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Pet Myocardial Perfusion Imaging-MPI PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "PET Myocardial Perfusion Imaging (MPI)”.

This medical PowerPoint presentation is about PET myocardial perfusion imaging (MPI), a type of medical imaging that is used to evaluate the blood flow to the heart muscle. This imaging technique is often used to diagnose and monitor heart disease, including coronary artery disease and ischemic heart disease.

During a PET MPI scan, a small amount of radioactive tracer is injected into the patients bloodstream. The tracer is typically a radioactive form of glucose that is taken up by the heart muscle in proportion to the amount of blood flow. The patient is then placed in a PET scanner, which detects the radiation emitted by the tracer and produces images of the heart.

The images produced by a PET MPI scan can show areas of reduced blood flow in the heart muscle, indicating areas of ischemia or infarction. This information can be used to identify the presence and extent of heart disease, and to guide treatment decisions.

PET MPI scans are typically performed in conjunction with a stress test, which can be induced through physical exercise or medication. This helps to simulate the conditions of increased cardiac demand that can reveal underlying heart disease.

Overall, PET MPI is a valuable tool for evaluating heart disease and guiding treatment decisions, and is often used in conjunction with other imaging techniques such as echocardiography and cardiac catheterization.

Tags : PET myocardial perfusion imaging, medical imaging, blood flow, heart muscle, heart disease, coronary artery disease,ischemic heart disease, PET MPI scan, Nuclear Medicine, Nuclear Medicine PowerPoint presentation

