ID/g (R = 0.60, P = 0.023). The lesion size as percent cross sectional area was significantly smaller in the treated (14.3 ± 7.8%) vs untreated (29.5 ± 10.9%) (P = 0.03).
Conclusion: These data further support the important role of RAGE expression in atherosclerosis in diabetes, the value of in-vivo imaging of RAGE expression in atherosclerosis, and the value of glucose control to reduce atherosclerotic burden.
315
In vivo diagnosis of experimental infective endocarditis: Comparison between 99mTc-labeled HYNIC-Annexin A5 and Annexin A5-128 for
K. Khadija Ben Ali1; F. Rouzet1; R. Ben Azzouna1; A. Petiet2; L. Louedec2; D. Chicco3; A. Filannino3; L. Sarda-Mantel1; M. Jean-Baptiste2; D. Le Guludec1
1AP-HP—Hospital Bichat-Claude Bernard, Department of Nuclear Medicine, Paris, France; 2Inserm U698—Hospital Bichat-Claude Bernard, Paris, France; 3Advanced Accelerator Applications, Colleretto Giacosa, Italy
Objectives: AnnexinA5 (AnxA5) is a ligand of phosphatidylderines exposed by activated platelets and apoptotic cells. 99mTc-HYNIC-annexinA5 (HYNIC-Anx) has already been shown to be sensitive for in vivo detection of platelet activation in animal models. Anx A5-128 is a new mutant of AnxA5 which possess an endogenous peptidic chelation site at its N terminus. We compared biodistribution and diagnostic value of HYNIC-Anx and Anx A5-128 in rat model of infective endocarditis (IE).
Methods and Results: Blood clearance and tissue biodistribution was assessed in 12 control rats. Anx A5-128 was rapidly cleared from the blood according to a 2-compartment model (rapid component: 83%; 1/2-life 10 minutes) with less than 10% of the injected dose remaining in blood at 30 minutes (vs 23% for HYNIC-Anx). Tissue biodistribution at 60 minutes was similar between both forms of AnxA5 except for kidney uptake which was fivefold lower with Anx A5-128. IE was induced in 12 rats and SPECT/CT performed 1 hour after injection of the tracer (HYNIC-Anx, n = 6; Anx A5-128, n = 6). On visual analysis, all animals presented a focal uptake in the aortic valve area with both tracers. The uptake to background ratio was similar for both tracers (median and range): 8.7 [5.6-9.7] and 5.0 [2.1-8.1] for HYNIC-Anx and Anx A5-128 respectively, P = .10. On autoradiography, the uptake matched with platelets (P-selectin/Annexin A5 positivity on immunostaining) valvular vegetations and platelets immunostaining.
Conclusions: Blood clearance and tissue biodistribution of Anx A5-128 is quite similar to that of HYNIC-Anx except for kidney uptake which is much lower. Its diagnostic value in a rat model of IE is good and comparable to that of HYNIC-Anx. These results support the evaluation of Anx A5-128 as a tracer in the diagnosis of IE in humans.
316
Myocardial uptake and tetention mechanisms of novel F-18 sympathetic nerve imaging tracer LMI1195
T. Higuchi1; B.H. Yousefi2; F. Kaiser1; F. Gaertner2; M. Beschorner2; R. Reder2; Y. Ming3; S. Robinson3; M. Schwaiger2; S. Nekolla2
1Würzburg University, CHFC/Nuclear Medicine, Würzburg, Germany; 2Technical University of Munich, Department of Nuclear Medicine, Munich, Germany; 3Lantheus Medical Imaging, Departments of Discovery Chemistry and Discovery Biology, North Billerica, United States of America
Background: A novel 18F-labeled tracer, LMI1195 is being developed for sympathetic nerve terminal PET imaging of the heart. Its high specificity for neural uptake-1 mechanism has previously been demonstrated in cell associative studies and in rabbit and non-human primate in-vivo studies assessing heart uptake. The aim of this study is to further characterize the mechanisms of LMI1195 cardiac uptake and retention utilizing isolated perfused rabbit heart to avoids systemic recirculation of tracer and radiolabeled metabolites.
Methods: Cardiac first pass tracer extraction fraction and retention of the LMI1195 were measured by a pair of bismuth germanate detectors interfaced to coincidence detection circuitry of whole isolated rabbit hearts perfused with the Langendorff method (n = 6). Effect of neural uptake-1 blocker desipramine 40 nM added to the perfusion media was monitored during first pass extraction and tracer retention (n = 4).
Results: LMI1195 first pass extraction fraction was calculated as 23.4 ± 3.4% in the isolated rabbit heart using a flow of 40 mL/minutes. Desipramine decreased the extraction fraction to 7.7 ± 3.2% (P < .001). There was a minimal tracer washout with a rate of 0.39 ± 0.05%/minutes during the initial 10 minutes, but from thereon, tracer retention remained stable in the hearts. The washout rate did not change under the 40 nM desipramine additive during the early washout phase (0.51 ± 0.12%/minutes, n.s.).
Conclusion: Utilizing the isolated rabbit heart system, cardiac first pass extraction fraction of LMI1195 was determined. The extraction fraction was decreased significantly by desipramine indicating highly specific uptake mechanism for norepinephrine uptake in nerve terminals consistent with previous cellular and in-vivo studies. High tracer retention indicated minimal metabolism in the heart, and it was not influenced by desipramine suggesting stable tracer storage into the nerve terminals. Thus, LMI1195 is promising for the cardiac nerve terminal PET imaging.
317
GSAO-based molecular targeting of myocardial necrosis in acute ischemic insult
H.J. Hans De Haas1; H.R. Zandbergen2; N. Tahara3; A.D. Petrov1; R.H.J.A. Slart4; H.H. Boersma4; C.P. Reutelingsperger2; J. Narula1
1The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, United States of America; 2Maastricht University, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands; 3Kurume University, Kurume, Japan; 4University Medical Center Groningen, Department of Nuclear Medicine and Molecular Imaging, Groningen, Netherlands
Purpose: GSAO has an arsenic group that binds to dithiols on various intracellular proteins that are upregulated during cellular stress including HSP90, PDI, which plays a role in the unfolded protein response and apoptosis, and Beclin-1, which drives autophagy. Extracellular dithiols are uncommon. As 111In-GSAO is membrane impermeable, intracellular uptake shows membrane disruption, a hallmark of necrotic cell death. It is proposed that information about preferential protein binding other than HSP90 would determine the likely initial cell death pathway. The current study sought to show feasibility of GSAO imaging in animal models of acute and chronic myocardial infarction and to evaluate the relation between myocardial apoptosis and necrosis.
Methods: Chronic and acute myocardial infarction were induced by persistent occlusion and by 30 minutes occlusion + release of the LAD in rabbits and mice. In acute MI rabbits, in vivo and ex vivo SPECT imaging using GSAO (n = 6), GSAO + sestamibi (n = 4), GSAO + AA5 (n = 3) and control compound GSCA (n = 5) were performed, followed by gamma-counting and immunohistochemistry. In mice, ex vivo imaging and gamma-counting using GSAO was performed after acute MI (n = 6), after chronic MI at 2 (n = 6), 4 (n = 6) and 12 (n = 8) weeks and in controls (n = 5). GSCA was employed at 2 (n = 6) weeks. Six mice received fluorescently labeled AA5 and GSAO after acute MI.
Results: In rabbits, myocardial GSAO uptake was high (1.1 ± 0.43%ID/g), localized in the perfusion defect and was significantly higher than in the remote area (0.07 ± 0.03%ID/g, P < 0.001). GSAO and AA5 uptake were observed in the same region and showed a strong correlation (0.75, P < .001). IHC revealed correlation with apoptosis markers TUNEL (r = 0.54 P < .001) and Caspase-3 (R = 0.27 P < .001); no significant correlation was observed with Beclin or PDI. In mice, high GSAO uptake was observed in acute MI (2.56 ± 2.51 %ID/g) and significantly reduced over time in chronic MI to level of controls (0.13 ± 0.02%) paralleling apoptosis as shown by TUNEL. No specific uptake of GSCA was seen in mice or rabbits. Fluoro-microscopy in acute MI mice showed that all GSAO-positive cells were AA5-positive, GSAO-negative Annexin-positive cells were seldomly seen. Extracellular GSAO was not observed.
Conclusions: GSAO SPECT is feasible after acute MI. Colocalization of GSAO and AA5 shows that necrosis after acute MI is secondary to apoptosis. The lack of correlation of GSAO with Beclin-1 or PDI, and the correlation of GSAO with AA5, and TUNEL and Caspase-3 show that necrosis following apoptosis is a dominant cell death mode in this setting.
Oral Abstract Session
Cardiac CT: New approaches and applications
Wednesday 8 May, 2013, 14:00–15:30 Room 4 – A05
344
Correlation between calcium score on attenuation correction CT and gated non-contrast computed tomography
M. Al-Mallah1; H. Alziady1; I. Suleiman1; M. Alharthi1; A. Alsaileek1
1National Guard Hospital, King Abdulaziz Cardiac Center (KACC), Riyadh, Saudi Arabia
Introduction: Quantification of coronary artery calcification with non-contrast gated cardiac CT has been well validated using Agatston method. While visual estimation of CCS using attenuation correction CT (CTAC) images obtained during positron emission tomography (PET) appears to agree with CAC scans, the quantification of CCS by CTAC has not been extensively studied. The aim of this analysis is to determine the correlation between coronary artery calcium score (CCS) using a low dose radiation non ECG gated CTAC and a dedicated ECG gated non contrast Cardiac CT (CAC).
Methods: We included 147 patients (mean age 62 years, 52% male) who underwent myocardial perfusion positron emission tomography (PET) and coronary calcium score in the same setting. Calcium score was calculated twice on both non-contrast gated CT (120 Kvp, 200 mA, 2.5 mm slice thickness), and computed tomography attenuation correction CTAC (120 Kvp, 20 mA, 3.8 mm slice thickness) using Agatston method by two physicians blinded to the results of the other study. A threshold of 130 HU was used to define detected calcium.
Results: Nearly half of the patients included in the study were obese (median BMI > 31 kg/m2). 92 cases (63%) had CCS > 0. There was a strong statistical correlation between calcium score obtained from the two scans at patient level (R = 0.897, P < .0001) and at vessel level. (r = 0.827, P < .001). However, compared to CAC, calcium score on CTAC was overestimated in five cases and underestimated in 86 (59%) patients with median difference of 88 (range 1-1468). Of the 92 patients with detected calcium on CAC, 39 (42%) patients had no detected calcium on CTAC.
Conclusion: A very low radiation attenuation correction computed tomography scan underestimates calcium score often. A total of 42% of patients with coronary calcifications were missed on the CT attenuation correction.
345
Can we achieve a benefit in all-cause mortality by coronary computed tomographic angiography routine screening in asymptomatic diabetic patients?
B.-H. Byung-Hee Hwang1; M.-K. Kang1; C.-J. Kim1; J.-J. Kim1; M.-O. Jang1; K.-Y. Chang1; S.-M. Yim1; I.-J. Choi1; T.-H. Kim1
1The Catholic University of Korea, St. Mary’s Hospital, Seoul, Republic of Korea
Background: Coronary computed tomography angiography (CCTA) is a noninvasive imaging test that demonstrates high diagnostic performance for the detection and exclusion of CAD, with recent multicenter studies demonstrating a robust prognostic utility to CT angiographic findings for the prediction of mortality and other major adverse cardiac events (MACE).
But till now, only few studies are aimed at the prediction of mortality and other MACE in asymptomatic diabetic patients. Since diabetes is already known as a coronary artery disease equivalent, there might be a benefit in all-cause mortality by performing coronary CT routinely in diabetic patients.
Methods: We have enrolled 2866 asymptomatic, adult diabetic patients from 2005 to 2011. CCTA scans were performed in 955 patients, and 1910 patients were enrolled as control group with no CCTA scans. Control group was matched with CCTA scan group in age, gender with 2:1 ratio. All patients had a follow-up for death, MI, stroke with a median duration of 31 months.
Results: CCTA scan group had a longer DM duration (12.45 ± 9.5 vs 10.19 ± 8.98, P < .001), higher HbA1c (8 ± 1.94 vs 7.59 ± 1.8, P < 0.001), BUN (18.42 ± 9.14 vs 17.13 ± 7.32, P < .001), Cr (1.03 ± 0.56 vs 0.92 ± 0.22, P < .001) level, and lower Hb (13.52 ± 1.67 vs 13.27 ± 1.82, P = .01), AST (27.25 ± 35.82 vs 23.71 ± 9.89, P < .001), premeal C-peptide (2.12 ± 2.31 vs 1.8 ± 1.26, P < .001) level. Univariate hazard ratio in CCTA scan group for all death in 5-year landmark analysis had statistical significance (HR 0.610, 95% CI 0.424-0.876, P = .008). After adjusting for multivariables, CCTA scan group still showed statistical significance (HR 0.670, 95% CI 0.457-0.982, P = .040).
Conclusion: Performing CCTA scans in asymptomatic diabetic patients as a routine screening study has a benefit in all-cause mortality.
Cumulative hazard between 2 groups
346
Prognostic value of MDCT in diabetes: Excellent long-term prognosis in patients with normal coronary arteries
S. Mushtaq1; D. Andreini2; G. Pontone1; E. Bertella1; E. Conte1; A. Baggiano1; S. Cortinovis1; M. Pepi1; G. Ballerini1; C. Fiorentini2
1Cardiology Center Monzino (IRCCS), Milan, Italy; 2Cardiology Center Monzino (IRCCS), Department of Cardiovascular Sciences, University of Milan, Milan, Italy
Purpose: To assess the prognostic role of multidetector computed tomography coronary angiography (MDCT-CA) in diabetics with suspected coronary artery disease (CAD). Use of MDCT-CA is increasing in patients with suspected CAD. However, data supporting its prognostic value in diabetics are limited.
Methods and Results: Between January 2006 and September 2007, 429 consecutive diabetic patients were prospectively studied with MDCT-CA for detecting presence and assessing extent of CAD (disease extension and coronary plaque scores). Patients were classified according to the presence of normal coronaries, non-obstructive (<50%) and obstructive (>50%) coronary lesions. The composite rates of hard cardiac events (cardiac death, non-fatal myocardial infarction, unstable angina) and all cardiac events (including revascularization) were the end points of the study. Twenty-four patients were excluded because MDCT-CA data were uninterruptable. Of the remaining 405 patients, clinical follow-up (mean 62 ± 9 months) was obtained in 390 (98%). By multivariate analysis, predictors of hard and all events were obstructive CAD, 3-vessel CAD and left main coronary artery (LMCA) disease. Cumulative event-free survival was 100% for hard and all events in patients with normal coronary arteries, 78% for hard events and 56% for all events in patients with non-obstructive CAD, and 60% for hard events and 16% for all events in patients with obstructive CAD. Three-vessel CAD and LMCA disease was associated with higher rate of hard cardiac events.
Conclusion: MDCT-CA provides long-term prognostic information in diabetics with suspected CAD, showing excellent prognosis when there is no evidence of atherosclerosis and allowing risk stratification when CAD is present.
347
Automatic quantification and characterization of coronary atherosclerosis with computed tomography angiography (CTA): Cross-correlation with intravascular ultrasound virtual histology (IVUS VH)
M.A. De Graaf1; A. Broersen2; P.H. Kitslaar2; J. Dijkstra2; M.J. Schalij1; J.H. Reiber2; J.J. Bax1; V. Delgado1; A.J. Scholte1
1Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands; 2Leiden University Medical Center, Department of Radiology, Division of Image Processing, Leiden, Netherlands
Purpose: Plaque constitution on CTA is associated with prognosis. At present only visual assessment of plaque constitution is possible. An accurate automatic, quantitative approach for CTA plaque constitution assessment would improve reproducibility and allows higher accuracy. The present study assessed the feasibility of a fully automatic and quantitative analysis of atherosclerosis on CTA. Clinically derived CTA and IVUS VH datasets were used to investigate the correlation between quantitatively automatically derived CTA parameters and IVUS VH.
Methods: A total of 57 Patients underwent CTA prior to IVUS VH. First, quantitative CTA (QCT) was performed. Per lesion stenosis parameters and plaque volumes were assessed. Using predefined HU thresholds, CTA plaque volume was differentiated in four different plaque types (necrotic core (NC), dense calcium (DC), fibrotic (FI) and fibro-fatty tissue (FF). At the identical level of the coronary, the same parameters were derived from IVUS VH. Bland-Altman analyses were performed to assess the agreement between QCT and IVUS VH.
Results: Assessment of plaque volume using QCT in 108 lesions showed excellent correlation with IVUS VH (r = 0.928, P < .001) (Figure 1). The correlation of both FF and FI volume on IVUS VH and QCT was good(r = 0.714, P < .001 and r = 0.695, P < .001 respectively) with corresponding bias and 95% limits of agreement of 24 (−42; 90) and 7.7 (−54; 70). Furthermore, NC and DC were well-correlated in both modalities (r = 0.523, P < .001) and (r = 0.736, P < .001).
.
Conclusion: Automatic, quantitative CTA tissue characterization is feasible using a dedicated software tool.
348
Absence of coronary calcification is associated with a low long term revascularization rate
M. Al-Mallah1; W. Qureshi2; K. Nour2
1National Guard Hospital, King Abdulaziz Cardiac Center (KACC), Riyadh, Saudi Arabia; 2Henry Ford Hospital, Detroit, United States of America
Background: The absence of coronary artery calcification (CAC) is associated with excellent long term survival. However, some data suggest that the absence of coronary calcification does not rule out the need for revascularization. The aim of this analysis is to determine the long term need for revascularization among patients with zero calcium score.
Methods: CAC measurement was performed in 1255 consecutive patients without known coronary artery disease (CAD). (Mean age 58 ± 12 years, 49% males, and 78% symptomatic) Patients were followed up for future angiography and revascularization using medical records review and insurance claims data.
