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Introduction toCardiac PET Perfusion Imaging
with CardioGen-82®
(Rubidium Rb 82 Generator)
Please see full prescribing information accompanying this presentation
Objectives
• Understand advantages of cardiac PET perfusion imaging
• List commercially available cardiac PET agents• Review technical aspects of CardioGen-82®• Discuss dedicated cardiac PET and PET/CT
protocols• Review clinical case studies
Advantages of Cardiac PET Perfusion Imaging
• Improved efficiency1 • Lower radiation exposure1
• Fewer attenuation artifacts1
• Improved resolution1
1. Bateman TM. PET Myocardial Perfusion Imaging: Making the Transition to a Clinical Routine. Appl Imaging: Applications Nucl Cardiol. 2002; 3(1): 1-6
Commercially Available Cardiac PET Agents
• Perfusion Imaging– Rubidium Rb 82– N-13 Ammonia
• Viability Imaging– F-18 Fluorodeoxyglucose (FDG)
Sensitivity & Specificity2 Author Sensitivity Specificity # Patients
Gould 95% 100% 50
Demer 94% 95% 193
Go 93% 78% 202
Schelbert 97% 100% 45
Yonekura 93% 100% 49
Williams 98% 93% 146
Stewart 84% 88% 319
Weighted Avg. 93% +/- 8 92% +/- 5 766
2. Nuclear Medicine Self-Study Program III: Nuclear Medicine Cardiology. Botvinik, EH, Ed. 1998: Society of Nuclear Medicine, Reston, VA.
CardioGen-82® (Rubidium Rb 82 Generator)
• Indication:
Useful in distinguishing normal from abnormal myocardium in patients with suspected myocardial infarction.
CardioGen-82® (Rubidium Rb 82 Generator)
• Rubidium-82 (Rb-82) is produced by decay of Strontium-82 (Sr-82)
• 75 second T½ • Kinetics:
– Potassium analog– High extraction fraction at high flow rates
• Defects visualized 2-7 minutes after injection• Same sized dose at stress & rest due to short T½ • New generator every 28 days• Fixed price, not unit dose• Dose available 24 hours per day, 7 days per week• Pharmacologic stress studies
CardioGen-82® (Rubidium Rb 82 Generator)
• Generator replaced every 28 days• Rb-82 dose is provided within 10
minutes• Generator must be utilized with the
calibrated CardioGen-82® Infusion System
• Infusion System is automated for the infusion and patient dose
• Permits accurate dosing with minimal operator interface, thus decreasing radiation exposure
• Contains shielding vault for CardioGen-82® Generator and waste container
Protocols
Sample Dedicated PET Protocol
Protocol courtesy of Timothy Bateman, MDProtocol courtesy of Timothy Bateman, MDApproximately 35 minutesApproximately 35 minutes
Rest Tx Rest Tx ScanScan
Rb-82Rb-82
DipyDipy0.56 mg/kg0.56 mg/kg
Rb-82Rb-82
Approx 4 minApprox 4 minApprox 5 minApprox 5 min
Approx 4 minApprox 4 minApprox 5 minApprox 5 min
Approx 3 minApprox 3 min
EmissionEmissionScan 2DScan 2D
10 phases10 phases30 seconds30 seconds
Rb-82Rb-82
3D Gated3D Gated ScanScan
Approx 3 minApprox 3 min
3D Gated3D Gated ScanScan
EmissionEmissionScan 2DScan 2D
Stress Tx Stress Tx ScanScan
10 phases10 phases30 seconds30 seconds
Sample PET/CT Protocol
Protocol courtesy of Marcelo DiCarli, MDProtocol courtesy of Marcelo DiCarli, MDApproximately 30 minutesApproximately 30 minutes
scoutscout CT-transCT-trans
Rb-82Rb-8250-60 mCi50-60 mCi
70-90 sec70-90 sec90-120 sec90-120 sec
gatedgatedrestrest
pt outpt out
DipyDipy0.56 mg/kg0.56 mg/kg
scoutscoutCT-transCT-trans
70-90 sec70-90 sec90-120 sec90-120 sec
Rb-82Rb-8250-60 mCi50-60 mCi
gatedgatedstressstress
Approx 1 minApprox 1 min Approx 7 minApprox 7 min Approx 6 minApprox 6 min Approx 1 minApprox 1 min Approx 7 minApprox 7 min
Case Studies
Normal Rest-Stress CardioGen-82® Myocardial
Perfusion PET StudyRest/Dipyridamole Stress CardioGen-82®
Courtesy of Tim Bateman, MDMid America Heart InstituteKansas City, MO
CASE 1
HX: 60 year-old female admitted to hospital in the early morning after a 45 minute episode of central chest pain that began after smoking a cigarette.