Published on : Jun 20, 2023 | Views : 470 | Downloads : 1

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Slide 1-

Insert Name Here PET Myocardial Perfusion Imaging (MPI)
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Objectives Discuss the technical aspects of positron emission tomography (PET) Review Cardiac PET tracers and imaging protocols Compare Cardiac PET to SPECT Review clinical case studies Understand the role of Cardiac PET in optimizing the management of patients with known or suspected CAD
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Why not just use SPECT for nuclear cardiology? SPECT diagnostic accuracy is good for some patients, but leaves room for improvement Pharm stress studies are often difficult to read due to gut uptake1-2 Obese and some female patients may have attenuation issues1-2 Underestimation of extent & severity of CAD Tc-99m SPECT tracer kinetics are not proportional to blood flow, and have extracardiac uptake1,3 Limited detection of multi-vessel disease1,3 Desire for Improved Efficiency 30 minutes with PET vs. 2.5 – 4 hours with SPECT1-2,4 1. Bateman, et. al. Journal of Nuclear Cardiology. 2006. 2. Merhige, et al. J Nucl Med. 2007 3. Yoshinaga, et al. JACC. 2006. 4. Bateman Amer J Cardiol. 2004.
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Image Quality1,3 Excellent spatial resolution and attenuation correction Diagnostic Accuracy5 95% sensitivity, 95% specificity Interpretive Certainty1-3 Better images = greater diagnostic confidence Efficiency1-2,4 30-45min. complete gated rest/stress studies Prognostic Value, Risk Stratification3,6 Useful for making patient management decisions What are the advantages of PET MPI? 1. Bateman, et. al. Journal of Nuclear Cardiology. 2006. 2. Merhige, et al. J Nucl Med. 2007 3. Yoshinaga, et al. JACC. 2006. 4. Bateman Amer J Cardiol. 2004. 5. Gould, KL. Circulation. 1994. 6. Chow, et al. J Nucl Med. 2005.
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Q: Who else is doing Cardiac PET? A: All Top 10 Hospitals (U.S. News & World Report)7 7. http://health.usnews.com/articles/health/best-hospitals/2008/07/10/best-hospitals-honor-roll.html
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Siemens PET/CT Camera Image Courtesy of Siemens Healthcare
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GE PET/CT Camera Image Courtesy of GE Healthcare
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Positron Emission Tomography http://en.wikipedia.org/wiki/Image:PET-schema.png
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Physics of Rb-82 PET Video courtesy of Simon Cherry, Ph.D., University of California-Davis
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PET MPI Tracers Currently Available Rubidium-82 N-13 Ammonia 0-15 Water (research) In Development F-18 labeled agents
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PET MPI Tracers 8. Nuclear Medicine Self-Study Program III: Nuclear Medicine Cardiology. Botvinik, EH, Ed. 1998: Society of Nuclear Medicine, Reston, VA.
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Pharmacokinetics & Physics Benefits of PET MPI PET MPI uses higher energy tracers (511keV vs. 140KeV for SPECT) Leads to higher count rates, improved image quality1-4 PET MPI tracers (Rb-82 & N-13 Ammonia) have a high myocardial extraction fraction at peak stress flow1,9-10 Tracer uptake is more proportional to myocardial blood flow, facilitates better detection of disease PET MPI offers attenuation correction on all scans1,4-5 Reduces ambiguity, enhances interpretive certainty 1. Bateman, et. al. Journal of Nuclear Cardiology. 2006. 2. Merhige, et al. J Nucl Med. 2007 3. Yoshinaga, et al. JACC. 2006. 4. Bateman Amer J Cardiol. 2004. 5. Gould, KL. Circulation. 1994. 9. Mullani, NM. Journal of Nuclear Medicine. 1983. 10. Dilsizian, V. Atlas of Nuclear Cardiology. 2003.