Results: A total of 497 (37%) patients had zero calcium score. Patients with zero CAC were more often females (64% vs 42%, P < .001), more often symptomatic (78% vs. 71%, P = .012) with higher prevalence of hypertension and diabetes. After a median follow-up duration of 47 months (25-75th percentile 32-63 months, range up to 101 months), 218 (17.4%) patients underwent clinically indicated coronary angiography and 75 (6.1%) patients underwent clinically indicated revascularization, 5 patients (1%) with zero CAC vs 70 patients (9%) with non-zero CAC (P < .001) (Figure). In multivariable Cox regression, coronary calcification was the strongest predictor of the need of long term revascularization. [Hazard ratio (HR) 8.3, 95% CI 3.2-21.5, P < .001]. Other predictors were symptoms (HR 2.4) and male gender (HR 2.1).
Conclusions: In an up to 8 years of follow-up, the absence of coronary calcification excludes the need for coronary revascularization.
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Poster Session 5
Clinical General and Outcome: Cardiac CT Posters
Wednesday 8 May, 2013, 08:30–12:30 Poster Area
350
Quantitative cardiac SPECT and coronary calcium score in the detection of coronary artery disease: Validation of findings by coronary angiography
M. Kaminek1; I. Metelkova1; M. Budikova1; E. Buriankova1; R. Formanek1; L. Henzlova1; P. Koranda1; E. Sovova1; V. Kincl2
1University Hospital Olomouc, Olomouc, Czech Republic; 2CMI, ICRC-FNUSA, Brno, Czech Republic
Purpose: To analyse sensitivity and specificity of SPECT and to assess the diagnostic potential of quantitative parameters of perfusion, left ventricular function and coronary artery calcium (CAC) score to identify high risk patients with multivessel coronary artery disease.
Methods: 702 patients underwent stress gated SPECT study and then coronary angiography. We quantified summed difference score (converted to % of ischemic myocardium), left ventricular ejection fraction (LVEF), end-diastolic/end-systolic volumes, transient ischemic dilatation (TID) ratio. In patients with a dilated left ventricle, we measured CAC score.
Results: Sensitivity and specificity of SPECT were 91% (456/502) and 76% (151/200), respectively. There was not significant difference between sensitivity in men and women (91% vs 90%, P = NS). Sensitivity was significantly higher in patients with multivessel disease (87% in 1-vessel disease vs 95% and 94% in 2- and 3-vessel disease, respectively, P < 0.05). In quantitative analysis, % of ischemic myocardium rose with a number of diseased vessels: 11% ± 11%, 15% ± 12% and 19% ± 14% in patients with 1-, 2- and 3-vessel disease, respectively. The sign of postischemic left ventricular stunning (poststress worsening of the LVEF > 5% and/or TID ratio > 1.17) was observed in 46%, 49%, and 63% of patients with 1-, 2- and 3-vessel disease, respectively. In the subgroup of 81 patients with a dilated left ventricle, combining SPECT with CAC score (at a cutoff of 1000) improved sensitivity from 80% to 91% and negative predictive value from 66% to 81% (P < .05), in association with not significant change in specificity and positive predictive value.
Conclusions: Quantitative SPECT enables identification of high risk patients with a large ischemia and postischemic stunning with probable multivessel disease. In patients with a dilated left ventricle, the accuracy of SPECT has been improved by combination with CAC score.
351
Simultaneous evaluation of myocardial perfusion imaging (MPI) and coronary calcium score (CCS) in patients with intermediate likelihood of CAD: A 5 year follow-up study
C. Cittanti1; E. Succi Leonelli2; D. Mele3; S. Panareo1; I. Santi1; C. Peterle1; V. De Cristofaro1; I. Rambaldi1; V. Rossetti1; L. Feggi1
1Nuclear Medicine Unit—University Hospital, Ferrara, Italy; 2Cardiology Unit—Delta’s Hospital, Lagosanto, Italy; 3Cardiology Unit—University Hospital, Ferrara, Italy
Aim: Hybrid SPECT-CT tomographs offer the opportunity to simultaneously evaluate both functional (MPI) and morphoanatomical (CCS) aspects of the atherosclerosis. The aim of this study is to assess the additional prognostic value of CCS in adjunct to MPI in the evaluation of patients with intermediate-risk of CAD.
Materials and Methods: Study population consisted of 367 prospective patients who were clinically scheduled for MPI and classified at intermediate risk on the basis of the Framingham Risk Score. All subjects underwent contextual rest sestamibi MPI and CCS evaluation as a part of a standard two-days stress-rest MPI protocol. Studies were acquired with an hybrid Symbia T2 tomograph (Siemens). Summed Stress Scores (SSS) and Agatston data were calculated for all patients and MPI studies were considered “positive” (+) if SSS > 3. Subjects were divided into four groups on the basis of tests results: MPI− and CCS < 400 (group A); MPI− and CCS ≥ 400 (group B); MPI+and CCS < 400 (group C); and MPI+ and CCS ≥ 400 (group D).
Results: Fifteen patients were excluded because of sub-optimal quality of imaging and other 22 subjects did not complete the follow-up. The remaining 330 patients (216 men, mean age 67 ± 12 years) were prospectively followed for an average of 63 ± 9 months and the outcome events considered were: cardiac death, non-fatal myocardial infarction, hospitalization for unstable angina and late (>90 days) coronary revascularization. Group A consisted of 126 patients, group B of 58, group C of 32 and group D of 114. The cardiac event rate in the study population was 2.7%/year. Annual event rates for overall cardiac events in group A, B, C and D were 0.3, 1.4, 4.4 and 5.6%/year respectively. Patients with a normal MPI had higher survival free of cardiac events (P < .01); additionally an increase in global chi-square in predicting all cardiac events occurred when CCS data were added to MPI information. Kaplan-Meier curves showed a significant difference in event-free survival at 5 years in the four groups.
Conclusions: Although this study suffers from several limitations it outlines that an “hybrid” approach, combining an anatomic assessment of coronary atherosclerotic plaque burden (which probably better estimates longer-term prognosis) with a functional evaluation of myocardial ischemia (more closely related to a “short-term risk”) may contribute to refine temporal risk stratification among subjects at intermediate likelihood of CAD. Multicenter trials are mandatory to confirm these preliminary findings and to assess their potential impact in larger clinical settings.
352
More anatomy and more physiology: Hybrid SPECT-CT images as the gold standard of a culprit lesion
M.N. Pizzi1; A. Roque2; S. Aguade-Bruix3; G. Cuberas-Borros4; H. Cuellar-Calabria2; B. Garcia Del Blanco4; G. Romero-Farina4; J. Castell-Conesa3; D. Garcia-Dorado4; J. Candell-Riera4
1Universitary Hospital Vall d’Hebron, Cardiology Department, Nuclear Cardiology and Cardiac CT Unit, Barcelona, Spain; 2Universitary Hospital Vall d’Hebron, Radiology Department, Barcelona, Spain; 3Universitary Hospital Vall d’Hebron, Nuclear Medicine Department, Barcelona, Spain; 4Universitary Hospital Vall d’Hebron, Cardiology Department, Barcelona, Spain
Introduction and Objectives: The anatomic extension and severity of the coronary disease have routinely used in the prognosis evaluation of patients and the decision of revascularization. However, this is a uni-dimensional viewpoint of a multi-dimensional problem. We have now the possibility of integrating non-invasively function and anatomic images to improve our understanding of the coronary artery disease, especially helpful in the determination of the culprit lesion.
Methods: We analyzed 30 patients (mean age: 65.5 ± 6.77 years, 90% men, pre-test prevalence of 63.3% ± 21.88%) with known significant coronary artery disease (>50% stenoses) in at least one vessel who had undergone a gated SPECT, a coronary computed tomography angiography (CTA) and an invasive angiography (IA). We looked for the ability of the different techniques in the determination of the culprit lesion (the most stenotic lesion in the anatomic explorations and the most severe perfusion defect in the functional test) using the hybrid imaging as the gold standard. In the hybrid images we considered the culprit vessel the one with a significant stenosis causing the most severe perfusion defect.
Results: In 3 of 30 CTA (10%), in 4 of 30 IA (13%), and in 3 of 30 SPECT (10%) we could not determine only one culprit vessel-region due to the presence of two similar stenoses or two similar perfusion defects. In all these cases SPECT-CTA hybrid images could determine culprit lesion. After the exclusion of these doubtful cases, we observed an 81% (22/27) concordance (kappa: 0.692) between SPECT and hybrid images, 85% (23/27) of concordance (kappa: 0.776) between CTA and hybrid images, and 88% (23/26) concordance (kappa: 0.817) between IA and hybrid images. Concordance between SPECT and hybrid images was 100% for left anterior descending artery (LDA) but only 64% (9/14) for right coronary-left circumflex artery. Concordance between anatomic explorations was 80% (20/25) for LDA and 93% (26/28) for right coronary-left circumflex artery.
Conclusions: When analyzed separately, SPECT, CTA and IA could not determine the culprit vessel-region in 10-13% of patients while hybrid images could do it in all cases. There is 80-85% of concordance between SPECT, CTA, IA and hybrid images for the diagnosis of the culprit lesion. SPECT was more accurate in the LDA territory while anatomic explorations did it better in the inferior territory.
353
Prevalence and morphologic features of myocardial bridging: A coronary computed tomography angiographic study from Northern Greece
C. Christos Graidis1; T. Christoforidou1; D. Dimitriadis1; V. Karasavvidis1; V. Psifos1; K. Gourgiotis1; G. Karakostas1; M. Giannadaki1; I. Neroladakis1; G. Dimitriadis1
1Euromedica-Blue Cross Hospital, Thessaloniki, Greece
Background: Myocardial bridging (MB) is a congenital structural variant in which a segment of the epicardial coronary artery tunnels into and is surrounded by the myocardium. The depiction rate of MB varies significantly between catheter coronary angiography and autopsy studies. Conventional coronary angiography is the gold standard for detection, but it is invasive and may not be sensitive enough to detect a thin bridge.
Purpose: The aim of this study was to assess the depiction rate of MB by coronary computed tomographic angiography in Northern Greece and to determine the anatomical features of the tunneling vessels.
Methods: Between January 2009 and March 2012, a total of 1884 consecutive patients who underwent 64-row MDCT coronary angiography in our institution, were retrospectively reviewed to identify the presence and the location of MB and determine morphologic features and relation to atherosclerosis.
Results: A total of 338 (226 males, 44 females; mean age, 55.4 ± 12.6 years; age range 24-90 years) out of 1,884 (17.9%) patients showed 353 cases of MB. One hundred ninety-one tunneling segments (54.2%) were situated in the middle portion of the left anterior descending coronary artery (LAD), 103 segments (29.2%) were in the distal portion of the LAD, 38 segments were in the proximal part of the LAD (10.8%), 6 (1.7%) in the first diagonal branch, 6 (1.7%) in the ramus intermediate, 3 (0.8%) in the second diagonal branch, and 3 (0.8%) in the Right coronary artery. Depth ranged from 0.1 to 4.1 mm. Intramuscular segment length ranged from 9 to 38 mm. All intramuscular segments were without evidence of atherosclerosis. We found proximal intima to be without atherosclerosis in 44.1% of patients (149/338) and with atherosclerosis in 55.9%. Distally atherosclerosis was absent in 95.9% of cases.
Conclusions: Our study showed that MDCT is a reliable and noninvasive tool for diagnosing coronary myocardial bridging, since it accurately determines the location, depth, and length of MB. We found the incidence of myocardial bridging in this patient group to be 17.9%, higher than the depiction rate of MB by catheter CAG reported in the literature and in concordance with other studies using MDCT. The most common location of MB was in the LAD. We also observed that most atherosclerotic plaques in the “host” vessel were located at the segment proximal to the tunneled segment there was no evidence of atherosclerosis within any intramuscular segment.
354
Cost-effectiveness of performing coronary computed tomography angiography in patients with mild ischemia by SPECT-MPI
M. Zapparoli1; J. Vitola1; F.R. Farias1; S.S. Zier1; C. Cunha1; J.J. Cerci1; O.J. Kormann1; A. Stier Jr1; O. Franca Neto1; R.J. Cerci1
1Quanta Diagnostico e Terapia, Curitiba, Brazil
Purpose: To determine the cost effectiveness of performing coronary CT angiography (CCTA) as a gatekeeper for invasive angiography (ICA) in patients with suspected coronary artery disease and mild ischemia on SPECT-MPI.
Methods: Data from patients without known coronary artery disease (CAD), with mild ischemia (SSS ranging from 4 to 8) detected on SPECT-MPI and submitted or not to CCTA between 12/2011 and 08/2012, were retrospectively analyzed from Quanta database (Curitiba, Brazil). We modeled two diagnostic scenarios in which patients would be: (1) submitted directly to ICA (U$ 800.00 per procedure) after the abnormal SPECT; (2) submitted to CCTA (U$ 500.00 per procedure), followed by ICA only when obstructive disease was detected. For cost analysis purposes, the CCTA frequencies of normal, non-obstructive (<50% stenosis) and obstructive (≥50% stenosis) CAD results of the subgroup submitted to CCTA were extrapolated to the whole cohort.
Results: During the observation period of 9 months, 5,345 patients were referred for SPECT-MPI. Of these, 1,450 had mild ischemia on SPECT-MPI, but 564 had previous history of CAD. From the remaining 886 patients suitable for analysis, CCTA was performed in only 75 (8.5%). The clinical and SPECT characteristics of the groups submitted or not to CCTA are presented in the Table. There were 36 (48%) normal, 26 (34.7%) non-obstructive and only 13 (18.3%) obstructive results by CCTA. The CCTA first strategy would avoid an unnecessary ICA in 82.7% of patients. Applying the procedures costs in each strategy, the total cost would be U$ 708,800.00 on the direct ICA group and U$ 566,200.00 on the CCTA first strategy, with a net economy of 20.1%.
Conclusion: A CAD diagnostic strategy in which CCTA is applied as a gatekeeper to ICA in patients with mild ischemia by SPECT is very cost-effective, but still remains highly underused in Curitiba, Brazil.
Clinical and SPECT variables by group
Clinical and SPECT variables | CCTA group (N = 75) | Non-CCTA group (N = 811) | P value |
|---|---|---|---|
Age [mean (SD)] | 61.6 (11.8) | 65.1 (12.1) | .02 |
Female (%) | 57.3 | 61.9 | .43 |
Diabetes (%) | 28.0 | 32.5 | .43 |
Hypertension (%) | 64.0 | 69.8 | .29 |
Ejection fraction [mean (SD)] | 63.0 (10.6) | 61.8 (11.4) | .34 |
Summed stress score [mean (SD)] | 4.7 (1.2) | 5.3 (1.5) | .0003 |
355
Integration of single-photon emission computed tomography (SPECT) and cardiac computed tomography (CCT) for the triage of patients with equivocal stenoses in clinical practice
L. Luigi Di Serafino1; G. Toth1; S.A. Pyxaras1; F. De Vroey1; J. Geraedts2; H. Declercq2; P. Vanhoenacker1; B. De Bruyne1; W. Wijns1; C. Van Mieghem1
1OLV Hospital Aalst, Cardiovascular Center, Aalst, Belgium; 2St Blasius Hospital, Dendermonde, Belgium
Purposes: The aim of this study was to evaluate the diagnostic accuracy of sequential CCT and SPECT imaging in the evaluation of patients with CAD and at least one equivocal stenosis detected at CCT, in comparison with invasive coronary angiography (ICA) and FFR.
Methods: All consecutive patients with stable angina and at least one equivocal stenosis (% diameter stenosis between 30% and 70%) detected at CCT (Dual source CT), underwent SPECT followed by ICA and FFR measurement. At CCT, an equivocal stenosis was assessed as being significant (50-70%) by visual estimation. Intravenous (IV) adenosine infusion was used as stressor for SPECT. At quantitative coronary angiography, a lesion was considered significant when the %DS was >50%. FFR was measured for all equivocal stenoses detected by CCT using a 0.014” pressure guide wire system (St Jude Medical Systems). Maximum hyperemia was induced by IV adenosine infusion. An FFR ≤ 0.80 was used as threshold to define a functionally significant stenosis.
Results: A total of 51 patients were prospectively enrolled and 121 stenoses were evaluated. At CCT, 60 stenoses (49%) in 43 patients (84%), were considered anatomically significant. Using SPECT, inducible myocardial ischemia was detected in only 30 patients. At ICA, 45 stenoses (37%), in 29 patients (57%), were found to be anatomically significant. Using FFR, only 36 stenoses (30%), in 28 patients (55%), were determined as being functionally significant: these patients subsequently underwent revascularization. In comparison with ICA, CCT showed high sensitivity (90%) and lower specificity (77%), when assessing anatomical severity of CAD. In comparison with FFR, CCT was suboptimal for determining the functional significance of a stenosis (sensitivity: 89%, specificity: 22%). Combining CCT with SPECT imaging (hybrid imaging), as compared with FFR, did not improve diagnostic accuracy (sensitivity: 64%, specificity: 48%). In addition, hybrid imaging was significantly less sensitive (64% vs 89%, P = .05) as compared with CCT alone. Considering patient management, the FFR result was used as decisive to proceed with revascularization. The noninvasive hybrid approach resulted in appropriate patient triage in 65% of the patients: 17 of the 22 patients who underwent revascularization were correctly identified, 16 of the 29 patients who were treated medically had a normal CCT-SPECT result.
Conclusions: In patients with equivocal stenoses at CCT, the combination with SPECT imaging did not improve diagnostic accuracy to detect ischemia-provoking CAD. This combination of tests did not result in reliable patient management.
356
Pre-operative CT coronary angiography in patients with mitral valve prolapse referred for surgical repair: Comparison of accuracy, radiation dose and cost versus invasive coronary angiography
G. Gianluca Pontone1; D. Andreini1; E. Bertella1; S. Mushtaq1; S. Cortinovis1; A. Baggiano1; A.D. Annoni1; A. Formenti1; G. Ballerini1; M. Pepi1
1University of Milan, Foundation Monzino (IRCCS), Center Cardiology, Department of Cardiology, Milan, Italy
Purpose: To evaluate the accuracy of low dose multidetector computed tomography coronary angiography (MDCT) vs invasive coronary angiography (ICA) in ruling out CAD in patients with mitral valve prolapse and severe mitral regurgitation (MVP) before cardiac surgery and to compare the overall effective radiation dose (ED) and cost of a diagnostic approach in which conventional ICA should be performed only in patients with significant CAD as detected by MDCT.
