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Jamshid Maddahi, M.D., FACC, FASNCJamshid Maddahi, M.D., FACC, FASNC
Assessment of Myocardial ViabilityAssessment of Myocardial Viability
Professor Molecular and Medical Pharmacology
(Nuclear Medicine) and Medicine (Cardiology)
David Geffen School of Medicine at UCLA
Professor Molecular and Medical Pharmacology
(Nuclear Medicine) and Medicine (Cardiology)
David Geffen School of Medicine at UCLA
Director, Biomedical Imaging InstituteDirector, Biomedical Imaging Institute
Definition of Myocardial ViabilityDefinition of Myocardial Viability
Potential for improvement ofPotential for improvement of
myocardial dysfunctionmyocardial dysfunction
after revascularizationafter revascularization
Potential for improvement ofPotential for improvement of
myocardial dysfunctionmyocardial dysfunction
after revascularizationafter revascularization
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Causes of Abnormal Regional Wall Motion andPotential for Recovery after RevascularizationCauses of Abnormal Regional Wall Motion andPotential for Recovery after Revascularization
Recovery afterRecovery afterCauses of AbnormalCauses of Abnormal
Transmural MITransmural MI
Nontransmural MINontransmural MI
HibernatingHibernating
Transmural MITransmural MI
Nontransmural MINontransmural MI
HibernatingHibernating
Recovery after Revascularization
Recovery after Revascularization
NoNo
NoNo
NoNo
NoNo
Causes of Abnormal Regional Wall motionCauses of Abnormal
Regional Wall motion
HibernatingHibernating
StunnedStunned
Repetitively StunnedRepetitively Stunned
MyopathicMyopathic
HibernatingHibernating
StunnedStunned
Repetitively StunnedRepetitively Stunned
MyopathicMyopathic
YesYes
SpontaneousSpontaneous
YesYes
NoNo
YesYes
SpontaneousSpontaneous
YesYes
NoNo
Myocardial Perfusion, Reperfusion, and FunctionMyocardial Perfusion, Reperfusion, and Function
Hibernation100
PerfusionFunctionPerfusionFunction
(%)
Nor
mal
80
60
40
20
010
Elapsed Time
0 2 6 8 104Days Weeks
RevascularizationRevascularization
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Myocardial Perfusion, Reperfusion, and FunctionMyocardial Perfusion, Reperfusion, and Function
100
Repetitive Stunning
RevascularizationRevascularization
(%)
Nor
mal
80
60
40
RevascularizationRevascularization
PerfusionFunctionPerfusionFunction
20
00 2 6 8 104
Days Weeks
Elapsed Time
rest
redist
Short Axis
rest
redist
Vertical Long Axis
rest
redist
Horizontal Long Axis
UCLA
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Rest
Redist
Rest
Redist
Rest
Redist
Rest
Redist
Question
What is the likelihood of improvement of functionf ll i l i ti ?following revascularization?
A) High (>80%)
B) High-intermediate (60%-70%)
C) Intermediate (50% 60%)C) Intermediate (50%-60%)
D) Low-intermediate (30%-40%)
E) Low (<20%)
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D.S. 1
Question
Resting LVEF is 24%. What is the most likely LVEFf ll i l i ti ?following revascularization?
A) <30%
B) 30%-34%
C) 35% 39%C) 35%-39%
D) 40%-44%
E) 45%-50%
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D.S. 1
• SPECT tracers are inherently good markers of
PET vs. SPECT for Viability AssessmentWhen to Use What
PET vs. SPECT for Viability AssessmentWhen to Use What
myocardial viability, but their myocardial uptake is flow dependent.
• About 35% of nonreversible SPECT defects are hibernating myocardium with severe reduction of blood flow.
• SPECT underestimates the extent of myocardial viability.
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Clinical History
M.L.
76 year-old male with history of MI and S/P CABG
Presenting with angina and symptoms of heart failure
SPECT study showed nonreversible inferior, apical,and inferolateral defects
PET was performed to assess viability
VerticalLong Axis
M.L. p51896
ShortAxis Axial
Rest NH3
Rest FDG
UCLA
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Rest NH3 Rest FDG
M.L. p51896
UCLA
PET Viability Patterns
Perfusion-R FDG-PP FDG-Fast
Normal Normal Normal
Tx MI Absent Absent
Non-Tx MI 1-2+ Reduced 1-2 + Reduced
Hibernating 1-3 + Reduced Normalg
Repetitively stunned
Myopathic
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Restperfusion
RestFDG
Horizontallong axis
Verticallong axis
Short axis
UT Health Science Center
What is the patient’s metabolic state?
Question
A) Fasting
B) Post-prandial
C) Diabetic
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What is the pattern of viability in the inferior wall?
Question
A) Hibernating
B) Non-transmural infarction
C) Transmural infarction
D) Non-ischemic myopathy
E) Repetitively stunned
Restperfusion
RestFDG
Pt#20
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PET Viability Patterns
Perfusion-R FDG-PP FDG-Fast
Normal Normal Normal Absent
Tx MI Absent Absent Absent
Non-Tx MI 1-2+ Reduced 1-2 + Reduced Absent
Hibernating 1-3 + Reduced Normal Normalg
Repetitively stunned
Myopathic
Clinical History
C.S.• 47 year-old male with no prior cardiac history,
experienced sudden death at a job interview. VFib p jconverted to NSR and was transferred to UCLA.
• Emergency coronary angiogram:– LAD: 90% proximal, 80% mid, 90% Dx– LCX: 100% OM– RCA: 100% proximal
E h di EF 20 25% LVEDD 69 l b l• Echocardiogram: EF 20-25%, LVEDD 69 mm, global hypokinesis. Normal RV size with reduced function. Mild pulmonary HTN, RVSP 35-40 mmHg. Moderate MR
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EKG on admissionEKG on admission
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Restperfusion
Stressperfusion
Horizontallong axis
Verticallong axis
Short axis
UT Health Science Center
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PET Viability Patterns
Perfusion-R FDG-PP FDG-Fast
Normal Normal Normal Absent
Tx MI Absent Absent Absent
Non-Tx MI 1-2+ Reduced 1-2 + Reduced Absent
Hibernating 1-3 + Reduced Normal Normalg
Repetitively stunned
Normal/
1+ reduced
Normal Variable
Myopathic Normal Normal Absent
Added Benefits of Stress Perfusion Imaging
1 Better Identification of candidates for revascularization1. Better Identification of candidates for revascularization
by detecting jeopardized myocardium
2. Differentiation of repetitively stunned from myopathic
myocardium
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PET Viability Patterns
Perfusion-R FDG-PP Perfusion-S
Normal Normal Normal Normal/
decrease
Tx MI Absent Absent Absent
Non-Tx MI 1-2+ Reduced 1-2+ Reduced No change/
More decrease
Hibernating 1-3 + Reduced Normal No change/Hibernating 1 3 + Reduced Normal No change/
More decrease
Repetitively stunned
Normal/
1+ reduced
Normal Decrease
Myopathic Normal Normal Normal