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PET Myocardial Perfusion Imaging Evaluation of known or suspected CAD May be used in place of or following an equivocal SPECT study FDG Imaging Myocardial Viability Evaluation of cardiac metabolism Helpful to compare PET Viability to PET MPI for perfusion/metabolism mismatch Cardiac sarcoid Cardiac PET Indications 11. Machac et al. J Nucl Cardiol 2006.
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PET vs. SPECT: An MPI Case Review
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PET MPI provides better Image Quality than SPECT MPI 1. Bateman, et. al. Journal of Nuclear Cardiology. 2006
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Why is the Image Quality with PET better than SPECT? Enhanced Image Quality for PET vs. SPECT due to:1-3,6 Higher count rates (240% increase over SPECT) Improved spatial resolution Routine and robust attenuation correction on all scans Images can be sliced at 3mm (PET) instead of 6mm (SPECT) to better detect multi-vessel disease 1. Bateman, et. al. Journal of Nuclear Cardiology. 2006, 2. Merhige, et al. J Nucl Med. 2007, 3. Yoshinaga, et al. JACC. 2006. 6. Chow, et al. J Nucl Med. 2005.
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Case #1: Patient Profile Demographics: 77-year-old female Body Habitus: Weight:160 lbs., Height: 61 inches, BMI: 31 Reason for Test: Atypical chest pain Risk Factor: Hypertension ECG: Shows normal sinus rhythm and nonspecific T-wave abnormalities Meds: atenolol, famotidine, aspirin, Lovenox®* *Lovenox (enoxaparin sodium injection) is a registered trademark of Aventis Pharmaceuticals Inc. Following are images of a patient who underwent a SPECT MPI and a PET MPI study 2 weeks apart at Harvard/Brigham & Women’s Hospital in Boston, MA
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Cardiac PET/CT Protocol Protocol courtesy of Marcelo DiCarli, MD Harvard/Brigham & Women’s Hospital scout CT-trans Rb-82 50-60 mCi 70-90 sec 90-120 sec gated rest pt out Dipy 0.56 mg/kg scout CT-trans 70-90 sec 90-120 sec Rb-82 50-60 mCi gated stress Approx 1 min Approx 7 min Approx 6 min Approx 1 min Approx 7 min Approximately 30 minutes
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Case courtesy of Marcelo DiCarli, MD, Harvard/Brigham & Women’s Hospital, Boston, MA Case #1: SPECT Images
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Case courtesy of Marcelo DiCarli, MD, Harvard/Brigham & Women’s Hospital, Boston, MA Case #1: 82Rb PET Images
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Protocols SPECT PET Adenosine (4 min.) ◄ Mode of Stress ► Dipyridamole (4 min.) Non-ischemic ◄ Clinical Response ► Non-ischemic Normal ◄ BP Response ► Normal Negative ◄ ECG Response ► Negative Tc-99m sestamibi ◄ Radiopharmaceutical ► Rubidium-82 11mCi / 33mCi ◄ Rest/Stress Dose ► 60mCi / 60mCi Yes ◄ Gated ► Yes Coronary Angiography Cardiac catheterization was not performed because the PET MPI study was normal. Case #1 Summary Case courtesy of Marcelo DiCarli, MD, Harvard/Brigham & Women’s Hospital, Boston, MA
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Case #2 Patient Profile Patient Demographics Demographics: 59 yr old female Body Habitus: H: 5’ 5”, W: 140 lbs, BMI: 23.3 Kg/m2 Reason for Test: Referred for evaluation of atypical chest pain and dyspnea Time between PET and SPECT: 12 days Meds: Lopressor, Amlodipine, Captopril, Lasix, Aspirin, Zocor, Bupropion Following are images from a patient who underwent a SPECT MPI study followed by a PET MPI study at Harvard/Brigham & Women’s Hospital in Boston, MA Case courtesy of Marcelo DiCarli, MD, Harvard/Brigham & Women’s Hospital, Boston, MA
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Case #2 SPECT Images Case courtesy of Marcelo DiCarli, MD and Sharmila Dorbala, MBBS, Harvard/Brigham & Women’s Hospital, Boston, MA
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Case #2: 82Rb PET Images Case courtesy of Marcelo DiCarli, MD and Sharmila Dorbala, MBBS, Harvard/Brigham & Women’s Hospital, Boston, MA