Materials and Methods: Eighty patients with MVP and without history of CAD were randomized to MDCT (Group 1) or ICA (Group 2) to rule out CAD before surgery. However, ICA was also performed as gold standard reference in Group 1 to test the diagnostic accuracy of MDCT. A diagnostic work-up A in whom all patients underwent low-dose MDCT as initial diagnostic test and those with positive findings were referred for ICA was compared with work-up B in which all patients were referred for ICA according to the standard of care in terms of ED and cost.
Results: The two groups were homogeneous in terms of gender, age and body mass index. The overall feasibility and accuracy in a patient-based model were 99% and 93%, respectively. The overall ED and costs were significantly lower in diagnostic work-up A compared to diagnostic work-up B.
Conclusions: The accuracy of low dose MDCT for ruling out the presence of significant CAD in patients undergoing elective valve surgery for mitral valve prolapse is excellent with a reduction of overall radiation dose exposure and costs.
357
Association of atherosclerosis of the descending thoracic aorta with coronary artery disease on multi-detector row computed tomography in patients with suspected coronary artery disease
C.J. Cornelis Jacobus Roos1; A.J. Witkowska-Grzeslo1; V. Delgado1; M.A. De Graaf1; C.E. Veltman1; J.J. Bax1; A.J. Scholte1
1Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands
Purpose: The association between atherosclerosis in the descending thoracic aorta (DTA) visualized on CTA and CAD has not been extensively explored. Therefore, we assessed the presence, severity and extent of DTA atherosclerosis and evaluated the association of DTA atherosclerosis with CAD in patients with suspected CAD who underwent CTA.
Methods: A total of 345 patients (54 ± 12 years, 54% men) with suspected CAD underwent a non-contrast enhanced scan for calcium scoring and a CTA to evaluate CAD. CTA scans were classified as non-significant CAD or significant CAD, based on <50% or ≥50% luminal stenosis, respectively. The DTA was divided into segments according to the posterior intercostal arteries. Per segment maximal wall thickness was measured and the presence of plaque (≥2 mm wall thickness) was determined. In addition, plaque composition was scored as non-calcified or mixed and mean wall thickness was calculated.
Results: Significant CAD was present in 152 (44%) patients. DTA atherosclerotic plaque was identified in 279 (81%) patients. Differences in DTA atherosclerosis between patients with and without CAD are presented in the table. Multivariate linear regression analysis corrected for age and other risk factors demonstrated independent associations of DTA wall thickness (OR 2.3, 95% CI 1.4-3.8, P = .001) and presence of DTA plaque (OR 6.8, 95% CI 1.4-32.6, P = .017) with significant CAD.
Conclusions: The presence, severity and extent of DTA atherosclerosis were independently related with significant CAD on CTA in patients with suspected CAD.
DTA atherosclerosis
DTA variable | All patients n = 345 | Non-significant CAD n = 193 | Significant CAD n = 152 | P value |
|---|---|---|---|---|
Max wall thickness (mm) | 2.7 ± 1 | 2.3 ± 0.7 | 3.2 ± 1.1 | <.001 |
Atherosclerotic plaque [n (%)] | 279 (81%) | 130 (67%) | 149 (98%) | <.001 |
Mean wall thickness (mm) | 2.4 ± 0.7 | 2.1 ± 0.5 | 2.7 ± 0.7 | <.001 |
358
Cardiac CT and non-invasive electrocardiographic imaging of chronic myocardial infarction arrhythmia substrates
F. Fady Dawoud1; K.H. Schuleri1; R. Beinart1; M. Horacek2; H. Halperin1; A.C. Lardo1
1Johns Hopkins University, Baltimore, United States of America; 2Dalhousie University, Halifax, Canada
Introduction: Chronic myocardial infarction (MI) constitutes a substrate for ventricular tachyarrhythmias (VT) and its delineation is important to facilitate catheter ablation procedures. While MI can be delineated with cardiac CT, electrical propagation can only be identified with electrophysiological techniques. We investigated the feasibility of cardiac CT combined with a novel non-invasive electrical imaging technique (ECGI) to delineate scar and gain insight into VT reentry mechanism.
Methods: MI was induced in three pigs by LAD occlusion. Whole body ECG mapping was performed during native rhythm and VT induction 6 months post MI. Delayed-enhancement CT (DE-CT) was acquired 7.5-minutes post contrast injection. Inverse electrograms were reconstructed according to previously developed methodology utilizing CT-segmented torso- and heart geometries. Regional electrical activation times were computed and Q-wave integral maps were used to estimate scar from inverse electrograms.
Results: Figure 1 shows an example of DE-CT volume-rendered image showing the MI (pink outline, AHA segments 2, 7, 8, 13, 14 in panel A) and Q-wave integral map from ECGI in pig 1 showing scar (values < 0, pink outlined shadowed with black, segments 2, 7, 6, 8, 12, 13, 14 in panel B top) over extending to lateral segments while the inferior/infero-lateral segments show viable tissue (values > 0, green to red, panel B bottom). The reconstructed VT activation map shows early antero-apical activation at the scar border implying an exit site of the reentrant VT. Similar patterns were observed in other animals.
DE-CT and inverse ECGI scar and VT maps
Conclusion: We demonstrated a promising application of CT in combination with ECGI to delineate the location of MI and reconstruct activation times during VT which can greatly guide planning of catheter ablation procedures.
359
Influence of calcium channel blocker usage on results of 123I-mIBG myocardial scintigraphy in heart failure patients: Diagnostic and prognostic implications
A. Arnold Jacobson1
1GE Healthcare, Princeton, United States of America
Background: Previous studies have suggested that calcium (Ca) channel blockers may interfere with stimulation of neuronal cell bodies and may also inhibit release of meta-iodobenzylguanidine (mIBG). The present analysis examined the influence of Ca channel blocker usage on 123I-mIBG imaging results and clinical outcomes during 2 years follow-up of HF subjects in the ADMIRE-HFX study.
Methods: Of the 961 HF subjects in ADMIRE-HFX (LVEF ≤ 35%; 83% NYHA II, 17% NYHA III), 78 (8%) were using Ca channel blockers at the time of 123I-mIBG imaging. Cardiac 123I-mIBG uptake was quantified as the heart/mediastinum ratio (H/M) on early (15 minute) and late (4-hour) anterior planar (p) images, background-corrected washout (WO) rate between the two planar images, and H/M on OSEM-reconstructed SPECT (s) images. Outcomes determined during median 2 years follow-up were cardiac death, and all-cause mortality. Summary statistics were compared using t-tests, while survival was compared using Kaplan Meier analyses and log-rank tests (P < .05 considered significant).
Results: During follow-up, there were 64 cardiac (7%) and 101 total deaths (11%). In the total population, there was no difference in baseline 123I-mIBG parameters between subjects who were and were not using Ca channel blockers (With vs without Ca blockers: Mean Early H/Mp: 1.55 vs 1.57 (P = .38); Mean Late H/Mp: 1.41 vs 1.45 (P = .16); Mean WO Rate: 39.2% vs 37.3% (P = .36); Mean H/Ms: 2.19 vs 2.19 (P = .99)). However, when subjects were categorized as having either reduced (late H/Mp < 1.60) or preserved (late H/Mp ≥ 1.60) myocardial innervation, those using Ca blockers had lower 2 year all-cause mortality rates (With vs without Ca blockers: 8.3% vs 16.8% for late H/Mp < 1.60, 0 vs 3.2% for late H/Mp ≥ 1.60; P = .002) and lower 2 year cardiac mortality rates (With vs without Ca blockers: 6.7% vs 11.5% for late H/Mp < 1.60, 0 vs 3.2% for late H/Mp ≥ 1.60; P = .013).
Conclusions: Although Ca channel blockers had no effect on population-based measures of myocardial 123I-mIBG uptake, HF subjects using these medications had lower cardiac and all-cause mortality rates during 2-year follow-up. In light of the higher mortality rate among subjects with reduced myocardial innervation, the potential value of addition of Ca channel blockers to the therapeutic regimen of such subjects may warrant further investigation.
360
Epicardial fat volume on cardiac computed tomography as a marker of high risk patients with subclinical coronary artery disease
I. Vassiliadis1; E. Despotopoulos2; O. Kaitozis3; C. Tekedis4; S. Koropouli4
1Euroclinic Hospital, Institute Euromedica-Encephalos, Athens, Greece; 2Institute Euromedica-Encephalos, 251 Hellenic Airforce Hospital, Athens, Greece; 3Institute Euromedica-Encephalos, Athens, Greece; 4251 Hellenic Airforce Hospital, Athens, Greece
Epicardial fat volume (EFV) measurement, using cardiac computed tomography (CT) has been shown to be a reliable marker of coronary atherosclerosis, and greater EFV is associated with coronary artery disease (CAD). However, little is known on the relation between the amount of EAT and the severity of coronary atherosclerosis in identifying high risk patients with subclinical CAD.
Purpose: The aim of this study was to investigate the relationship between EFV and severity of coronary artery disease measured by CT.
Methods: We retrospectively analyzed data of 600 individuals who were referred for evaluation of CAD with cardiac CT from 2007 to 2012. Subjects who had history of primary coronary intervention or coronary artery by-pass graft were excluded. Thickness of epicardial adipose tissue (EAT cm3), was measured on noncontrast multiplanar reformat images with parasternal short axis view at basal, mid-ventricular and apical levels and horizontal long axis view as the sum of the EAT areas with 2 mm thick from the whole heart. CAD severity was determined by, the presence of significant coronary stenosis (>50% luminal narrowing of at least one major coronary artery), high coronary artery calcium score (CACS > 100) and plaque characteristics (any plaque causing significant stenosis and/or vulnerable plaques), in the subsequent CT angiography.
Results: Ιn the finally studied population of 434 individuals, 155 (35.7%) had atherosclerotic coronary artery disease and 279 (64.3%) of them were normal. Overall, 75.2% were male; mean age was 58 ± 18 years with a mean EAT 155.54 cm3. Patients with coronary atherosclerosis had significantly greater mean EAT compared to normals (P = .011). Linear regression analysis revealed that the incidence of significant stenosis, atherosclerotic plaque and high calcium score increased with EFV (P < .01).
Conclusion: EFV measured by 64-slice CT scanning, was closely associated with significant CAD and its measurement might be used in addition to CT angiography as an early indicator of increased risk of coronary atherosclerosis.
361
Incidence of coronary artery disease at CT coronary angiography in patients with hypertrophic cardiomyopathy presenting with chest pain or angina-equivalent symptoms
M. Shariat1; A.M. Crean1
1University Health Network, Toronto, Canada
Incidence of coronary artery disease at CT coronary angiography in patients with hypertrophic cardiomyopathy presenting with chest pain or angina-equivalent symptoms.
Background: Angina is a frequent symptom in patients with hypertrophic cardiomyopathy (HCM). Many of these patients will present with exertional chest pain or angina-equivalent symptoms, such as effort-related breathlessness, which appear indistinguishable from symptoms in the arteriopathic population.
CT coronary angiography (CTCA) is often regarded as the non-invasive test of choice to rule out significant coronary artery disease in the low and medium risk patient group category—into which many of these patients fall.
Objectives: To describe the prevalence of severe coronary artery disease in patients with HCM referred to CTCA for investigation of anginal symptoms.
Patients and Methods: We retrospectively reviewed CTCA studies of 93 patients who were known to have HCM or in whom the diagnosis was unequivocally present based on the CTCA images.
CTCA studies were done on 320 slice CT scanner. Volumetric data acquisition was done at 0.5 mm slice thickness and 0.25 mm gap. The coronary arteries were carefully evaluated and any luminal narrowing more than 70% was labeled ‘severe’. Any narrowing less than 50% was labeled mild and between 50% and 70% was called moderate. Cases were reviewed by two blinded observers. Disagreements were arbitrated by a third reader.
Results: The indications for the CTCA included chest pain in 87 patients (93.5%) and shortness of breath in 6 patients (6.5%). Out of 93 patients, 14 (15.1%) had apical HCM, 13 (14%) had concentric hypertrophy and 66 (70.9%) had asymmetric septal hypertrophy.
54 patients (58%) had completely normal coronary arteries, 31 (33.3%) had mild disease and 6 (6.5%) had moderate disease. Only 2 patients (2.2%) had severe disease in at least one segment of the coronary arteries. The left anterior descending artery was the most commonly involved vessel. It showed mild disease in 28 patients, moderate disease in five patients and severe disease in 1 patient. Myocardial bridging was present in 34 patients (36.6%) and it involved the LAD in 31 patients (33.3%).
Conclusion: Although angina is a common symptom in patients with HCM, in our study, only 2.2% of these symptomatic patients had severe coronary artery disease on CTCA. Coronary CTA may be useful for preventing inappropriate treatment of HCM patients with anti-anginal and lipid lowering therapies.
362
A quantitative computed tomography angiography (QCT) derived risk score for automatic risk stratification of patients with suspected coronary artery disease (CAD): Preliminary results
M.A. Michiel De Graaf1; A. Broersen2; P.H. Kitslaar2; J. Dijkstra2; B.P. Lelieveldt2; J.H. Reiber2; J.J. Bax1; A.J. Scholte1
1Leiden University Medical Center, Department of Cardiology, Leiden, Netherlands; 2Leiden University Medical Center, Department of Radiology, Division of Image Processing, Leiden, Netherlands
Purpose: Computed tomography coronary angiography (CTA) has important prognostic value. Additionally, QCT provides a more detailed, accurate assessment of CAD on CTA. Potentially, a score incorporating all quantitative stenosis parameters allows for accurate risk stratification. Therefore, the purpose of this study was to determine if a detailed automatic assessment of coronary atherosclerosis using QCT combined into a single risk score allows automatic risk stratification of patients.
Methods: In 300 consecutive patients QCT was performed. First, using an automatic tree labeling algorithm, segments were labeled according to the AHA 17-segment model. Second, vessel wall and lumen were automatically segmented. Finally, an automatic lesion detection algorithm identified all lesions in the coronary tree. Using QCT, patients risk was calculated based on plaque extent, severity, composition and location on a segment basis and integrated into a single score (0-42). During follow-up, the composite endpoint of all cause mortality, PCI and non-fatal infarction was recorded.
Results: At present, results are available for 65 of the 300 patients. Event rate was 12%. In all eight patients with events an automatic, quantitative assessed significant stenosis was present. Furthermore, in these patients the median risk score was higher compared to patients without events (median 8.6 (IQR 4.7-12.8) vs median 0 (IQR 0-4.8) respectively) (P = .007).
Conclusion: Integration of detailed plaque characteristics on QCT into a single risk score could provide accurate risk stratification.
363
Evaluation of nonculprit vulnerable plaque with 64-Slice multidetector computed tomography in comparison to intravascular ultrasound
K. Kunihiko Makino1; T. Takagi2; Y. Tajiri2; J. Yamaguchi2; Y. Kusunose2; T. Lee2; M. Nakamura1; K. Sugi1
1Toho University, Ohashi Medical Center, Department of Cardiovascular Medicine, Tokyo, Japan; 2Toshiba Hospital, Tokyo, Japan
Background: Coronary atherosclerotic plaque composition plays an important role in the progression of future coronary event. Especially, coronary atherosclerotic plaque with intravascular ultrasound (IVUS) attenuation might be related to the deterioration of coronary flow and worse long-term outcomes after coronary artery disease (CAD) and interventions. Noninvasively characterizing vulnerable plaque is an important method in risk stratification and following the progression of coronary plaques. Multidetector computed tomography (MDCT) is most reliable method to evaluate coronary plaque composition. The aim of this study is to evaluate possibility of 64-slice MDCT to detect nonculprit IVUS attenuated plaque and identification of atherosclerotic plaque with future coronary events.
Methods and Results: Fifty-seven patients (15 with ACS, 42 with stable CAD) and 240 plaques were evaluated by 64-slice MDCT. One hundred sixty-eight nonculprit plaques of the 240 plaques were evaluated by IVUS. Of the 168 plaques, 59 (47 calcified and 12 mixed plaques) were excluded from the present analysis. The remaining 109 plaques (40 soft plaques, 30 attenuated plaques, 39 fibrous plaques) represent the present analysis. In the attenuated plaques, CT density had significantly higher than soft plaques (70 ± 9 HU vs 40 ± 6 HU; P < .001) and lower than fibrous plaques (70 ± 9 HU vs 94 ± 6 HU; P < .001). Spotty calcification with lipid pool was more common (37% vs 13%; P < .05) in the attenuated plaques compared to the soft plaques. The attenuated plaques were present significantly more frequently in patients with lower high-density lipoprotein cholesterol levels than those without attenuated plaques (40 ± 9 vs 48 ± 9 mg/dL; P < .001, 40 ± 9 vs 47 ± 11 mg/dL; P < .005).
Conclusions: Nonculprit plaque analysis by MDCT would be a useful method for predicting atherosclerotic plaque with high risk of future coronary events.
364
Prevalence and characteristics of coronary artery anomalies in an adult population undergoing multidetector-row computed tomography for the evaluation of coronary artery disease
C. Christos Graidis1; T. Christoforidou1; D. Dimitriadis1; V. Karasavvidis1; K. Gourgiotis1; M. Giannadaki1; I. Neroladakis1; G. Karakostas1; N. Karadimitras1; G. Dimitriadis1
1Euromedica-Blue Cross Hospital, Thessaloniki, Greece
Background: Congenital coronary anomalies are uncommon with an incidence ranging from 0.17% in autopsy cases to 1.2% in angiographically evaluated cases. The recent development of ECG-gated multi-detector row computed tomography (MDCT) coronary angiography allows accurate and noninvasive depiction of coronary artery anomalies.
Purpose: The aim of this study was to evaluate the prevalence of anomalous origin, course and termination of coronary arteries in consecutive symptomatic patients, who underwent cardiac 64- slice MDCT coronary angiography.
Methods-Results: This retrospective study included 2572 patients who underwent coronary 64-slice MDCT coronary angiography from January 2008 to March 2012. Of the 2572 patients, 60 (2.33%) were diagnosed with coronary artery anomalies (CAAs), with a mean age of 53.6 ± 11.8 years. High take-off of the RCA was seen in 16 patients (0.62%), of the left main coronary artery (LMCA) in 2 patients (0.08%) and both of them in 2 patients (0.08%). Separate origin of the LAD and Cx from Left Sinus of Valsalva (LSV) was found in 15 patients (an incidence of 0.58%). In 9 patients (0.35%) the RCA arose from the opposite sinus of Valsalva with a separate ostium. In 6 patients (0.23%) an abnormal origin of LCX from the right sinus of Valsalva (RSV) was found. A single coronary artery was seen in 3 patients (0.12%). In 2 patients (0.08%) left coronary trunk was found to originate from the RSV with separate ostium from the RCA. LCA from the pulmonary artery was seen in one patient (0.04%). A coronary artery fistula was detected in 4 patients (0.15%).