Risks: Smoker, Hypertension
Rest ECG: T-wave flattening
Enzymes: Normal X2
PMH: GERD, Depression, Post-traumatic stress disorder
Meds: Atenolol
Reason for PET CardioGen-82® study:
• Patient was on beta blocker, pharm stress preferred
• Referring MD seeking results within 1 hour
STRESS
REST
CASE 1
TID Ratio 0.96
CASE 1
PEAK STRESS
REST
LVEF 76%
LVEF 67%
Rest/Stress Dipyridamole CardioGen-82® Myocardial Perfusion PET Report: Case 1
Clinical Response: Non-diagnostic (Dipyridamole)
ECG-Response: Non-ischemic
Scintigraphic Response: Non-ischemic
The combined test findings indicate the following:
• Low-likelihood for acute coronary syndrome
• No ischemia or regions of myocardial injury
• Normal segmental contraction and thickening
• Normal global LV function with rest LVEF 67% and peak stress LVEF 76%
Characteristics of a Normal CardioGen-82® Myocardial Perfusion PET Study
• Uniform distribution of tracer, independent of gender
• LV cavity at peak stress equal to or smaller than at rest
• Uniform and normal wall thickness and thickening
• Uniform and normal regional wall motion
• Peak stress LVEF > rest LVEF
Abnormal Rest-Stress CardioGen-82® Myocardial
Perfusion PET Study: Multivessel Abnormality
Rest/Dipyridamole Stress CardioGen-82® Myocardial Perfusion PET Study
Courtesy of Timothy Bateman, MDMid America Heart InstituteKansas City, MO
CASE 2: Abnormal (MVD)
History: 73 year-old large female (BMI 40) admitted to hospital after 2 hours of left-sided chest pain
and acute left-sided weakness and numbness
Hospital course: Neurologic symptoms resolved; troponins nl.
PMH: Stents in PDA and proximal LAD; polymyositis
ECG: Normal
Reason for PET CardioGen-82® study:
• Polymyositis and recent CVA event, pharm stress preferred
• Patient’s body habitus
CASE 2 STRESS
REST
TID Ratio 1.38
CASE 2PEAK
STRESS
REST
LVEF 58%
LVEF 68%
Rest/Stress Dipyridamole CardioGen-82® Myocardial Perfusion PET Report: Case 2
The combined test findings indicate the following:
• Moderate sized region of intense ischemia involving the entire septum, from base to apex
• Peak-stress transient myocardial stunning with loss of regional contraction and thickening
• Normal LV regional and global function at rest (LVEF 68%)
• Ventricular decompensation with stress (transient cavity enlargement and drop in LVEF to 58%)
• Results communicated verbally at time of dictation
CASE 2 (Continued)
Results
Coronary angiography showed an 80% stenosis of a posterior descending branch of the right coronary artery, and a large 1st septal perforator that was “jailed” by the LAD stent.
The PDA was stented; the septal perforator was judged to best be left alone due to concerns about compromising the LAD itself.
Characteristics of an Abnormal CardioGen-82® Myocardial Perfusion PET Study in Multiple Coronary Territories
• Decrease in regional tracer uptake at peak stress in more than one coronary artery distribution
• LV cavity at peak stress much larger than at rest
• Frequent and multiple regional contraction abnormalities (stunning) at peak stress
• Peak stress LVEF < rest LVEF
Summary
• Cardiac PET perfusion offers:– Improved efficiency1 – Lower radiation exposure1
– Fewer attenuation artifacts1 – Improved resolution1
• CardioGen-82® (Rubidium Rb 82 Generator) fits well into any cardiac PET perfusion operation
1. Bateman TM. PET Myocardial Perfusion Imaging: Making the Transition to a Clinical Routine. Appl Imaging: Applications Nucl Cardiol. 2002; 3(1): 1-6