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Protocols SPECT PET Adenosine (4 min.) ◄ Mode of Stress ► Dipyridamole (4 min.) Non-ischemic ◄ Clinical Response ► Non-ischemic Normal ◄ BP Response ► Normal Negative* ◄ ECG Response ► Negative* Tc-99m sestamibi ◄ Radiopharmaceutical ► Rubidium-82 12mCi / 30mCi ◄ Rest/Stress Dose ► 36mCi / 36mCi Yes ◄ Gated ► Yes * Patient had normal sinus rhythm and non-specific ST-T wave abnormalities on the resting ECG prior to the MPI studies Case #2 Protocol Comparison Case courtesy of Marcelo DiCarli, MD and Sharmila Dorbala, MBBS, Harvard/Brigham & Women’s Hospital, Boston, MA
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Case #2 Report Comparison SPECT MPI Report There was a small defect of moderate intensity in the mid to apical anterior wall that remained fixed on the rest images and most likely is due to breast attenuation artifact; however a non-transmural myocardial scar cannot be excluded. PET MPI Report There were no regional perfusion defects seen on the stress or rest images. The patient’s PET/CT test results are normal and suggest no evidence of flow-limiting CAD. The results suggest that the previously described fixed anterior wall defect (her prior SPECT study) is likely to represent an attenuation artifact. Cardiac catheterization was not performed because the PET MPI study was normal. Case courtesy of Marcelo DiCarli, MD and Sharmila Dorbala, MBBS, Harvard/Brigham & Women’s Hospital, Boston, MA
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Case #3 Patient Profile Demographics: 82 year old male Body Habitus: 5’10”, 210lbs., BMI: 30.1 Kg/m2 PMH: hypertension Reason for Test: Preoperative cardiac evaluation prior to hip replacement surgery Meds: ASA, Bisoprolol Fulmate Following are images from a patient who underwent a SPECT MPI study followed by a PET MPI study at University Hospitals Case Medical Center in Cleveland, OH. Case courtesy of Jim O’Donnell, MD, University Hospitals Case Medical Center, Cleveland, OH
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Case #3 SPECT Images Case courtesy of Jim O’Donnell, MD, University Hospitals Case Medical Center, Cleveland, OH
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Case courtesy of Jim O’Donnell, MD, University Hospitals Health System, Cleveland, OH Case #3 82Rb PET Images Case courtesy of Jim O’Donnell, MD, University Hospitals Case Medical Center, Cleveland, OH
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Protocols SPECT PET Dipyridamole ◄ Mode of Stress ► Dipyridamole Non-ischemic ◄ Clinical Response ► Non-ischemic Normal ◄ BP Response ► Normal Negative ◄ ECG Response ► Negative Tc-99m sestamibi ◄ Radiopharmaceutical ► Rubidium-82 10mCi / 33mCi ◄ Rest/Stress Dose ► 47mCi / 47mCi Yes ◄ Gated ► Yes 2.5 hours ◄ Length of TIme ► 40 min Case #3 Protocol Comparison Case courtesy of Jim O’Donnell, MD, University Hospitals Case Medical Center, Cleveland, OH
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Case #3 Report Comparison SPECT MPI Report Fixed defect is noted at the apex, which does not move or thicken appropriately and likely represents a scar. There is no SPECT evidence of ischemia. LV ejection fraction of 40 percent (normal above 45 percent). PET MPI Report The PET images demonstrate the above-described apical scar pattern but also demonstrate a mild to moderate anterior ischemic pattern involving the distal half of the anterior segment. This is suggestive of mild peri-infarct ischemia. The LV ejection fraction in the PET study is 53% at rest rising to 57% with pharmacologic stress (normal left ventricular function). Statistically, the likelihood of a perioperative event is still fairly low. Even though this patient received pre-op clearance for hip surgery, the detection of ischemia on the PET study provided prognostically useful information to assist in the management of this patient’s progressive CAD. Case courtesy of Jim O’Donnell, MD, University Hospitals Case Medical Center, Cleveland, OH
Slide 32-