Conclusion: The results of this study support the use MDCT coronary angiography as a safe and effective noninvasive imaging modality for defining CAAs in an appropriate clinical setting, providing detailed three-dimensional anatomic information that may be difficult to obtain with invasive angiography.
365
Association of cardiac calcification and coronary artery disease detected by 64-multislice detector computed tomography coronary angiography in a juvenile Albanian population
N.X.H. Xhabija1; I.A. Allajbeu1; A.D. Duni1; M.H. Heba2; E.P. Petrela3
1American Hospital, Balkan Alliance Group, Tirana, Albania; 2University Hospital “Nene Teresa”, Tirana, Albania; 3Medicine Faculty, Department of Biostatistics, Tirana, Albania
Aortic valve sclerocalcification (AVSC) and mitral annulus calcification (MAC) is common with aging and have been considered as a manifestation of generalized atherosclerosis in elderly population. However, the significance of these calcifications in younger populations has not been previously determined. AVSC and MAC can be easily detected by transthoracic echocardiography (TTE). Recently, Coronary CT angiography (CTA) has become widely available in detecting occult coronary atherosclerosis disease (CAD).
Purpose: We hypothesized that in subjects age < 60 years, AVSC and MAC would be associated with a higher prevalence of positive CCTA.
Methods: In a prospective, cohort study, we identified patients younger that 60 years, who all underwent both CCTA and TTE for various clinical indications. We utilized positive CTA as a surrogate for angiographically CAD. All known risk factors for atherosclerosis including age, gender, hypertension, smoking, dyslipidemia, diabetes and family history were also investigated.
Results: The mean age of our study population included 155 patients (109 men and 46 women) was 50 ± 4.2 years. When the cohort was divided by the presence of atherosclerosis, we found that 81 patients had CAD and 74 had normal coronary arteries (75.8% vs 24.2%). Of the 81 patients with CAD, 69 had AVSC compared with 22 in the non- CAD group (P < .001).Hypertension and MAC were found significantly more prevalent in the CAD group than in non-CAD group, respectively (61% vs 39%, with P = .006 and 70.4 vs 29.6, with P = 0,042). Multivariate analysis identified only AVSC and age as independent predictors of coronary atherosclerosis. The sensitivity, specificity, positive and negative predictive values for AVSC in diagnosing CAD were 72.2.1%, 60%, 81% and 50%, respectively. Although AVS is highly associated with CAD, it has only modest sensitivity and specificity (72% and 60%), respectively. Despite a low negative predictive value (50%), it has a high positive predictive value (81%) for the presence of significant CAD.
Conclusion: Our study demonstrates that aortic valve sclerocalcification and coronary atherosclerosis are significantly associated with each-other, even in a juvenile population. The presence of aortal sclerocalcifications may help in predicting CAD and should be added to conventional risk factors.
366
The correlation between the major adverse cardiac events and coronary plaque characteristics
J. Jingjing Gai1; L.Y. Gai1; H.Y. Qiao1; S.Y. Zhang1; Z.W. Guan2; L. Yang3; Y.D. Chen1
1China PLA General Hospital, Department of Cardiology, Beijing, People’s Republic of China; 2China PLA General Hospital, Department of Nuclear Medicine, Beijing, People’s Republic of China; 3China PLA General Hospital, Department of Radiology, Beijing, People’s Republic of China
Objective: Major adverse cardiac events (MACE) often occur suddenly resulting in high mortality and morbidity. Analyzing the characteristics of coronary plaque by Coronary Computed Tomography Angiography (CCTA) may help forecasting the MACE.
Methods: The patients who underwent CCTA from Jan 2008 to Feb 2010 were consecutively enrolled in the study. The hospital data base was screened for patients who later developed acute ST elevated myocardial infarction (STEMI) or non ST elevated acute myocardial infarction (NSTEMI) or cardiac death. The definition of the plaque score as follow: 1. Minor plaque, 1 point; 2. Moderate plaque, 2 points; 3. Severe localized stenosis, 3 points; 4. The erosive plaque, 5 points; 5. Calcification, 1 point; 6. DES, 5 points; 7. Plaque with positive remodeling, 3 points; 8. Complete occlusion, 3 points; 9. Diffused moderate lesions, 2 points. Two-way analysis of variance was performed.
Results: A total of 8557 consecutive cases of CCTA were performed in the institution. Among them 1055 were hospitalized during which 25 patients developed MACE, including 6 cases of deaths, 2 cases of heart failure, 11 cases of STEMI and 6 cases of NSTEMI. One way ANOVA analysis showed that advanced age, AF, past history of PCI, low Hb, tachycardia and high Grace Score contributed to death and heart failure. The differences were significant, P < .05. The plaque characteristics of the plaques were analyzed. The patients who had erosion plaques and high degree localized lesions had high likelihood of developing MACE, 95% CI: 0.6472-1.538, P = .000. The death and heart failure had the highest plaque score, 95% CI: 0.4882-1.379, P = .000.
Conclusion: The plaque characteristics identify high risk patients.
368
Comparation of agatston coronary artery calcium score using contrast-enhanced CT coronary angiography, framingham score and multiple blood biomarkers as predictors of coronary artery stenosis
A. Ana Lanca1; Z. Madzar1; D. Javoran1; V. Bursic1; V. Pehar-Pejcinovic1; V. Persic1; M. Boban1
1Clinical Hospital Thalassotherapia Opatija, Opatija, Croatia
Purpose: To analyze efficiency of Agatston score, Framingham risk score, and multiple blood biomarkers as predictors of coronary artery stenosis in patients with nonspecific chest pain.
Methods: The study included 161 patients (mean age 63 ± 7.7, 70% of females) with atypical chest pain and unknown coronary heart disease, who underwent coronary multi detector computed tomography coronarography and obtained Agatston score. Scanning was done with the Definition Flash 2 × 128 slice CT scanner by dual source technique, and the mean received amount radiation was 4.6 ± 1.2 mSv. The mean heart rate during scanning was 68 ± 9.3/minute, and patients body mass index (BMI) 27.4 ± 4.3. Patients with known cardiovascular risk factors, including hypertension (77%), diabetes mellitus (25%), dyslipidemia (77%) or smoking (28%) and various Framingham risk score values (0.6-59.9, mean 22.3 ± 12.7) were considered. Blood biomarkers included glucose, C-reactive protein (CRP), total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, creatinine, eGFR and uric acid. Participants were divided in two groups, based on coronary artery stenosis greater than 50% (40 of participants), and the other with stenosis smaller than 50% (121 of participants). Frequency of demographic and clinical characteries, blood biomarkers and risk factors were tested between the groups by using Chi square test and Student T test as appropriate. To test for factors associated with predicting coronary artery stenosis, Likelihood Ratio, and Receiver Operating Characteristics (ROC) analyses were used. Relative Risk was calculated in context of developing coronary artery stenosis greater than 50% in participants with Agatston score above 100.
Results: The most accurate predictor of coronary artery stenosis greater then 50% was Agatstone score (AUC 0.99, P < .0001). Agatstone score higher than 100, had relative risk for developing of coronary stenosis over 50%, 17 times higher than values under 100. CRP (AUC 0.76), glucose (AUC 0.59), uric acid (AUC 0.61) and Framingham risk score (AUC 0.57) had high sensitivity but low specificity for coronary artery stenosis.
Conclusion: Among all considered demographic and clinical characteristics, blood biomarkers and risk factors, Agatstone score was the most accurate predictor for developing of coronary artery stenosis.
369
A diagnostic/therapeutic proposed approach to the myocardial bridge
G. Scrima1; G. Giovanni Bertuccio2
1UOA Cardiologia, Moncalieri, Italy; 2UOA Medicina Nucleare, Moncalieri, Italy
Myocardial “bridge” is the most frequent congenital coronary anomaly (about 1.5% of patients already undergone to coronary angiography).
Prognosis is quite variable: a negative prognosis could be related to the so-called type III “bridges” (deep intra-myocardial course; > 10 mm length; > 75% systolic “milking”) with myocardial ischemia and major ventricular arrhythmias (0,6% among Patients pertaining to our department).
We have considered consecutively all symptomatic patients with type III myocardial “bridge” afferent to our department from 01/’08 to 01/’11. All of them were submitted to coronary angiography.
We selected 22 patients out of them, 13 with stable angina symptoms (angina CCS II-III): 11/13 with exercise test positive for ischemia; 2/13 had a positive SPECT with mild/moderate amounts of anterior ischemia in the absence of specific medical therapy.
The remaining 9 Patients exhibited a clinical SCA (2 antero-lateral STEMI; 7 anterior/UA NSTEMI) related to the myocardial “bridge” on IVA.
All Patients with stable angina symptoms were treated with beta-blockers, followed by myocardial SPECT resulted negative for inducible ischemia in the same site. All of them were asymptomatic to the clinical follow-up (22 months).
All Patients, with “bridge-related” SCA, were treated with PTCA and medicated stent (DES). This procedure in 8/9 Patients was guided by intracoronary ultrasound (IVUS) that allowed the diameter’s optimization and the length of the implanted stent (in-flow and out-flow of the stent at least 3 mm before and after the intra-myocardial stretch), as well its final relaxation.
Only the patient submitted to PTCA without IVUS was hospitalized again for a SCA recurrence 7 months after first procedure, secondary to the re-stenosis of the medicated stent. The IVUS control demonstrated an evident under-sizing of the implanted stent compared to the native vessel; it was solved with a simply re-PTCA using an adequate diameter NC balloon.
Finally we could affirm that: Patients with myocardial “bridge” on IVA with stable angina symptoms have indication to medical therapy with Beta-blockers or, if not indicated, Ca-antagonist. They should be subjected to a myocardial SPECT with full therapy to evaluate the residual functional significance of the “bridge” during medical therapy. PTCA is useful with persisting ischemia despite medical treatment.
In SCA “bridge-related”, IVUS guided percutaneous treatment with medicated stent appears to be safe and effective because it isn’t related to late thrombotic events (no patient in our casistic) and it’s associated with a very low restenosis rate.
370
Additional value of myocardial perfusion imaging after coronary calcium score in low to intermediate risk of coronary artery disease patients
P. Smanio1; P. Filippi1; M.A. Oliveira1; L. Machado1; P. Cestari1
1Grupo Fleury, Sao Paulo, Brazil
Background: Cardiovascular disease is the leading cause of mortality in the world. An early investigation and management can improve survival. The non-invasive diagnostic methods in the evaluation of coronary artery disease have been widely used even those that submit patients (p) to radiation. If the association of myocardial perfusion imaging (MPI) and coronary calcium score (CAC) is important in the management of low to intermediate risk of coronary artery disease (CAD) patients (p) is not yet well established.
Purpose: The aim of this study was to evaluate if the information of MPI add value to CAC in a low to intermediate risk of CAD group of patients.
Methods: It was analyzed 212 p that performed CAC and MPI between 01 and 07 of 2012 without any cardiac procedure in between. From the total, 166 p (78.3%) were male, mean age of 47 years, 49 p (23.1%) with diabetes, 122 p (57.5%) with dyslipidemia, 48 p (22.6%) with hypertension, and none p had known CAD or cardiac symptoms. The CAC and the sestamibi-Tc-99m MPI were performed by standard techniques. CAC were divided in zero (101 p), <100 (27 p), 100-400 (44 p) and >400 (40 p). MPI was considered normal if no perfusion defect and suggestive of ischemia if reversible perfusion defect after stress phase. Statistical analysis was performed by Fisher exact test, being considered significant P values ≤ 0.05.
Results: In the group of CAC zero 2 p (1.9%) had presented ischemia on MPI. In the other groups with CAC < 100, CAC 100-400 and CAC > 400, 1 p (3.7%), 6 p (13.6%) and 14 p (35%) had presented ischemia on MPI, respectively (P ≤ 0.05). The three patients who presented ischemia on MPI and had CAC zero or <100 had suggestive of soft plaque on coronary tomography. Male gender and presence of diabetes were associated with ischemia in the group of patients with CAC 100-400 (P < 0.05). In the group with CAC > 400 only diabetes was associated with presence of ischemia on the MPI (P < 0.05).
Conclusion: The obtained results may suggested that MPI can add diagnostic information to CAC in a low to intermediate risk of CAD group of patients because of the detection of ischemia in p with soft plaques.
371
Calcified coronary arteries in patients with giant coronary artery aneurysms caused by Kawasaki disease
K. Kenji Suda1; Y. Kudo1; H. Yoshimoto1; M. Iemura1; T. Matsuishi1
1Kurume University School of Medicine, Kurume, Japan
Aim: To characterize coronary artery calcification in patients with giant coronary aneurysms (GAA) caused by Kawasaki disease (KD) using multi-detector x-ray computed tomography (MDCT).
Methods: Subjects were 25 pediatric and young adult patients (19 male and 6 female) with history of KD who had GAA with >8.0 mm of coronary artery diameter confirmed by coronary angiography (CAG). Using MDCT, calcification of the coronary arteries was identified and classified according to the degree of circumferential calcification; Type A, <90°; B 90–180°; C, 180-359°; D, 360°; E, luminal occlusion and internal lumen was evaluated at these calcified segments.
Results: Patient’s age at onset and at study were 2.6 ± 2.8 and 23.5 ± 7.1 (10.8-40.4) years old, with median of 20.8 (9.8-40.1) years after the onset. In these 25 patients, 11 (44%) underwent either catheter or surgical interventions for coronary stenosis.
On MDCT, all 25 patients showed calcification of the coronary arteries in total of 47 segments (1.9, range 1-4 segments for each patient). In these 47 segments, GAA presented in 36 (77%) segments, small to moderate aneurysms with diameter <8.0 mm in 11 (23%). Calcification was located at #1 in 15, #2 in 5, #3 in 5, #5 in 5, #6 in 12, and #11 in 15 patients. Degree of calcification was calcified as Type A, 28%; B, 6%; C, 17%; D, 34%; E, 15%. Among 29 segments where calcification presented with patent coronary lumen, we could evaluate the degree of stenosis in 18 of 19 (95%) segments of Type A, B, and C, but it was possible only 3 of 10 (30%) segments of Type D with complete circumferential calcification.
Conclusions: All patients with GAA after KD showed calcification at more than 10 years after the onset at proximal coronary segments, even at segments with small to moderate coronary aneurysms. Complete circumferential calcification present in one third of segments and preclude accurate evaluation of the internal lumen with current setting of the MDCT, hence other modalities including CAG or cardiac magnetic resonance imaging must be the choice of diagnostic test in these patients.
373
Visualization of coronary sinus and left circumflex coronary artery in computed tomography before percutaneous mitral annuloplasty
A. Mlynarska1; R. Mlynarski2; M. Sosnowski1
1Medical University of Silesia, Katowice, Poland; 2Upper Silesian Cardiology Center, Katowice, Poland
Multi-slice computed tomography (MSCT) offers possibility to visualize the relations between left circumflex artery (LCx) and coronary sinus (CS) before percutaneous mitral annuloplasty (PMA) to exclude patients with potentially dangerous relations LCx/CS. There are no data available showing quality of visualization both vessels in MSCT.
Methods: MSCT (Aquilion64) in 196 pts. (109 M; aged 56 ± 11) with suspected CAD was performed using retrospective scan with ECG-gating. In each case 3D VR and 2D MPR reconstructions were created (0.5 mm). A subjective assessment of the quality of visualization to find the optimal phases of visualization for LCx, CS and both vessels together (relations) was used. The quality of visualization was graded by 2 experts on 6-points scale: 0 = lack of vessel; 1 = image not diagnostic; 5 = smoothly bordered vascular structure. Independent 2 mm reconstructions optimized for the LCx (diastolic 70-80-90% RR) and CS (systolic 30-40-50% RR) were also performed.
Results: In parallel visualization of LCx and CS optimal image quality (score 5 and 4) was obtained in diastolic phases (70-80%)—72 cases (36.7%). Exact scoring for independent visualization in optimal phases is presented in the table below (n; %). Optimal score was achieved in 85 cases (43.4%) for LCx and in 133 cases (67.9%) for CS. Not diagnostic images (score 1) was obtained in 7 (3.6%) cases (LCx: 2; 1.0% CS: 5; 2.5%).
Conclusions: Quality of parallel as well as independent visualization of LCx and CS confirm potential role of MSCT before PMA procedures. Parallel visualization should be performed in diastolic phases as an addition for independent visualization.
Quality of visualization
Score 5 | Score 4 | Score 3 | Score 2 | Score 1 | |
|---|---|---|---|---|---|
Quality of visualization LCx | |||||
Phase 70% | 17; 9.7% | 12; 6.8% | 10; 5.7% | 1; 0.6% | 0 |
Phase 80% | 25; 14.2% | 23; 13.1% | 7; 3.8% | 7; 3.8% | 1; 0.6% |
Phase 90% | 5; 2.8% | 3; 1.7% | 2; 1.1% | 0 | 1; 0.6% |
Quality of visualization CS | |||||
Phase 30% | 19; 10.8% | 9; 5.1% | 2; 1.1% | 3; 1.7% | 3; 1.7% |
Phase 40% | 61; 34.6% | 31; 17.6% | 18; 10.2% | 6; 3.4% | 2; 1.1% |
Phase 50% | 8; 4.5% | 5; 2.8% | 9; 5.1% | 1; 1.7% | 0 |
374
A new algorithm for image post-processing to fulfill percutaneous mitral annuloplasty requirements image preparation
R. Mlynarski1; A. Mlynarska2; M. Sosnowski3
1Upper-Silesian Cardiology Center, Katowice, Poland; 2Medical University of Silesia, Katowice, Poland; 3Medical University of Slesia, Katowice, Poland
Cardiac imaging is almost mandatory in techniques like percutaneous mitral annuloplasty (PMA). During PMA the relationship between coronary sinus (CS) and circumflex artery (Cx) in relations to mitral valve (MV) is of special importance. In such circumstances, a new image reconstruction algorithm might be potentially useful.
