Non-invasive Imaging for Management of Cardiovascular

Diseases

Dr. Muhammad Ayub, FCPSDiplomate Certification Board of Nuclear Cardiology

Diplomate Board of Cardiovascular Computed Tomography

Department of Cardiovascular Imaging

Punjab Institute of Cardiology Lahore

Trends in Imaging

Cardiovascular Imaging

Comparative spatial resolution

SPECT

PET Echo MRI CT

Resolution

(mm)

7-15 3-10 <1 <1 <1

Function Structure

Atherosclerosis and Imaging Modalities

Accuracy for diagnosis of CAD

Parameters Assessed with Various imaging Modalities

LV Function

Perfusion Coronary Pathology

Viability Valve Function

Radiation Dose

PET + + - + -

10-25 mSvSPECT + + - + -

Echo + + -+

IVUS

+ + -

MSCT + - + _ - 9.3-11.3 mSv

MRI + + _ + + -

Cardiac Cath

+ +TIMI Flow,TIMI Blush

+ - + 3-5 mSv

Applications of Nuclear Cardiology

Coronary Artery Disease Assessment of LV /RV function Cardiomyopathy /Myocarditis Valvular Heart Disease Cardiac Shunts Secondary Hypertension Pulmonary Hypertension Assessment of Cardiac Transplant

Nuclear Studies for Diagnosis of CAD

5.17.4

25.0

33.5 33.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Clinical +Ex Clin+Ex

+Cath

Clin+Ex

+SPECT

All

P=ns

P<.01

P<.01 P=ns

2

Iskandrian AS, et al. J Am Coll Cardiol. 1993;22:665-670. Reproduced with permission. Copyright 1993 by the American College of Cardiology.

N = 316

Incremental Prognostic Value of MPI

NS=not significant

Cardiac CT

Applications of Cardiac CT

Diagnosis of Coronary Artery Disease (intermediate probability)

Suspected Coronary Anomalies Assessment of grafts prior to redo CABG Assessment of complex congenital heart disease

(difficult echo) Suspected Aortic Dissection Suspected Pulmonary Embolism Assessment of Cardiac masses (difficult echo) Assessment of pericardial conditions (difficult

echo) Assessment of pulmonary veins prior to

radiofrequency ablation Assessment of coronary veins prior to

biventricular pacing

CTA Accuracy of MDCT for CAD

CTA Limitations

Rapid (>80 bpm) and irregular HR High calcium scores (>800-1000) Stents Contrast requirements (Cr > 2.0

mg/dl) Small vessels (<1.5 mm) and

collaterals Obese and uncooperative patients RADIATION EXPOSURE

Cardiac MRI

Diagnosis of CADMRI Vs SPECT

88% 90%

71%

91%

52%

88%

52%

87%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MRI SSS SRS SDS

Sensitivity

Specificity

MR Assessment of Myocardial Viability

MR Assessment of Myocardial Viability

time

N Myocardium

Gdinjection

infarct

1st pass Delayed enhancement

MRI Pros

No Radiation Less Toxic Gadolinium Contrast

Cons Expensive Claustrophobic Long Acquisition time Operator dependant Technical Artifacts with 3T Problem in patients with metallic prosthesis

Diagnostic Testing According to Clinical Need

Chest pain syndromeIntermediate Likelihood for CAD

Resting ECG abnormal or patient not able to Exercise

CTA MPI

Low to Intermediate Intermediate to High• Stress MPI• Stress Echo• Dobutamine

MR

CT Angiography

Evaluation of Chest Pain Syndrome

Equivocal Test

Equivocal

Equivocal

Myocardial Perfusion Imaging CT Coronary Angiography

Myocardial Perfusion Imaging CT Coronary Angiography

Evaluation of Suspected Coronary Anomalies

CT Angiography MR Angiography

50 years old male underwent CCA for FC III angina but RCA could not be engaged

The patient was referred for CT Angiography for suspected coronary anomaly

Diagnosis of Acute Chest Pain

Detection of CAD: Symptomatic—Acute Chest Pain

Intermediate pre-test probability of CAD. No ECG changes and serial enzymes negative

CT Coronary Angiography Resting MPI

Assessment of myocardial Viability

Cardiac MRI PET Metabolism/

perfusion Thallium 201/Tc-sestamibi

SPECT Low dose dobutamine

echo

Assessment of Cardiac Function Echocardiograp

hy Nuclear Studies Cardiac MRI Cardiac MDCT

Assessment of Valvular Function

Echocardiography

Cardiac MRI Nuclear Studies Cardiac CT

Assessment of Cardiac Shunts

Echocardiography Nuclear first pass

study Cardiac MRI Cardiac MDCT

Assessment of Cardiac Masses

Echocardiography Cardiac MRI Cardiac MDCT

Assessment of Pericardial ConditionsEchocardiography (TTE; TEE)Cardiac MRICardiac CT

Echo

MDCT

MRI

Assessment of Complex Congenital Heart Disease

Echocardiography Cardiac CT Cardiac MRI

CT MR

Assessment of Pulmonary Venous Anatomy before Radiofrequency Ablation Echocardiography CT Angiography

Post CABG Assessment

Noninvasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization

• MPI• CT Angiography

Suspected Aortic Aneurysm/ Dissection Echocardiography CT Angiography Cardiac MRI

Structure and Function—Evaluation of Aortic and Pulmonary Disease

Evaluation of suspected aortic dissection or thoracic aortic aneurysm

A (9)

Suspected Pulmonary Embolism Echocardiography CT Pulmonary Angiography Lung Perfusion Ventilation

Scan

Calcium Deposit (Atherosclerotic patient)

Soft Plaque( CTA, new ligands)

Perfusion deficit(Rb-82 stress and rest)

Three (Five) Tests in One Sitting

LV Function

Substrate Metabolism

Courtesy of E. Garcia, Emory U.

Is there any one stop shop?

Conclusions

No simple Recipe Appropriate Usage of all available

technologies according to clinical need

Thank you for listening