SPECT PET DIAGNOSTIC ACCURACY BY GENDER DIAGNOSTIC ACCURACY BY BMI 69% 84% *P = 0.55 67% 88% *P = 0.009 70% 87% 67% 85% *P = 0.05 *P = 0.02 MVD SENSITIVITY 48% 71% *P = 0.03 1. Bateman TM et al. J Nucl Cardiol. 2006. Diagnostic Accuracy: PET vs. SPECT
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12. Dorbala et al. J Nucl Med. 2007;48:349-358. P < 0.0001 P < 0.0001 P = 0.003 Left Ventricular EF Reserve & Magnitude of Jeopardized Myocardium
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Case #4 Overview 69 year-old female admitted to hospital after a cerebrovascular accident; found to be in atrial fibrillation; small increase in troponin i. PMH: Hypertension; Type II diabetes Rest/dipyridamole stress Rubidium-82 myocardial perfusion PET study Case courtesy of Tim Bateman, MD, Cardiovascular Consultants, Kansas City, MO
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REST TID Ratio 1.63 STRESS Case #4 82Rb PET Images Case courtesy of Tim Bateman, MD, Cardiovascular Consultants, Kansas City, MO Near Balanced Flow Reduction
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PEAK STRESS REST LVEF 50% LVEF 61% Case #4 82Rb PET Functional Images Case courtesy of Tim Bateman, MD, Cardiovascular Consultants, Kansas City, MO
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Case #4 Report The combined test findings indicate the following: Virtually diagnostic for the presence of CAD. Apical ischemia probably in the distribution of the left anterior descending coronary artery. Severe transient ventricular dilation, suggesting possible near-balanced flow reduction in multiple coronary territories. Normal left ventricular function at rest (LVEF 61%). Significant drop in LVEF in response to pharmacologic stress. Prognostically concerning scan, with numerous markers of high-risk for major adverse coronary events. See the text box for this person’s full PET interpretation report. Case courtesy of Tim Bateman, MD, Cardiovascular Consultants, Kansas City, MO
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Case #4 Cath Correlation Coronary angiography showed a 75% left main stenosis, a 90% stenosis of the mid LAD, and a 70% right coronary artery stenosis. CABG surgery was performed after recovery from the CVA. Case courtesy of Tim Bateman, MD, Cardiovascular Consultants, Kansas City, MO
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PET MPI offers improved Interpretive Certainty compared to SPECT MPI 1. Bateman, et. al. Journal of Nuclear Cardiology. 2006
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Which patient types may benefit from a PET MPI study?
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Pharmacologic Stress MPI Patients A study conducted by 2 past presidents of the American Society of Nuclear Cardiology (ASNC) - Tim Bateman, MD and Gary Heller, MD, PhD - and colleagues concluded, “Our investigation provides evidence that for patients who require pharmacologic stress, PET imaging may be preferable to SPECT.” 1. Bateman, et. al. Journal of Nuclear Cardiology. 2006
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Female Patients1,3,6 Image courtesy of GE Healthcare 1. Bateman, et. al. Journal of Nuclear Cardiology. 2006. 3. Yoshinaga, et al. JACC. 2006. 6. Chow, et al. J Nucl Med. 2005. Women may have diffuse coronary artery disease which can be more challenging to diagnose with SPECT Female patients can have smaller hearts This requires a test with greater resolution for better image quality Especially those who are: Pharm Stress Large Breasted Obese (BMI >30)
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Obese Patients 3. Yoshinaga, et. al. JACC. 2006.
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Prognostic Value of PET MPI: Utility for Making Patient Management Decisions Figure 1. (A) Risk-adjusted survival, free from hard cardiac events (cardiac death and nonfatal myocardial infarction), as a function of summed stress score (SSS). 3. Yoshinaga, et. al. JACC. 2006.
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Summary The physics of PET and pharmacokinetics of the tracers are more optimal for MPI1-5, 9-10 PET MPI addresses the need for improved interpretive certainty and greater efficiency1-4 Cardiac PET performs well even with challenging patient types (e.g. pharm stress, obese, female) and more accurately identifies multi-vessel disease1,3-4,6 PET MPI can help improve the management of patients with known or suspected CAD1-3,6 1. Bateman, et. al. Journal of Nuclear Cardiology. 2006. 2. Merhige, et al. J Nucl Med. 2007 3. Yoshinaga, et al. JACC. 2006. 4. Bateman Amer J Cardiol. 2004. 5. Gould, KL. Circulation. 1994. 6. Chow, et al. J Nucl Med. 2005. 9. Mullani, NM. Journal of Nuclear Medicine. 1983. 10. Dilsizian, V. Atlas of Nuclear Cardiology. 2003.
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References Bateman, TM, Heller, GV, McGhie, IA, et. al. Diagnostic Accuracy of Rest/Stress ECG-gated Rb-82 Myocardial Perfusion PET: Comparison with ECG-gated Tc-99m Sestamibi SPECT. Journal of Nuclear Cardiology. 2006;13:24-33. Merhige ME, Breen WJ, Shelton V, et al. Impact of myocardial perfusion imaging with PET and (82)Rb on downstream invasive procedure utilization, costs, and outcomes in coronary disease management. J Nucl Med. 2007;48:1069-1076. Yoshinaga, K, Chow, BW, Williams, K, et. al. What is the Prognostic Value of Myocardial Perfusion Imaging Using Rubidium-82 Positron Emission Tomography? JACC. 2006; 48:1029-39. Bateman, TM. Cardiac Positron Emission Tomography and the Role of Adenosine Pharmacalogic Stress. American Journal of Cardiology. 2004; 94:19-24. Gould, KL. Reversal of Coronary Atherosclerosis: Clinical Promise as the Basis for Non-invasive Management of Coronary Artery Disease. Circulation. 1994;90:1558-1571. Chow BJ, Wong JW, Yoshinaga K, et. al. Prognostic Significance of Dipyridamole-Induced ST Depression in Patients with Normal 82Rb PET Myocardial Perfusion Imaging. J Nucl Med. 2005;46:1095-1101. http://health.usnews.com/articles/health/best-hospitals/2008/07/10/best-hospitals-honor-roll.html, accessed Feb. 9, 2009 Nuclear Medicine Self-Study Program III: Nuclear Medicine Cardiology. Botvinik, EH, Ed. 1998: Society of Nuclear Medicine, Reston, VA. Mullani, NM, Goldstein, RA, Gould KL, et. al. Myocardial perfusion with rubidium-82. Measurement of extraction fraction and flow with external detectors. J Nucl Med. 1983; 24:898-906. Dilsizian, V. Atlas of Nuclear Cardiology. 2003. Machac et al. PET Myocardial Perfusion and Glucose Metabolism Imaging. J Nucl Cardiol 2006.13:e121-51. Dorbala, S, Vangala, D, Sampson, U, et al. Value of Vasodilator Left Ventricular EjectionFraction Reserve in Evaluating the Magnitude ofMyocardium at Risk and the Extent ofAngiographic Coronary Artery Disease:A 82Rb PET/CT Study. J Nucl Med. 2007;48:349-358.