Methods: In 46 pts (24 M) a 64 slice computed tomography (Aquilion 64) was performed. Pts with critical changes in LCx were excluded. A scan with ECG-gating was performed using: slice 0.5 mm, helical pitch 12.8 and tube voltage 135 kV (380 mA). 100 ml of non-ionic contrast agent at a rate of 4.5 mL/second was given. In each case 3D VR and 2D MPR reconstructions were created (Vitrea 2). In all pts various visualization modes were tested (MPR measurements and visualizations) to create optimal visualization LCx/CS/MV, defined as a consensus between 2 experienced observers to fulfill PMA requirements.
Results: The following stages in post-processing were recognized as optimal: 3DVR visualization of lateral view of the heart (Figure A); 3x (±10°) virtual cutting of the of the heart (Figure B); digital analysis (own project—Figure C) of the relations LCx/CS/MV. Examples of image preparation are presented on the figures below. Presented method was applicable in all patients. Selected 2D measurements vessels of interest (Figure C) were as follow: LCx diameter 3.7 ± 0.7 mm, CS diameter 4.9 ± 1.5 mm, LCx-MVd diameter 44.5 ± 7.9 mm, and CS-MVd diameter 42.8 ± 6.6 mm. In 26 pts (56.5%) the LCx run closer to the MV—it potentially cause problems (LCx occlusion) after PMA device implantation.
Conclusions: Presented method may be useful for visualization of LCx/CS/MV in cardiac CT in patients before PMA, however applicability of this method requires verification in further clinical studies.
Scheme of CT image post-processing
375
Usefulness of computed tomography coronary angiography in screening patients in the presence of atypical chest pain and risk factors for coronary disease
R. Moran1; O. Rana1; R. Patel1; R. Swallow1; J. Kingston1; T. Levy1
1Royal Bournemouth Hospital, Bournemouth, United Kingdom
Purpose: Assessment of patients with chest pain and risk factors for coronary artery disease (CAD) in the presence of atypical symptoms can be difficult. Such patients often have equivocal exercise tolerance tests or cannot perform one. Consequently they undergo quantitative coronary angiography to exclude significant CAD, with normal results in up to 25%. Non-invasive imaging modalities such as computed tomography coronary angiography (CTCA) have emerged as alternatives. We performed a retrospective review to assess the hypothesis that CTCA is diagnostically useful in this cohort.
Methods: We examined the referral pathway of 168 consecutive patients (58.4 ± 11.3 years) over 14 months who had been referred to 3 cardiologists for possible CAD. All had atypical chest pain with co-existing risk factors (see table) and either had an equivocal exercise tolerance test or were unable to perform one. The cohort had an intermediate pre-test probability of CAD (52.1% ± 26.4) derived from the United Kingdom national guidelines. All patients underwent CTCA (Aquilion 1 Toshiba, Japan) and proceeded to invasive coronary angiography only if CTCA showed significant CAD (defined as at least one moderate lesion, >50% stenosis).
Results: Of 168 patients, 123 (73.2%) were normal (63, 37.5%) or had non-significant CAD (60, 35.7%) based on CTCA. The remaining 45 patients (26.8%) underwent quantitative coronary angiography, revealing severe CAD (>70% stenosis) in only 13 patients (7.7%). All 13 had been correctly identified by CTCA. Moderate CAD (50-70% stenosis) was seen in the other 32 (19%), CTCA being concordant with this in 28 patients (88%). CTCA overestimated CAD severity in the other 4 (12%).
Conclusions: Our data suggest CTCA is an alternative to quantitative coronary angiography in screening patients with atypical chest pain and equivocal exercise tolerance tests, despite the presence of risk factors for CAD. Risk scores appear to overestimate the true incidence of significant CAD.
Frequency of CAD risk factors (%)
Smoking history | 42 |
Family history | 42 |
Hyperlipidaemia | 37 |
Hypertension | 36 |
Diabetes mellitus | 13 |
376
Cardiac CT angiography in patients with inconclusive functional stress fest, a follow up clinical study
M.J. Moncy Jacob Oommen1; L. Nazar1
1Division of Cardiology, RIPAS Hospital, Brunei, BANDER SERI BEGAWAN, Brunei Darussalam
Introduction: Patients with inconclusive stress tests and suspected CAD often present a diagnostic challenge in a non interventional cardiac centre. In deed the yield of invasive CAG in this group of patients is not significant. Coronary CTA in patients with equivocal stress test is considered as an appropriate indication.
Objectives: We attempted to determine the clinical events of the patients who had the inconclusive stress tests and CTA, tried to classify these a patients based on the risk factors, severity of CAD by CTA and tried to find the significance of the risk factors and CTA results with the clinical events during this period.
Methods: We studied 175 patients who had suspected CAD and inconclusive stress tests done from April 2007 to December 2009. All these patients had 64 slice cardiac CTA. Patients are classified based on age, sex risk profile, CCS and CTA results of the CAD severity. Patients are reviewed for the cardiac events in the followup clinic. The primary outcome of the study was all cause mortality, cardiac admissions for ACS or for CAG and PCI. However only 139 patients were followed up in the clinic and by telephonic interview till date.
Results: 43% of the patients were in the age group 50 to 69, 53% were females, 69% has hypertension 44% hyperlidaemia. 40% had atypical chest pain, 70% had CCS less than 100. CTA results showed no CAD in 54% patients. Follow up of these patients with significant CAD once in six months till date showed 69% of these patients had no cardiac events, there was one death (0.7%, 8 (5.6%) admissions for ACS, 34 (24%) patients had CAG and PCI.
Conclusion: Among patients with inconclusive stress tests, a significant number did not show any obstructive CAD by CTA. During the follow up study, clinical events are higher in patients with increasing severity of CAD by CTA. This clinical approach based on CTA is useful for short term prognostic assessment in this group of patients especially in a non interventional cardiac centre.
378
Assessment of functional severity of borderline coronary artery lesions using noninvasive computed fractional flow reserve
L. Velicki1; N. Cemerlic-Adjic1; R. Jung1; N. Tomic1; O. Adjic1; D. Nikolic2; I. Saveljic2; D. Milasinovic2; N. Filipovic2
1Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia; 2University of Kragujevac, Kragujevac, Serbia
Purpose: Fractional flow reserve (FFR) is an easily obtained index of the physiologic significance of coronary stenosis that can optimize treatment strategy. The purpose of this work was to compare diagnostic performance of noninvasive computed FFR (FFRct) with standard invasive FFR angiogram patient data and to assess the impact of FFRct on diagnostic improvement in borderline coronary lesions.
Methods: Three patients admitted for coronary artery disease underwent coronary CT angiography (Siemens 256-slice SOMATOM Definition CT scanner) and cardiac catheterization with FFR assessment. Internally designed software was used for computer simulation of FFR based on the coronary CT angiogram. The 3D blood flow was described by the Navier-Stokes equations, in conjunction with the continuity equation. A parabolic flow waveform was applied at the location of aortic root, while outlet boundary conditions were configured to an inverse resistance of the corresponding diameter.
Results: Coronary CT angiography discovered that two patients had single vessel CAD with significant stenosis (>50%) observed on ACD and LAD respectively, and one patient had triple vessel CAD. There was no difference between the FFR and FFRct values (P > .22). Coronary CT angiogram designated 2 (66%) lesions as significant and after performing FFRct none of these lesions proved to be hemodynamically significant. Coronary CT angiogram tended to overestimate the degree of stenosis but with no statistical difference compared to coronary angiography (P = .75).
Conclusions: We found a solid correlation between standard FFR and FFRct results. Computer simulation may offer distinct advantage due to non-invasive nature of the analysis, and as such may prove to be of particular benefit when assessing borderline cardiac patients.
379
Presence of stenosis in the left circumflex artery influence the anatomy of coronary sinus: Lesson from cardiac CT
R. Mlynarski1; A. Mlynarska2; M. Sosnowski2
1Upper-Silesian Cardiology Center, Katowice, Poland; 2Medical University of Silesia, Katowice, Poland
Assessment of coronary vessels surrounding left ventricle in the atrioventricular sulcus is an important step before percutaneous mitral annuloplasty (PMA). There are no research evidencing whether and how the presence of flow-limiting stenosis in the left circumflex artery (LCx) influence the venous circulation of the heart.
Methods: In 66 consecutive patients (41 M, aged 61.7 ± 10.4), a 64-slice CT (Aquilion 64) was performed due to a CAD suspicion. Pts were divided into two groups according to the presence of stenosis in LCx: 38 pts with LCx stenosis (stenosis) and 28 pts without changes in LCx (control). A scan with ECG-gating was performed using: slice 0.5 mm; helical pitch: 12.8; rotation time: 0.4 seconds and average tube voltage: 135 kV at 380 mA. 100 mL of non-ionic contrast agent at a rate of 4-5 mL/second was given. All measurements were performed on 2D MPR and VR reconstructions. Following measurements were made: CS ostium diameter (mm), angle of entrance CS to RA (º), average LCx diameter (mm), average CS diameter (mm), max distance between CS and LCx (mm), minimal distance between CS and LCx (mm), distance between LAD and CS/LCx intersection (mm)—examples Fig below.
Results: A significant reduction of angle of entrance CS to the right atrium was observed in the group with LCx stenosis: 102.3 ± 8.5 (stenosis) vs 110.5 ± 8.3 (control); P < .001. In this group, a significant increase of the maximum distance between CS and LCx was also observed: 16.9 ± 4.9 (stenosis) vs 13.6 ± 4.4 (control); P < .01. Differences in the other analyzed parameters did not reach statistical significance.
Conclusions: Presence of stenosis in the left circumflex branch of left coronary artery influence the anatomy of coronary sinus, however further studies are necessary to explore clinical significance of our findings.
Example of measurements
380
Comparative results angio CT versus CG to non-obese patients
S. Huidu1; D. Dimulescu1; A. Popescu1; S. Lacau1; S. Barsan1; L. Ionescu1; I. Stanca1; L. Arama1
1Elias Emergency Universitary Hospital, Bucharest, Romania
Purpose: We evaluated the feasibility and image quality of coronary CT to 120 patients screening for CT angiography in Elias-Prolife Hospital between 2010 and 1012.
Method: All patients were symptomatic with low or intermediate probability of having severe coronary stenosis. Other patients had known coronary heart disease and CT were performed to check for patency of coronary stents or by-passes.
120 patients were screen.
Were excluded those who had renal insufficiency or allergy to contrast substance.
Inclusion criteria were: age over 29 years, weight less than 100 kg, heart rate below 60 bpm after administration of premedication beta-blockers.
It is known that about 60 bpm heart rate allows a better image quality in CT angiography.
It influences body weight and image quality.
Of the 120 patients, 11 were excluded by the inability to obtain a heart rate below 60/minute after 100 mg of atenolol ± 10-20 mg metoprolol IV, 5 were excluded by the presence of renal insufficiency, 4 because of marked obesity. To 100 patients were performed CT angiographies.
Among patients who carried angio CT all 100 images were good results without having no interpretable.
32% of patients were women and 68% men;
46 patients were aged below 60 years.
Results: Calcium score was 0 in 26% patients.
9% had PCI with stent in one or two coronary arteries prior CT and 2% CABG 2, 3 coronary arteries.
All the stenosis more than 50% was considered significant stenosis. One patient had a significant lesion on LM segment, 18 cases had LAD stenosis, 8 cases CD and 13 cases—circumflex artery. 11 patients had two or more coronary arteries with stenosis.
76% patients had insignificant coronary stenosis. Of all patients, 24 were sent for coronary lesions confirmation to CG, and one single false positive result was found. 12 patients had confirmed the lesions through CG. 11 patients had indication to perform CG because of significant stenosis but did not complete it.
Conclusion: Angio CT remains a noninvasive method for assessing coronary stenosis that is recommended to patients with low or moderate probability of significant coronary stenosis and provides excellent image quality for non-obese patients with AV below 60/minute.
381
Guidance by computed tomographic angiography for ad hoc PCI. Lesson from a registry
W. Wilson Pimentel1; W. Custodio1; J. Buchler1; S. Assis1; M. Macedo Soares1; E. Bocchi1
1Beneficência Portuguesa Hospital, Sao Paulo, Brazil
Aims: The aim of this study was to evaluate the diagnostic performance of coronary computed tomographic angiography (CCTA) and its influence on modification of percutaneous coronary interventions (PCI) strategies that means, we discuss the potential application of CCTA for the guidance of PCI.
Methods and Results: The study included two groups of patients: a main group (MG), including 200 patients screened with a suspect of severe CAD by CCTA and indication for coronary cineangiography (CINE), and a control group (CG) for comparison, including 200 patients selected during the same period, with indication for CINE according to clinical criteria or by positive functional tests. We evaluated the performance of CCTA for the diagnosis of lesions >50% in coronary segments, arteries and patients and the revascularization strategies adopted.
Results: The sensitivity, specificity and positive and negative predictive values of CCTA were 85%, 85%, 71% and 98% for the coronary segments, 90%, 91%, 82% and 100% for the coronary arteries and 100%, 88%, 96% and 98% for patients, respectively. In the MG, percutaneous coronary intervention (PCI) was performed in 90% of the patients, whereas in the CG, percutaneous coronary intervention was performed in 43% of the patients (P = .01).
Conclusions: CCTA had a high diagnostic performance in detecting CAD and allowed ad hoc PCI to be performed in 90% of the patients. This strategy, however, must await randomized studies to confirm these results.
382
Superiority of CT coronary angiography over catheter angiography in detection of variants/anomalies/disease of the coronary arteries: A problem solver
A. Abhishek Bansal1; M.M. D’souza1; H. Wardhan2; R. Sharma1; P.K. Chugh1; R.P. Tripathi1
1Institute of Nuclear Medicine and Allied Sciences, New Delhi, India; 2Dr. Ram Manohar Lohia Hospital, New Delhi, India
Purpose: To describe various coronary artery variants/ anomalies and diseases that were identified on coronary CT angiography (CCTA), and better delineated and characterized than on the catheter angiography (CAG), thus, emphasizing the increasing role of CCTA in accurately diagnosing such conditions which went unnoticed previously.
Methods: We retrospectively studied 94 patients who had undergone CCTA at our institute. Out of these, we identified 10 patients showing variations/anomalies/disease of the coronary arteries, which were not adequately assessed on CAG. The CCTA was then performed on a 40-slice MDCT scanner (SOMATOM Sensation, Siemens Medical Systems). Informed consent was taken from each patient.
Results: Patients ranged in age from 22-64 years. Out of 10 patients, 4 were females and 6 were males. In 2 patients, the right coronary artery (RCA) showed an intra-atrial course in the right atrium for variable lengths, which was not identified on CAG. A patient with Tetralogy of Fallot demonstrated markedly tortuous and dilated coronary arteries with multiple coronary-cameral fistulae. CCTA also depicted all the characteristic abnormalities namely, ventricular septal defect, overriding of aorta, infundibular pulmonary stenosis and right ventricular hypertrophy. 1 patient with single coronary artery arising from the right coronary sinus was identified. The exact course of all the branches was delineated accurately on CCTA only. In another patient, the RCA was seen arising from the ascending aorta anteriorly, which was not identified on the CAG. 1 patient had the left main coronary artery (LMCA) arising from the non-coronary sinus. In another patient, CAG showed complete occlusion of the RCA in its proximal part, the cause of which- an intra-luminal thrombus and its exact extent was identified on CCTA only. In another patient the LAD had an aberrant course on CAG, the cause of which was identified as marked dilatation of the right atrium and ventricle exerting pressure effects over the LAD on CCTA. 1 patient showed a non-enhancing mass in the left ventricular cavity, diagnosed as a cystic thrombus on CCTA. In 1 patient the RCA showed focal long segment ectatic dilatation.
Conclusions: This study illustrates the utility of CCTA in depiction of coronary artery anomalies/variants and its superiority over CAG. It is highly likely that such anomalies/variants of the coronary arteries were missed in the past due to the availability of only CAG. CCTA allows simultaneous depiction of coronary arteries, surrounding tissue and cardiac chambers and comprehensive evaluation of the arterial course in multiple planes.
383
Multidetector ct angiography as a noninvasive tool to assess graft patency of surgically reconstructed diffusely diseased coronary arteries
A. Rezk1; M. Bazid1; Z. Saad2
1King Fahad Military Hospital, Southern Region, Kamis Mushyat, Saudi Arabia; 2Aseer Central Hospital, Abha, Saudi Arabia
Background: Long reconstruction of the diffusely diseased vessel may be a useful surgical option for patients with diffuse coronary artery disease. Close and careful follow up of such subgroup of patients is mandatory. Invasive graft angiography serves as the diagnostic standard for follow up of graft patency for such extensive procedure; however, because of the risks, discomfort, and costs of a hospital stay, a noninvasive diagnostic tool is desirable. The purpose of current study is to evaluate the results of extensive reconstruction of the diffusely diseased left anterior descending coronary artery (LAD) using an left internal thoracic artery (LITA) graft and assess the reliability of multidetector computed tomography (MDCT) angiography as a noninvasive and safe alternative to assess graft patency in asymptomatic patients after (coronary artery bypass surgery (CABG) with reconstructed diffusely diseased vessels.
Methods: 25 patients with the diffusely diseased LAD underwent a long-segmental reconstruction procedure with a LITA graft. The diffusely diseased LAD was extensively incised, additional endarterectomy was performed if necessary, and then the LAD was reconstructed with an ITA graft in a long on-lay fashion. Postoperative MDCT angiography as a non-invasive single tool was performed in 25 asymptomatic patients to assess graft patency.
Results: The cohort consisted of 23 men (92%) and 2 women (8%). The mean age was 58.5 ± 9.2 years. The mean length of the arteriotomy incision was 3.5 ± 1.2 cm. Endarterectomy was performed in 3 patients (12%). Preoperative MI was recorded among 1 patient (4%). While all arterial grafts 27 (100%) were classified as patent, 51 venous grafts (89%) were considered as patent where 11% of venous grafts were considered as non patent. All the significant stenosis were found in the body of venous graft.
Conclusion: Extensive reconstruction of the diffusely diseased LAD using an ITA graft could be performed safely with very encouraging results. MDCT angiography is an excellent non invasive tool not only to evaluate graft patency in the reconstructed LAD but also to detect other findings in asymptomatic patients with diffuse coronary artery disease for better and more close follow up.
384
Non-invasive assessment by Cardiac CT of bypass grafts and native coronary versus invasive coronary angiography
N. Nieves Romero Rodriguez1; F.J. Guerrero Marquez1; P. Cristobo Sainz1; S. Navarro Herrero1; M.P. Serrano Gotarredona1; J.L. Martos Maine1; A. Martinez Martinez1
1Virgen del Rocio University Hospital, Seville, Spain
Introduction: Cardiac CT has proven usefulness in the study of coronary patients, especially with low and intermediate risk profile. However there are few published studies on its usefulness in the diagnosis of patients who have underwent coronary bypass graft. This study attempts to determine its diagnostic accuracy in this area.
Methods: From October 2008 to January 2012 a total of 632 coronary CT have been performed in our center of which 12 occurred in patients with coronary bypass. Finally 9 of them underwent coronary angiography, on which this study is based. We analyzed the diagnostic accuracy in the evaluation of both types of grafts and in the assessment of segments distal to the anastomosis.
Results: A total of 8 males were included with 23 aortocoronary grafts (12 arterial and 11 venous). 18 were visualized by CT angiography with a sensitivity of 100% and specificity of 90.9% and with positive and negative predictive values of 75% and 100% respectively. We also analyzed the 18 vessels distal to the anastomosis detected (11 anterior descending, 5 circumflex and 3 right coronary artery), with a sensitivity of 100%, specificity of 91.6%, negative predictive value of 66.7% and positive predictive value of 100%.
Conclusions: Cardiac CT has a high sensitivity in the assessment of coronary grafts and native arteries in this setting.
385
Does the pre-test probability of CAD improve prediction of coronary artery calcification and stenosis on CTA?
M.C. Maria Cecilia Ziadi1; R.L.V. Villavicencio1
1Diagnostico Medico Orono, Rosario, Argentina
Objective: Computed tomography angiography (CTA) is mainly applied to patients (pts) with low to intermediate risk of coronary artery disease (CAD). Our goal was to assess how the clinical pre-test categorization impacts on the coronary calcium score (CCS) and the presence of severe CAD evaluated with non-invasive CTA.
Methods: We identified 133 consecutive adult pts with suspected CAD, who underwent CTA. According to the pre-test likelihood of CAD, pts were divided into 3 groups: I (low), II (intermediate) and III (high). CCS was categorized as follows: 0, 1-100, 101-400 and >400. Coronary artery lumen was classified into normal = 0%, mild = 1-49%, moderate = 50-69% and severe ≥70% stenosis.
Results: Mean age was 57 (±14) years old, 56% were males. A CCS = 0 was present in 43 of 65 (66%) and in 15 of 48 (31%) pts from groups I and II, respectively. Conversely, none of the pts from group III had a CCS = 0, but 70% (14/20) presented with CCS > 400 (P < .05). The prevalence of severe obstructive CAD was 3.1% (n = 2) in group I, 8.3% (n = 4) in group II and it was significantly higher in pts from group III, 65% (n = 13), (P < .05) (Figure). CTA ruled out obstructive CAD in 95.4% of pts in group I and in 79.2% of pts in group II. Regardless of the pre-test likelihood of CAD, ≥70% stenosis was present 1 of 58 (1.7%) pts with CCS = 0, in 2 of 33 (6.1%) pts with CCS ≤ 100, in 5 of 16 (31.2%) pts with CCS = 100-400 and in 11 of 26 (42.3%) pts with CCS > 400, (P < .05).
Conclusions: There is a direct correlation between the clinical probability of CAD and the calcified atherosclerotic burden. Pre-test likelihood assessment facilitates prediction of severe coronary stenosis with non-invasive CTA. These findings underscore the role of clinical categorization for appropriate selection of pts referred for CTA.
Pre-test probability vs CTA lumen
386
Predictors of significant coronary lesions in patients with abnormal myocardial single photon emission computed tomography
V.A. Vadim Kuznetsov1; E.I. Yaroslavskaya1; D.V. Krinochkin1; G.V. Kolunin1; E.A. Gorbatenko1
1Tyumen Cardiology Center, Tyumen, Russian Federation
Background: It is difficult often to detect coronary artery disease (CAD) without coronary angiography (CAG) in atypical patients by clinical and echocardiography and single photon emission computed tomography (SPECT) data.
Purpose: The present study aimed to reveal predictors of significant coronary lesions in patients with myocardial perfusion abnormalities by SPECT.
Methods: From 13,283 consecutive patients suspected CAD we selected patients after (99)Tc(m)-methoxyisobutylisonitrile (MIBI) gated SPECT and CAG who had no more than 3 months between the tests. There were 47 patients among them who had abnormal SPECT. We divided these patients in two groups: with significant coronary lesions (≥50% of lumen) on CAG and without.
Results: In 16 patients (34%) with abnormal SPECT and CAD compared to patient without CAD we observed more often acute myocardial infarction (37.1% vs 6.5%, P = .005) and higher level of serum glucose (6.9 ± 2.5 vs 5.3 ± 0.8 mmol/L, P = .007). Reduced left ventricular (LV) systolic function (LV ejection fraction < 50%) was more frequent in these patients (17.4% vs 7.4%, P < .001), as well as mild, moderate or severe mitral regurgitation (81.3% vs 59.4%, P = .026). They had higher extent and index of LV wall motion abnormalities (20.8% ±18.0% vs 2.0% ±5.5%, 20.8% ±18.0% vs 2.0% ±5.5%, respectively), and only patients of this group had signs of myocardial scars detected by echocardiography (31.3%, all P < .001). According to the results of discriminant analysis, CAD was associated with index of LV wall motion abnormalities and mitral regurgitation. The obtained sensitivity, specificity, and positive predictivity were 80.6%, 81.8%, and 80.9%, respectively.
Conclusion: An extent of LV wall motion abnormalities and mitral regurgitation are independent predictors of CAD in patients suspected CAD with abnormal SPECT.
387
Stress myocardial perfusion imaging in the evaluation of functional significance of coronary artery disease verified on CT coronarography
A. Andrea Peter1; S. Lucic1; M. Lucic1; R. Jung2; S. Tadic2; S. Stojsic2; M. Stefanovic2
1Institute of Oncology of Vojvodina, Sremska Kamenica, Serbia; 2Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia
Introduction: Noninvasive coronary angiography (CTA) using multidetector computed tomography is used to detect anatomical coronary artery stenosis in patients who are suspected to have coronary artery disease (CAD) with an intermediate to high pretest likelihood. Stress myocardial perfusion imaging (MPI) is an important diagnostic tool since it provides information about the functional severity of the detected coronary artery lesion.
Aim of the Study: To evaluate the findings of MPI after CTA detected coronary artery lesions and follow up of these patients in terms of therapeutic decision making and potential cardiac events.
Material and Methods: In 25 patients MPI was performed after CT coronarography detected coronary artery stenoses. A two-day protocol, dipyridamole stress/ rest Tc-99m-MIBI myocardial perfusion imaging (MPI) was performed. Myocardial perfusion images were analyzed quantitatively, perfusion scores (Summed Stress Score—SSS and Summed Difference Score—SDS), ejection fraction (EF) and the percentage of affected left ventricle myocardium was calculated using 4DMSPECT commercial software package.
Results: Average age in the examined group was 67.78 ± 8.22 years. A total number of 46 coronary stenoses were verified during CT coronarography and the majority had two or mutlivessel coronary artery disease. The percentage of coronary stenoses detected on CT coronarography ranged from a minimal of 30% to a maximal narrowing of 98%. The findings of stress MPI showed normal perfusion of the left ventricle in 22 patients (88%) and reversible ischemia was detected in 3 patients (12%). The group with normal MPI finding had an average follow up period of 29.20 ± 9.75 month and out of this group only one patient was admitted to the hospital because of suspected acute coronary syndrome and coronarography was performed, non-significant narrowings were found on the coronary arteries. Out of the group with reversible ischemia all of them underwent coronarography and have been treated with stent implantation on coronary arteries that had functionaly significant stenosis on stress MPI. The average follow up period in this group was 18.20 ± 3.65 months and during this period they had no symptoms and were without any major cardiovascular incidents.
Conclusion: The evaluation of functional significance of coronary artery lesions with stress MPI is a very important tool in the diagnostic algorithm of stenoses verified on CT coronarography. Stress MPI successfully identifies patients with coronary artery lesions that need revascularization.
388
The reproducibility of coronary calcium scoring on multiple software platforms
M. Al-Mallah1; N. Abukhaled1; A. Alskaini1; H. Alziadey1; I. Suleiman1; E. Ficaro2; A. Al Saileek1
1National Guard Hospital, King Abdulaziz Cardiac Center (KACC), Riyadh, Saudi Arabia; 2University of Michigan, Ann Arbor, United States of America
Introduction: The aim of this analysis is to evaluate the reproducibility of CAC calculated on different commercial softwares.
Methods: We included 159 patients who underwent CAC scoring with use of 64-slice multidetector computed tomography (CT) with prospective electrocardiographic gating for clinical reasons. The data sets were evaluated on two different commercially available softwares (4DM from INVIA, Ann Arbor, MI (software A) and Smart score from General Electric, Milwaukee, WI (software B)) by two blinded independent readers using the method of Agatston with a threshold of 130 Hounsfield units. Comparative analysis of CAC scores between the different software was performed by using Spearman rank correlation and Bland Altman analysis.
Results: Each software produced different absolute numeric results for Agatston score. CAC was detected on 107 scan on both softwares. A total of 59 scans (37%) had the same reading of which 50 patients are without detected calcium. In contrast, CAC reading were within 10 units in 86 scans (52%) There was excellent statistical correlation between the two softwares (r = 0.948, p400), 132 (87%) of the scans were in the same group by both softwares.
Conclusion: Our analysis shows that there is a close correlation between the different software calculation of CAC although the different CAC software different absolute CAC scores. The two softwares concordantly classified 87% of the study population prognostically.
Bland Altman plot of the abstract 388
390
Coronary artery calcium scores on admission trauma CT scans and their Association with in-hospital survival
H.D. De’ath1; K. Oakland1; C. Davies1; K. Brohi1
1Royal London Hospital, London, United Kingdom
Purpose: The presence of coronary artery calcium on Computerised Tomography (CT) scans is indicative of Coronary Heart Disease (CHD). Formal scoring of coronary artery calcium in patients with heart disease is a useful prognostic tool, and is predictive of future adverse cardiac events and survival. The ability to estimate coronary artery calcium scores (CACS) on CT scans undertaken in trauma patients has not been explored. The purpose of this study was to determine the feasibility of estimating CACS on trauma triage scans, and thereby determine the incidence of heart disease in injured patients. Finally, the study aimed to explore the relationship between coronary artery calcium and in-hospital mortality following injury.
Methods: A single centre retrospective cohort study of all injured patients aged 45 years or over presenting to a trauma centre between 2009 and 2011. Two observers estimated and graded CACS (none, mild, moderate, severe and extensive) on admission CT scans of the thorax, and the relationship with in-hospital mortality was determined.
Results: Four hundred and seventy four trauma patients had a CT scan of the thorax, of which the calcium scores of 432 (91%) were interpretable. No coronary artery calcium on CT was found in 137 (32%), whilst 292 (68%) patients had evidence of calcium. Patients with coronary calcium were older (60 years vs 50, P < .001) and had more co-morbidities (132 vs 46, P = .03, respectively). Of the patients with calcium, 139 (32%) had a mild score, 75 (17%) moderate, 64 (15%) severe and 17 (4%) had evidence of extensive coronary artery calcium. Only patients with severe coronary artery calcification had higher death rates (OR 2.4, 95% CI 1.1-4.9), whilst patients with mild, moderate and extensive calcium scores had similar death rates to those without evidence of calcification. Inter-observer agreement for calcium grading was substantial (κ = 0.74).
Conclusions: Admission trauma CT scans of injured patients may be used to determine CACS. These estimates demonstrated that the incidence of CHD approaches 70% in trauma patients aged ≥45 years. Only evidence of severe coronary artery calcium placed patients at an increased risk of in-hospital death following injury.
391
Coronary artery disease among patients with low coronary calcium score: A call for definition of low coronary artery calcium score-Multi-Detector Computed Tomography ANIN Registry
E. Edyta Kaczmarska1; C. Kepka1; Z. Dzielinska1; R. Pracon1; K. Kryczka1; J. Pregowski2; M. Kruk1; M. Demkow1
1National Institute of Cardiology, Department of Coronary Heart Disease, Warsaw, Poland; 2Department of Interventional Cardiology and Angiology Institute of Cardiology, Warsaw, Poland
Objectives: The prospective study was conducted to find the cut-off point for low CAC score and evaluated the incidence of CAD in relation to the low CAC score among patients with intermediate probability of CAD.
Methods: Consecutive patients (n = 1132) were included to the analysis (58.7 ± 10.9 years, 46.7% males). Coronary computed tomography (CCT) angiography was performed by multi-detector computed tomography scanner. CAC score was calculated by Agatston method. CAD was defined as presence of coronary artery stenosis ≥50% on CCT angiography.
Results: CAD was diagnosed in nearly one-fourth of patients (n = 272, 24%). CAD in subjects with CAC score ≤10 and ≤100 were detected in 4.9% (56 patients) and 12.4% (140 patients), respectively. In the ROC curve analysis, CAC score of 10 presented as optimal cut-off point for the discriminating the CAD (sensitivity 0.79, specificity 0.75, P < .0001). Whereas for CAC score of 100, the sensitivity and specificity was 0.48 and 0.92, respectively.
Conclusions: The cut-off point of 10 for CAC score with the best sensitivity and specificity determined patients with CAD. Furthermore, CAC score < 10 better defined patients with high risk obstructive plaque prone to rupture (non- or low calcified obstructive plaque) than CAC score 100. CAC score < 10 should be classified as “low”.
392
Quantitative assessment of extracoronary calcification using Coronary CT angiography may be helpful in predicting coronary artery disease
N.X.H. Xhabija1; I.A. Allajbeu1; E.P. Petrela2; M.H. Heba3
1American Hospital, Balkan Alliance Group, Tirana, Albania; 2University of Tirana, Faculty of Medicine, Department of Public Health, Division of Biostatistics, Tirana, Albania; 3University Hospital “Nene Teresa”, Tirana, Albania
Several studies have been suggested that the presence of multiple extracoronary sites with calcium deposits would infer a greater risk for CAD. But, most of them are based in echocardiographic studies that used categorical variables with poor reproducibility and does not quantify calcium. Cardio-vascular calcium screening with the use of EBCT is emerging as a potentially useful test to diagnose atherosclerotic burden.
Purpose: The aim of this study was to determine whether there is a significant association between calcification of the aortic/mitral annulus and/or thoracic aortic calcified plaques and coronary artery disease (CAD) in patients undergoing 64-slices angio-CT scan. If an association could be established between cardiovascular calcifications and CAD, their presence might be used as a marker of coronary atherosclerosis.
Methods: We identified the presence, absence and amount of calcification in each of the three extracoronary calcification (ECC) sites: aortic root, mitral annulus and ascending aorta, using Agatston calcium score. We applied a digitized method to quantify ECC so we had a good reproducibility in identifying them. All known cardiac risk factors for atherosclerosis including age, gender, hypertension, smoking, dyslipidemia, diabetes and family history were investigated.
Results: The mean age of our study population included 305 patients (184 men and 121 women) was 57 ± 11.28 years. These patients were divided in two groups, age and sex-matched 166 (58.7%) in the ECC group and 139 (41.3%) in the control group. The ECC group had a higher prevalence of positive CT for the presence of CAD (75.8 vs 19%, with P < .001). Multivariate analysis identified only ECC and age as independent predictors of coronary atherosclerosis. Logistic regression analysis showed also that ECC was strongly and significantly associated with CAD after adjusting for all coronary risk factors, except age (OR = 6.637; 95% CI 2.5-7.464, P < .001), hence patients with ECC had a sixfold higher risk for CAD than those without. The sensitivity, specificity, positive and negative predictive values for ECC in diagnosing CAD were 85.1%, 70%, 76% and 91%, respectively.
Conclusion: Calcium deposits at two or more sites may help in identifying patients with atherosclerosis. Their absence is a stronger predictor for absence also of CAD. Measuring extracoronary calcification using CTA is accurate, reproducible and may be clinically relevant.
393
Coronary calcification is superior to exercise stress testing in predicting significant coronary artery stenosis in symptomatic patients
T.M. Tarek Mohamed Bengrid1; R. Nicoll1; A. Schmermund2; M.Y. Henein1
1Heart Centre & Department of Public Health & Clinical Medicine, Umea University, Umea, Sweden; 2Bethanien Hospital, Frankfurt, Germany
Coronary calcification is generally recognised as a form of subclinical atherosclerosis and has been found, in various severities, in asymptomatic populations. Its relevance in predicting significant coronary artery (CA) stenosis in symptomatic patients remains uncertain. We retrospectively studied 360 patients, mean age 65, 58% males, who presented with angina-like symptoms and who underwent CT coronary calcium scoring CAC, conventional angiography and exercise tolerance testing (ETT). A CAC score > 0 was superior to ETT for prediction of significant coronary artery stenosis (≥50% narrowing), with sensitivity 97% vs 39% (P < .001) but specificity was only 26% vs 70% (P < .001). Patients aged ≥70 had higher sensitivity of CAC ≥ 400 in predicting CA stenosis ≥ 50% compared to those aged <70 (62% vs 26%, P = .018) and in predicting single vessel disease (SVD) (65% vs 28%, P = .008) and multivessel disease (MVD) (74% vs 28%, P = .039). The respective specificities for CAC > 0 were significantly lower in those aged ≥70 compared to age < 70 for SVD (9% vs 60%, P = .052) and MVD (5% vs 26%, P = .018). ROC curve analysis showed a CAC score of 46.5 as having the highest sensitivity and specificity (83% and 62%, respectively, P < .001) for predicting >50% CA stenosis with area under the curve (AUC) of 76%.
Conclusion: In symptomatic patients, coronary artery calcium score is more accurate in predicting the presence of significant stenosis but exercise tolerance testing is more specific in excluding significant multivessel disease.
Authors Index
Abdelaty, A.A.A., 140
Abreu, A., 141
Abreu, L., 66
Abu, E., 249
Abukhaled, N., 388
Acampa, W., 224, 238
Adams, D., 121
Adjic, O., 378
Agelaki, M., 123
Agostini, D., 161
Agra, R., 249
Aguade-Bruix, S., 111, 273, 275, 276, 284, 294, 352, 57, 59, 65
Aguilera, E., 243
Ahmed, T., 290
Ahmeti, I., 241
Ahtinen, H., 42
Airaksinen, J., 229
Ajmi, W., 246
Ak Sivrikoz, I., 256
Akashi, Y., 297
Akcay, O., 256
Al Badarin, F., 112
Al Saileek, A., 388
Alam, U., 113, 147
Albuquerque, A., 279
Alexanderson, E., 70
Alexanderson Rosas, E., 130, 262, 264, 265, 266, 287
Algalarrondo, V., 121
Alharthi, M., 344
Allajbeu, I.A., 365, 392
Allam, A.H., 101, 225, 230, 247
Allam, S., 290
Al-Mallah, M., 207, 344, 348, 388
Alonso, N., 243
Alsaileek, A., 344
Alskaini, A., 388
Alves, V., 285
Al-Younis, I., 272
Alziadey, H., 388
Alziady, H., 344
Amancharla, G.R.K., 278
Amegassi, F., 75, 94
Amitani, K., 282
Ananthasubramaniam, K., 207
Andersen, F., 146
Andreini, D., 118, 227, 346, 356, 71, 83, 86, 91
Androshchuk, V., 72
Annoni, A.D., 118, 227, 356, 83, 86, 91
Aoki, H., 105
Arama, L., 380
Aramayo, G.E.N., 280, 289
Araujo-Torres, L.V., 287
Argibay, S., 244, 249, 260, 270
Arias-Lloza, P., 219
Arita, Y., 213
Armstrong, I., 113, 147
Armstrong, I.S., 98
Arumugam, P., 113, 123, 147, 98
Ascheim, D., 234
Asghar, O., 113, 147
Ashikaga, K., 297
Askew, J., 128
Assante, R., 224, 238
Assis, S., 381
Attena, E., 110
Autio, A., 214
Azouri, L.A., 232
Baggiano, A., 227, 346, 356, 71
Baghdady, Y., 253, 254
Bai, C., 66
Bailey, J., 72
Bakos, Z., 41, 99
Balani, S., 226
Balazs, G.Y., 82
Baligh, E., 253, 254
Ballerini, G., 118, 227, 346, 356, 71, 83, 86, 91
Balogh, I., 296
Bang, L.E., 146
Bansal, A., 382
Barbarash, L., 302
Barbato, D., 40
Barsan, S., 380
Bartorelli, A.L., 118
Bartykowszki, A., 82, 90
Batalov, R.E., 144
Bateman, T., 60, 112
Battler, A., 259
Bauersachs, J., 160
Bax, J.J., 272, 347, 357, 362
Bazid, M., 383
Becher, H., 93
Beinart, R., 358
Bejarano, A., 260
Belin, A., 161
Belzer, D., 259
Ben Ali, K., 315, 40
Ben Azzouna, R., 315, 40
Bengel, F.M., 160, 313
Bengrid, T.M., 393
Bental, T., 259
Berding, G., 160
Berezin, A., 125, 133, 143, 145
Berezina, T., 145
Berman, J., 234
Bernal, E., 243
Bertella, E., 118, 227, 346, 356, 71, 83, 86, 91
Bertuccio, G., 369
Beschorner, M., 316
Bhat, G., 162
Bhatti, S., 60
Biggi, A., 291
Birdane, A., 256
Blagova, O.V., 298
Blankenberg, F.G., 217
Blankstein, R., 211
Blomberg, B., 120
Boban, M., 368
Bobbio, M., 291
Bocchi, E., 381
Boemio, A., 110, 129, 132, 224
Boersma, H., 138
Boersma, H.H., 317
Bojko, A., 119
Boldueva, S.A., 122
Bordenave, L., 258
Borges-Neto, S., 232
Borgquist, R., 41, 99
Borrego, J.M., 237
Both, M., 218
Braad, P.E., 120
Brinkert, M., 107
Broersen, A., 272, 347, 362
Brohi, K., 390
Brunken, R., 115
Brunkhorst, T., 160
Brunz, F., 313
Bruyere, J., 116
Bruzzese, D., 210
Bucci, C., 40
Buchler, J., 381
Budikova, M., 350
Budzynska, A., 100
Bullier, E., 258
Bundgaard, H., 288
Burchert, W., 76
Buriankova, E., 350
Bursic, V., 368
Bybee, K.A., 60
Cabanelas, N., 279
Candell-Riera, J., 111, 273, 275, 276, 284, 294, 352, 57, 59
Cantinho, G., 81, 85
Cardenas Perilla, R., 275, 294
Carlsson, M., 41, 99
Carmo, M., 141
Carrola, M., 141
Casaldaliga, J., 59
Casans-Tormo, I., 64
Caselli, C., 268
Castell-Conesa, C., 276
Castell-Conesa, J., 111, 273, 275, 284, 294, 352, 57, 59
Casuscelli, J.F., 280, 289
Caza, M., 92, 96
Cemerlic-Adjic, N., 378
Cencarik, J., 274
Cerci, J.J., 354
Cerci, R.J., 354
Cestari, P., 240, 250, 252, 370
Challela, W.C., 232
Chang, K.-Y., 212, 345
Chareonthaitawee, P., 128
Chauvie, S., 291
Chen, A.C., 293
Chen, Y.D., 366
Chequer, R., 121
Cherk, M.H., 56
Chicco, D., 315
Choi, I.-J., 345
Christensen, T.E., 146
Christoforidou, T., 353, 364
Chu, E.-H., 212
Chugh, P.K., 382
Cittanti, C., 351
Coaguila, C., 67, 75, 94
Cochet, H., 258
Collinot, J.A., 126
Collins, A.M., 102
Conte, E., 118, 346, 71, 91
Conwell, R., 66
Cordeiro, A., 250
Corman, I., 121
Correia, J., 279
Cortes, C.M., 280, 289
Cortes, J., 244, 260
Cortinovis, S., 227, 346, 356, 71, 83, 86, 91
Costa, G., 279
Coste, P., 258
Crean, A.M., 361
Cristobo Sainz, P., 384
Crochet, D., 92
Croft, L.B., 271, 58
Csobay-Novak, C.S., 82
Cuberas-Borros, G., 273, 276, 284, 352, 57, 59
Cuellar-Calabria, H., 352
Cunha, C., 354
Cunha, M.J., 279
Cunha, P., 141
Cuocolo, A., 110, 129, 132, 210, 224, 238
Custodio, W., 381
Czerwiec, A., 257
Dabrowski, A., 257
Daicz, M., 280, 289
Damian, A., 236
D’amore, C., 210
Daniele, S., 224, 238
Daou, D., 67, 75, 94
Davies, C., 390
Dawoud, F., 358
De Bruyne, B., 355
De Cristofaro, V., 351
De Feyter, P.J., 43
De Geer, J., 95
De Graaf, M.A., 272, 347, 357, 362
De Haas, H.J., 317
De Leon, G., 273, 275, 276, 57
De Leva, M., 129
De Luca, G., 301
De Luca, S., 129, 132
De Michele, G., 129
De Rosa, A., 129
De Vroey, F., 355
De’ath, H.D., 390
Declercq, H., 355
Dekany, M., 296
Delgado, V., 272, 347, 357
Dellegrottaglie, S., 210
Demkow, M., 391
Deshayes, E., 126
Despotopoulos, E., 360
Dharampal, A., 43
Dhillon, G., 60
Di Carli, M.F., 116, 211
Di Palo, A., 228
Di Serafino, L., 355
Di Stolfo, G., 301
Diaz-Exposito, R., 64
Diederichsen, A., 120
Dierckx, R.A., 138, 265, 266
Dijkstra, J., 272, 347, 362
Dimitriadis, D., 353, 364
Dimitriadis, G., 353, 364
Dimulescu, D., 380
Dominik, R., 78, 84
Dorbala, S., 116, 211
Dos Santos, A., 223
Douard, H., 258
D’souza, M.M., 382
Duchatelle, V., 215
Ducrocq, G., 215
Duni, A.D., 365
Duvall, W.L., 234, 271, 56, 58
Dzemeshkevich, S.L., 298
Dzielinska, Z., 391
Dziuk, M.A., 100
Eden, M., 218
Edenbrandt, L., 251, 88, 97
Edes, I., 89
Efimova, I., 142
Einstein, A.J., 271
Eliahou, L., 121
El-Nagger, H.M., 272
Elsingha, P., 138
Elzawawy, T.H.E., 140
Embon, M.A., 280, 289
Engvall, J.E., 95
Entok, E., 256
Espinet Coll, C., 111
Esteves, F.P., 56
Faber, L., 218
Facciorusso, A., 301
Falcao, A.F., 232
Fanelli, M., 228
Fardanesh, M., 58
Faria, T., 285
Farias, F.R., 354
Fau, G., 92
Fazzone-Chettiar, R., 106
Feggi, L., 351
Feldman, L., 215
Feola, M., 291
Ferrando, R., 236
Ferrari, C., 228
Ferreira, R., 141
Ficaro, E.P., 106, 388
Figueras, J., 276
Filannino, A., 315
Filipiak, K., 163
Filipovic, N., 378
Filippi, P., 370
Filla, A., 129
Fiorentini, C., 346, 71
Flotats, A., 251
Formanek, R., 350
Formenti, A., 227, 356, 83, 86, 91
Foster, C., 211
Fraile, M., 243
Franca, J.I., 240, 250, 252
Franca Neto, O., 354
Franquet, E., 59
Frega, N., 224
Frey, N., 218
Frolova, Y.U.V., 298
Fuerst, S., 38
Fujita, W., 105
Fukuda, H., 248, 281
Fukuya, H., 292
Fukuzawa, S., 135, 235
Furuhashi, T., 248, 281
Gaber, M., 211
Gaertner, F., 316
Gagarina, N.V., 298
Gai, J., 366
Gai, L.Y., 366
Galler, Z., 296
Galve-Basilio, E., 111
Ganyukov, V., 302
Garcia Del Blanco, B., 352
Garcia-Dorado, D., 273, 276, 352, 57, 59
Gargiulo, P., 132, 210
Garrido, M., 244, 249, 260, 270
Gazdic, P., 274
Geller, L., 90
Geraedts, J., 355
Gerbaud, E., 258
Ghaleb, M., 253, 254
Giannadaki, M., 353, 364
Giannessi, D., 268
Gibarti, C., 137
Gierloff, C., 218
Gimelli, A., 56
Gjerde, M., 95
Glauche, J., 266
Goda, A., 233
Godinho, F., 81, 85
Golestani, R., 138
Goncalves, M., 141
Gonsorcik, J., 137
Gonzalez-Juanatey, R., 244, 249, 270
Gorbatenko, E.A., 386
Gottfried, V., 119
Goulon, D., 96
Gourgiotis, K., 353, 364
Graidis, C., 353, 364
Grancini, L., 118
Grande, P., 146
Gratz, K.F., 313
Greco, G., 234
Gregg, S., 72
Gripari, P., 86
Guan, Z.W., 366
Guernou, M., 77
Guerrero Marquez, F.J., 237, 384
Guizar, C., 70
Guizar-Sanchez, C.A., 130, 262, 264, 287
Gutstein, A., 259
Gyory, F., 89
Haense, C., 313
Hainer, J., 211
Halperin, H., 358
Hamdy, A.M., 290
Hammami, H., 246
Han, C., 63
Han, E.-J., 212
Hansen, C.L., 261
Harada, T., 297
Hasbak, P., 146, 288
Hase, H., 281
Hasid, Y., 259
Heba, M.H., 365, 392
Hedman, M., 269
Hegazy, E., 101
Hejjaji, V.S., 278
Helias, J., 92
Helis, L., 139
Hellberg, S., 42
Helmy, D., 101
Henein, M.Y., 393
Henzlova, L., 350
Henzlova, M., 234, 271, 56, 58
Hermann, L., 271
Hernandez, H., 70
Hernandez Perales, H.J., 262
Hernandez-Sandoval, S., 70, 130, 262, 264, 287
Hesse, B., 251
Higuchi, T., 219, 316, 78, 84
Hiraoka, H., 213
Hohnhorst, M., 218
Hoilund-Carlsen, P.F., 120
Holmvang, L., 146
Holtz, J.V., 240
Horacek, M., 358
Hossen, L., 72
Hsu, B., 162
Hsu, P., 162
Huidu, S., 380
Hwang, B.-H., 212, 345
Hyafil, F., 121, 215
Icardi, L., 291
Ichikawa, S., 135, 235
Iemura, M., 371
Ihlemann, N., 288
Ikeda, A., 135, 235
Ilyushenkova, Y.U.N., 144
Inagaki, M., 135, 235
Inaki, A., 217
Ionescu, L., 380
Ishikawa, M., 282
Ishimura, H., 103
Iversen, K., 288
Jacobson, A., 209, 359
Jager, P.L., 39, 56, 73
Jakala, P., 269
Jalkanen, S., 214, 42
James, G., 74
Jang, M.-O., 345
Javoran, D., 368
Jean-Baptiste, M., 315, 40
Jeevarethinam, A., 286
Jenei, C.S., 89
Jennings, A., 74
Jensen, L.O., 120
Jespersen, C.H.B., 288
Jeyachandran, R., 226
Jimenez, L.J., 293
Jimenez, M., 70
Jimenez Santos, M., 262
Jimenez-Heffernan, A., 108, 263, 65
Jimenez-Santos, M., 130, 264, 287
Johansen, A., 120
Johansson, L.B., 97
John, M., 226
Johnson, L., 314
Joki, N., 281
Jordan-Rios, A., 264
Juarez-Orozco, L.E., 130, 264, 265, 266, 287
Jung, R., 242, 378, 387
Kaczmarska, E., 391
Kagan, M., 162
Kaiser, F., 219, 316, 78, 84
Kaitozis, O., 360
Kajander, S., 229, 80
Kajinami, K., 105
Kaliadka, M., 139
Kallil, R.K., 232
Kaminek, M., 350
Kang, M.-K., 345
Kapitan, M., 236
Karadimitras, N., 364
Karakostas, G., 353, 364
Karas, S., 255
Karasavvidis, V., 353, 364
Karolyi, M., 82, 90
Kasai, T., 295
Kasama, S., 209
Katoh, C., 164
Katsikis, A., 208
Kaufmann, P.A., 251, 56
Kechyn, I., 299
Kechyn, S., 299
Kennedy, K., 112, 60
Kepka, C., 391
Khalid, F., 207
Khan, M.A., 123
Khattar, R.S., 123
Kihara, S., 213
Kikuchi, A., 282
Kim, C.-J., 212, 345
Kim, H.S., 283, 87
Kim, J.-J., 345
Kim, T.-H., 345
Kincl, V., 350
Kingston, J., 375
Kinuya, S., 216, 217, 88
Kisko, A., 274
Kisteneva, I., 142
Kitsiou, A.N., 255
Kitslaar, P.H., 347, 362
Kitziri, E., 208
Kiugel, M., 214
Kjaer, A., 146
Klein, J., 211
Klotz, E., 43
Kmec, J., 274
Kmezic Grujin, J., 242
Knollema, S., 39
Knuuti, J., 214, 229, 251, 268, 42, 63, 80
Kobylecka, M., 163
Kochman, J., 163
Kogan, E.A., 298
Kolesnichenko, M.V., 122
Kollaros, M., 314
Kollaros, N., 208
Kolossvary, M., 90
Kolovou, G., 208
Kolunin, G.V., 386
Koopman, D., 73
Koranda, P., 350
Kormann, O.J., 354
Koropouli, S., 360
Kostina, I.S., 122
Kostkiewicz, M., 277
Kostova, N., 245
Koszegi, Z.S., 89
Kotbi, O., 94
Koutelou, M., 208
Kouzoumi, A., 208
Kracsko, B., 89
Kraeber-Bodere, F., 96
Kreissl, M., 219
Kremzer, A., 125, 143, 145
Krinochkin, D.V., 386
Kroft, L.J., 272
Krolicki, L., 163
Kruk, M., 391
Kryczka, K., 391
Kudo, Y., 371
Kumita, S., 282
Kunimasa, T., 248, 281
Kupryanova, A.G., 298
Kuroiwa, N., 135, 235
Kusunose, Y., 363
Kuznetsov, V.A., 386
Kyto, V., 214
Lacau, S., 380
Lahiri, A., 286
Lanca, A., 368
Langer, C., 218
Lanka, V., 116
Laporte, B., 92
Lardo, A.C., 358
Lassmann, M., 78
Latus, K., 107
Laurent, F., 258
Lazareva, I., 139
Lazewatsky, J., 162
Le Guludec, D., 121, 215, 315, 40
Lee, B.C., 106
Lee, T., 363
Legallois, D., 161
Lelieveldt, B.P., 362
Lemeunier, L., 78
Leonardi, B., 117
Leosco, D., 110, 132
Lesniak-Sobelga, A., 277
Levine, E.J., 271, 58
Levy, T., 375
Liljenback, H., 214, 42
Lindner, O., 76
Lindsay, A.C., 79
Lishmanov, Y., 142
Lishmanov, Y.U.B., 131, 144
Lisovaya, O., 133
Liu, Y., 62
Liu, Y.L., 61
Loft, A., 288
Lomsky, M., 97
Longmore, L., 60
Lopez-Aguilar, R., 263, 65
Lopez-Martin, J., 108, 263, 65
Lopez-Urdaneta, J., 260, 270
Lorenzoni, V., 268
Lots, D., 73
Louedec, L., 315, 40
Lucic, M., 242, 387
Lucic, S., 242, 387
Lujambio, M., 236
Lussato, D., 77
Lutz, M., 218
Lyngby Lassen, M., 146
Macedo Soares, M., 381
Machado, L., 240, 250, 252, 370
Maddahi, J., 66
Madzar, Z., 368
Maekawa, J., 135, 235
Maekawa, S., 135
Mahjoub, Y., 246
Majstorov, V., 241, 245
Makino, K., 363
Malik, R.A., 113, 147
Manabe, M., 297
Manabe, O., 164
Mandour Ali, M., 101, 225, 230, 247
Manrique, A., 161
Manso, B., 59
Marinelli, M., 268
Markava, I., 139
Markstad, H., 41, 99
Marosi, E., 296
Marques, C., 240
Marrero, H.G., 280, 289
Martinez, A., 244, 270
Martinez Martinez, A., 237, 384
Martinez-Aguilar, M.M., 130
Martins, E., 285
Martire, M.V., 222, 239
Martire, V.D., 222, 239
Martos Maine, J.L., 237, 384
Marwick, T., 115
Masai, H., 248, 281
Mastroianno, S., 301
Materukhin, A., 299
Mats, I., 259
Matsui, T., 209
Matsuishi, T., 371
Matsunari, I., 105, 217
Matsuo, S., 209, 216, 88
Matsuzawa, Y., 213
Maurovich-Horvat, P., 82, 90
Mazurek, A., 100
Mazurek, T., 163
Meave-Gonzalez, A., 130, 264, 265
Mehanaoui, L., 215
Mele, D., 351
Meneghetti, J.C.M., 232
Merisaari, H., 63
Merkely, B., 82, 90
Mershina, E.A., 298
Merzon, K., 119
Metelkova, I., 350
Meyer, C., 75, 94
Miadzvedzeva, A., 139
Michelini, S., 301
Michiels, V., 126
Mickley, H., 120
Mierzejewska, A., 257
Mihalkova, D., 128
Mila Lopez, M., 243
Milasinovic, D., 378
Miller, C., 113, 147
Miller, T., 128
Milliez, P., 161
Milliner, M., 40
Minakawa, M., 248, 281
Ming, Y., 316
Minin, S., 142
Mirfeizi, L., 138
Miszalski-Jamka, T., 277
Miyagawa, M., 103
Miyake, F., 297
Miyazaki, Y., 105
Mizumoto, R., 107, 109
Mizuno, K., 282
Mlynarska, A., 373, 374, 379
Mlynarski, R., 373, 374, 379
Mochizuki, T., 103
Momose, M., 209
Montaudon, M., 258
Monteiro, J., 81
Montivero, M., 223
Moody, J., 106
Moonthungal, S., 58
Moran, R., 375
Moreira, A.P., 279
Mori, Y., 164
Moroi, M., 248, 281
Motro, M., 119
Mouden, M., 39
Muller, O., 126
Munakata, K., 282
Murase, K., 103
Murthy, V.L., 211
Mushtaq, S., 118, 227, 346, 356, 71, 83, 86, 91
Mut, F., 236
Naeim, M., 290
Nagae, A., 233
Naib, T., 234
Nair, G., 278
Nakajima, K., 209, 216, 88
Nakamura, M., 363
Nakamura, T., 295
Nakata, T., 209
Nappi, C., 238
Narula, J., 317
Narula, J.H., 212
Navarro Herrero, S., 237, 384
Naya, M., 211
Nazar, L., 376
Nedostup, A.V., 298
Negishi, K., 115
Negishi, T., 115
Neglia, D., 268
Nekolla, S., 316
Nekolla, S.G., 162, 38
Neroladakis, I., 353, 364
Nesterov, S., 122, 63
Newton, J., 93
Niccoli Asabella, A., 228
Nicol, E., 79
Nicoll, R., 393
Nieves, S., 244, 260, 270
Nikolic, D., 378
Nishimura, T., 233
Nishiyama, Y., 103
Nkomo, Q., 107, 109
Notaristefano, A., 228
Notghi, A., 74
Nour, K., 348
Nyolczas, N., 296
Nystrom, K., 88
O, J.H., 212
Oakland, K., 390
O’brien, J., 74
O’connor, R., 90
Ohira, H., 164
Oikonen, V., 63
Okada, M., 292
Okamoto, S., 135, 235
Okino, S., 135, 235
Okuda, K., 216, 88
Oliveira, A., 285
Oliveira, L., 141
Oliveira, M., 141, 252
Oliveira, M.A., 250, 370
Oliveira, P., 285
Olsson, E., 95
Onthank, D., 162
Oommen, M.J., 376
Oostdijk, A.H.J., 39
Opolski, G., 163
Orozco-Molano, A.C., 64
Ortega-Carpio, A., 263, 65
Osama, D., 253, 254
Ostenfeld, E., 41, 99
Ottervanger, J.P., 39
Oyama-Manabe, N., 164
Padley, S., 79
Padma, S., 231
Pagano, G., 110, 132
Palaniswamy, P.S., 231
Pallardy, A., 96
Panareo, S., 351
Pandey, S., 124, 226
Paolillo, S., 110, 210
Pappata’, S., 129
Parienti, J.J., 161
Park, M.J., 78, 84
Patel, R., 375
Pavitt, C.W., 79
Pavlitchouk, S., 93
Pehar-Pejcinovic, V., 368
Peirano, J.D., 223
Pejovska, I., 245
Pellegrino, T., 110, 129, 132
Pellitero, S., 243
Pelzer, T., 219
Pena, C., 249
Pena, H., 81, 85
Penarrieta-Daher, E.A., 130, 264, 265, 266, 287
Pepi, M., 118, 227, 346, 356, 71, 83, 86
Pereira, E., 244
Pereira, J.G., 285
Perez, M.B., 285
Perez-Rodon, J., 111
Perrone-Filardi, P., 110, 132, 210, 238
Persic, V., 368
Persson, A., 95
Peter, A., 242, 387
Peterle, C., 351
Petersen, H., 120
Petersen, S.E., 43
Petiet, A., 315
Petrela, E.P., 365, 392
Petretta, M., 224, 238
Petrov, A.D., 317
Pettersson, K., 229
Pietila, M., 229, 268
Pimentel, W., 381
Pinar, J., 273, 284
Pineda, V., 276, 284
Pinskiy, M., 119
Pinter, N., 82
Piriou, N., 92, 96
Pis Diez, E.R., 222, 239
Piszczek, S., 100
Pizzi, M.N., 284, 352, 59, 111, 275, 294, 57, 276
Plaitano, M., 224, 238
Plancha-Burguera, E., 64
Podoksenov, Y.U., 131
Podolec, P., 277
Pombo, M., 244, 249, 260
Pongiglione, G., 117
Pontone, G., 118, 227, 346, 356, 71, 83, 86, 91
Pop Gjorceva, D., 241, 245
Popescu, A., 380
Popov, S., 142
Popov, V., 302
Pracon, R., 391
Pregowski, J., 391
Preuss, R., 76
Prinz, C., 218
Prior, J.O., 126
Prochorov, V., 119
Providencia, L.A., 279
Psifos, V., 353
Pubul, V., 244, 249, 260, 270
Pucheu, Y., 258
Pugliese, F., 43
Pyxaras, S.A., 355
Qiao, H.Y., 366
Queneau, M., 77
Qureshi, W., 207, 348
Racca, E., 291
Racekova, A., 137
Racz, I., 89
Ragot, C., 258
Ramaiah, L., 278
Rambaldi, I., 351
Ramirez, J.R., 232
Ramos-Font, C., 65, 108, 263
Rana, O., 375
Rank, G., 223
Raposeiras, S., 249
Ray, R., 79
Ray, S.G., 113, 147
Reder, R., 316
Reiber, J.H., 272, 347, 362
Reiffers, S., 39
Reist, K.B., 261
Rengo, G., 110, 132
Reutelingsperger, C.P., 317
Reverter, J., 243
Reyes, E., 107, 109, 72
Rezk, A., 383
Richter, J., 88
Rischpler, C., 38
Ristevska, N., 241, 245
Robinson, S.P., 162, 316
Rodriguez-Castellanos, L.E., 287
Rodriguez-Porcel, M., 128
Roentgen, P., 160
Roijer, A., 41, 99
Roivainen, A., 214, 42
Rolfo, F., 291
Romero Rodriguez, N., 237, 384
Romero-Farina, G., 57, 59, 111, 273, 275,276, 284, 294, 352
Roos, C.J., 357
Roque, A., 352
Roshd, D., 253, 254
Rossetti, V., 351
Rossi, A., 43
Rosso, G.L., 291
Rouzet, F., 121, 215, 315, 40
Rovai, D., 268
Rubens, M., 79
Rubini, G., 228
Ruddy, T.D., 56
Ruggiero, D., 210
Ruibal, A., 244, 249, 260, 270
Russell, R.R.R., 61, 62, 293
Russkikh, I., 139
Ryzhkova, D.V., 122
Saad, Z., 383
Saanijoki, T., 214, 42
Sabharwal, N.K., 93
Sadek, A.A., 101, 247
Sakata, K., 233
Salas P, M.J., 62
Saleh, H., 253, 254
Salgado, C., 108, 263
Salgado-Garcia, C., 65
Samir, A.S.A., 140
Samnick, S., 84
Samura, T., 125
Sanchez De Mora, E., 108, 263, 65
Sanchez-Gonzalez, C., 263
Sanchez-Salmon, A., 260
Santa-Clara, H., 141
Santi, I., 351
Santos, D., 252
Santos, L., 279
Saraste, A., 214, 229, 42, 80
Sarda-Mantel, L., 315, 40
Sato, N., 282
Sato, T., 164
Satoh, T., 233
Saushkina, Y., 142
Savarese, G., 210
Saveljic, I., 378
Savino, J., 271
Sazonova, S.I., 127.144
Scala, O., 210
Schaefer, A., 160
Schaefer, P., 218
Schalij, M.J., 347
Schatka, I., 160, 313
Schmermund, A., 393
Schmitt, M., 113, 147
Scholte, A.J., 357
Scholte, A.J., 272, 347, 362
Schuleri, K.H., 358
Schwaiger, M., 316, 38
Scrima, G., 369
Secinaro, A., 117
Sedov, V.P., 298
Sellem, A., 246
Selvakumar, J., 278
Seo, J.B., 283, 87
Sergienko, V., 136
Serrano Gotarredona, M.P., 237, 384
Serrano, S., 243
Seung, K.-B., 212
Sharara, S., 101
Shariat, M., 361
Sharir, T., 119
Sharma, R., 382
Shimoyama, K., 233
Shukevich, D., 302
Shulgin, D., 136
Sierraalta, W., 252
Sierra-Fernandez, C., 264
Silva, J., 240
Silva, S., 141
Silvestri, V., 117
Silvola, J.M.U., 42
Sinkov, M., 302
Sinusas, A.J., 106, 61, 62
Sipola, P., 269
Slama, M., 121
Slart, R., 138
Slart, R.H.J.A., 265, 266, 317
Slump, C.H., 73
Smanio, P., 240, 250, 252, 370
Soldevila, B., 243
Solodky, A., 259
Solomyanyy, V., 134
Songy, B., 56, 77
Sorbets, E., 121, 215
Sosnowski, M., 373, 374, 379
Souli, J., 246
Souvatzoglou, M., 38
Sovova, E., 350
Srivastava, A.V., 106
Stanca, I., 380
Standbridge, K., 107
Stanislao, M., 301
Stasko, J., 274
Stefanovic, M., 242, 387
Stier Jr, A., 354
Stojanoski, S., 241, 245
Stojiljkovic, J., 242
Stojsic, S., 242, 387
Su, M., 292
Succi Leonelli, E., 351
Suda, K., 371
Sugi, K., 248, 281, 363
Sugioka, J., 135, 235
Suleiman, I., 344, 388
Svensson, S.E., 97
Swallow, R., 375
Szabo, G.T., 89
Szeplaki, G., 90
Szmigielski, C., 93
Szot, W., 277
Szulc, M., 102
Tadic, S., 242, 387
Tahara, N., 317
Taina, M., 269
Tait, J.F., 217
Tajiri, Y., 363
Takagi, T., 363
Takahashi, N., 282
Takahashi, Y., 103
Taki, J., 216, 217
Tamaki, N., 164
Tamarappoo, B., 115
Tanaka, R., 295
Tandon, S., 106
Taniai, S., 233
Tawileh, M., 67, 94
Tekabe, Y., 314
Tekedis, C., 360
Teramoto, K., 297
Teras, M., 63
Teresinska, A., 257
Terulla, A., 291
Thayssen, P., 120
Theodorakos, A., 208
Thom, A., 250
Thomassen, A., 120
Timmer, J.R., 39
Tio, R., 138
Tio, R.A., 265, 266
Tobisaka, M., 216
Todiere, G., 268
Toma’, P., 117
Tomic, N., 378
Tomiyama, Y., 164
Tonge, C.M., 98
Torres-Araujo, L.V., 130, 264, 265, 266
Totaro, M., 301
Toth, G., 355
Tragardh, E., 251, 97
Travin, M., 209
Trimarco, B., 110
Tripathi, R.P., 382
Tsapaki, V., 208
Tsatkin, V., 61, 62
Tsujino, I., 164
Tuccillo, M., 129, 132, 224, 238
Tuomi, J.O., 80
Uchida, T., 282
Ueda, L., 240
Ukkonen, H., 229
Underwood, S.R., 107, 109, 72
Uotila, S., 214
Uusitalo, V., 229
Vaishnava, P., 234
Vajda, G., 89
Valette, F., 92, 96
Valle, G., 301
Vallejo, E.V., 293
Vallejos Arroyo, V., 243
Van Dalen, J.A., 73
Van Mieghem, C., 355
Vangala, D., 116
Vanhoenacker, P., 355
Vanninen, R., 269
Vassiliadis, I., 360
Vavlukis, M., 241, 245
Vega, M., 270
Veiga, A., 81, 85
Velicki, L., 378
Veltman, C.E., 357
Venuraju, S., 286
Vereb, M., 274
Verma, A., 124, 226
Vesnina, Z.H., 127, 131
Vidal, R., 270
Vidigal Ferreira, M.J., 279
Vieira, T., 285
Villavicencio, R.L.V., 385
Vink, D., 73
Vitola, J., 354
Wakabayashi, H., 216, 217
Walker, S., 107, 109
Wardhan, H., 382
Warin-Fresse, K., 92, 96
Washburn, D., 162
Wechalekar, K., 107, 109, 72
Weise, R., 76
Westra, J., 138
Wijns, W., 355
Wilimski, R., 163
Wimmer, A., 112
Witkowska-Grzeslo, A.J., 357
Wittfoot, S., 229
Wnuk, J., 257
Wollenweber, T., 160, 313
Wong, F.J., 102
Wood, P., 93
Wragg, A., 43
Xhabija, N.X.H., 365, 392
Yamada, T., 209
Yamagishi, M., 216
Yamaguchi, J., 363
Yamamoto, E., 282
Yamane, T., 78, 84
Yamasaki, S., 233
Yamashina, S., 209
Yang, L., 366
Yaroslavskaya, E.I., 386
Yim, S.-M., 345
Yla-Herttuala, S., 42
Ynfante, I., 108
Yoshimoto, H., 371
Yoshinaga, K., 164
Yoshino, H., 233
Yosry, A.H.Y., 140
Yousefi, B.H., 316
Yu, M., 162
Zafrir, N., 259
Zalkind, D., 293, 61
Zampella, E., 224, 238
Zandbergen, H.R., 317
Zapparoli, M., 354
Zdraveska Kocovska, M., 241, 245
Zeebregts, C., 138
Zemberova, E., 137
Zhang, S.Y., 366
Ziadi, M.C., 385
Ziegler, S.I., 38
Zielke, S., 79, 93
Zier, S.S., 354
Zwadlo, C., 160
Index of topics
Acute ischaemia/Acute ischaemic syndromes/Injury imaging, 160, 163, 217, 258, 295, 297, 317
Arrhythmias and sudden death, 142, 358
Attenuation correction clinical, 38, 61, 62, 94, 100
CAD and diabetes, renal disease, gender risk factors, 137, 145, 224, 225, 233, 238, 243, 244, 245, 246, 247, 248, 249, 250, 252, 253, 254, 256
Calcium scoring, 39, 344, 348, 388, 390, 391, 392, 393
Comparative techniques clinical, 83, 86, 92, 257, 271, 272, 288, 290, 355, 368, 381
Congestive heart failure, 110, 216, 277, 278, 296
Coronary revascularisation, 87, 283, 302
Cost effectiveness, health economics, quality assurance and guidelines, 223, 234
CT angiography, 71, 79, 80, 82, 90, 117, 229, 286, 292, 299, 345, 346, 347, 353, 354, 357, 361, 364, 366, 371, 375, 376, 379, 382, 383, 385
CT - Other, 99, 218, 360, 363, 373, 374
Diagnosis of CAD, 222, 235, 236, 239, 240, 242, 263, 268, 350, 352, 356, 369, 370, 378, 380, 386
Exercise ECG, 227, 232
Free fatty acid imaging, 213
Image patterns, artifact, 84
Instrumentation - other, 105
Instrumentation, software and image processing, 63, 72, 78, 88, 89, 91, 97, 103
Microvascular heart disease, 122
Molecular imaging, 40, 42, 138, 146, 214, 215, 313, 314
Myocardial perfusion and coronary flow, 66, 106, 116, 123, 126, 130, 134, 135, 161, 281, 301
Myocardial viability and hibernation, 95, 140, 226, 284, 291
Neurohumoral imaging, 112, 113, 129, 132, 141, 147, 209, 316, 359
New radiopharmaceuticals, 315
Other clinical general, 59, 127, 131, 136, 251, 255, 269, 273
Pacemakers, ICD, 41, 81, 85
Perfusion imaging methods and protocols, 56, 60, 64, 65, 70, 73, 74, 93, 101, 118, 119, 124, 237, 241, 384
PET imaging metabolism, 128, 164, 219, 228
PET imaging perfusion, 98, 120, 162, 212, 265, 266
Radiation exposure, 77, 102
Risk assessment and outcome in CAD, 125, 133, 139, 143, 207, 208, 211, 230, 231, 259, 270, 274, 351, 362, 365, 387
RNA (gated, first-pass) for LV and RV, 75, 293
SPECT gated and regional wall motion, 111, 261, 264, 275, 276, 279, 280, 282, 287, 289, 294
Stress techniques, 43, 57, 58, 76, 107, 108, 109, 210
Transplant, Cardiomyopathy, Myocarditis, 115, 121, 144, 262, 298
Ventricular function clinical, 67, 96, 260, 285
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11th International Conference of Non-Invasive Cardiovascular Imaging. J. Nucl. Cardiol. 20 (Suppl 1), 1–113 (2013). https://doi.org/10.1007/s12350-013-9685-3
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DOI: https://doi.org/10.1007/s12350-013-9685-3