cardio respiratory nuclear imaging ihab - copy

Cardio-Respiratory Nuclear Cardio-Respiratory Nuclear Imaging from basics to Imaging from basics to

challenging clinical caseschallenging clinical casesDr Ihab Suliman FESCDr Ihab Suliman FESC

Assistant professor of Cardiology and Assistant professor of Cardiology and Consultant Division of advanced Consultant Division of advanced

Cardiac ImagingCardiac ImagingMember of the European working Member of the European working group on nuclear cardiology and group on nuclear cardiology and

cardiac CTcardiac CTMember of the Saudi ministry of health Member of the Saudi ministry of health experts panel committee on guidelinesexperts panel committee on guidelines

3/9/20163/9/2016

DisclosureDisclosure Nothing to declareNothing to declare

NUCLEAR MEDICINE NMNUCLEAR MEDICINE NM IMAGING SPECIALITY THAT FOCUSES ON IMAGING SPECIALITY THAT FOCUSES ON

THE USE OF RADIOACTIVE MATERIALS THE USE OF RADIOACTIVE MATERIALS CALL “RADIOPHARMACEUTICALS” FOR CALL “RADIOPHARMACEUTICALS” FOR DIAGNOSIS, THERAPY, AND MEDICAL DIAGNOSIS, THERAPY, AND MEDICAL RESEARCH.RESEARCH.

NMNM

Physiology & FunctionPhysiology & Function

RadiopharmaceuticalsRadiopharmaceuticals

+Biochemical

BondingPharmaceutical

Traces physiology / localises in organs of interest

Radioactivenuclide

Emits radiation for detection or therapy

TRACERSTRACERS ARE SELECTED THAT LOCALIZE IN ARE SELECTED THAT LOCALIZE IN

SPECIFIC ORGANS OR TISSUESSPECIFIC ORGANS OR TISSUES Ex: GLUCOSEEx: GLUCOSE

THE AMOUNT OF RADIOACTIVE THE AMOUNT OF RADIOACTIVE TRACER MATERIAL IS SELECTED TRACER MATERIAL IS SELECTED CAREFULLY TO PROVIDE THE CAREFULLY TO PROVIDE THE LOWEST AMOUNT OF RADIATION LOWEST AMOUNT OF RADIATION EXPOSUREEXPOSURE

RADIOACTIVE TRACERSRADIOACTIVE TRACERS PRODUCE ALPHA,GAMMA or BETA PRODUCE ALPHA,GAMMA or BETA

EMISSION FROM WITHIN THE ORGAN EMISSION FROM WITHIN THE ORGAN BEING STUDIEDBEING STUDIED

EMISSIONS ARE TRANSFORMED INTO EMISSIONS ARE TRANSFORMED INTO IMAGE THAT PROVIDE INFORMATION IMAGE THAT PROVIDE INFORMATION ABOUT THE FUNCTION OF THE ABOUT THE FUNCTION OF THE ORGAN OR SYSTEM BEING STUDIED.ORGAN OR SYSTEM BEING STUDIED.

ALARA ALARA Radiation Radiation exposure is an exposure is an occupational reality in occupational reality in NMT. Good radiation NMT. Good radiation safety practices keep safety practices keep exposures “exposures “AAs s LLow ow AAs s RReasonably easonably AAchievable” (ALARA).chievable” (ALARA).

• FILM BADGESFILM BADGES

• RING BADGESRING BADGES

• SPILLED SPILLED CHEMICALS CHEMICALS MUST BE MUST BE CLEANED UP CLEANED UP IMMEDIATELYIMMEDIATELY

INSTRUMENTATIONINSTRUMENTATION• RADIOACTIVE DETECTORSRADIOACTIVE DETECTORS

– GEIGER COUNTERGEIGER COUNTER– DOSE CALIBRATORDOSE CALIBRATOR

Exposure vs Effective doseExposure vs Effective dose the mean effective dose: the mean effective dose:

• NM diagnostic NM diagnostic procedureprocedure

• CXRCXR• UGI seriesUGI series• Lower GI seriesLower GI series• CT HeadCT Head• CT ChestCT Chest• CT AbdomenCT Abdomen

• 4.6 mSv4.6 mSv

• 0.008 mSv0.008 mSv• 4.5 mSv4.5 mSv• 6 mSv6 mSv• 1.5 mSv1.5 mSv• 5.4 mSv5.4 mSv• 3.9 mSV – 6.1 mSv3.9 mSV – 6.1 mSv

Gamma CameraGamma Camera

Dual Head Gamma Dual Head Gamma CameraCamera

Single Head Gamma Single Head Gamma CameraCamera

Triple Head Gamma Triple Head Gamma CameraCamera

The Gamma CameraThe Gamma Camera

Positioncircuitry

X Y Z

Collimator

NaICrystal

Photo Multiplier Tubes

Analogue to Digital Converters

Digitalcircuitry

Output position & energy signals

Tc-99m preparationTc-99m preparation

Tc-99mTc-99m

What does the heart do ?What does the heart do ?• The heart is a powerful muscle

consisting of two pumps side by side.

• Its steady beating maintains flow of blood to all parts of the body throughout life.

ECG/ Treadmill RadiographyEchocardiographyCT scanMRIAngiographyRadionuclide Radionuclide imagingimaging

Diagnostic modalities in heart disease

History of nuclear cardiologyHistory of nuclear cardiology Blumgard and Weiss (1927) :Blumgard and Weiss (1927) : the first use of radioactivity in the study of the the first use of radioactivity in the study of the

cardiovascular systemcardiovascular system Wilson : measurement of the circulation times Wilson : measurement of the circulation times Tl-201 (1971) Tl-201 (1971) The development and improvement of SPECTThe development and improvement of SPECT The development and established Tc-labeled agentsThe development and established Tc-labeled agents Alternative stress than physical exerciseAlternative stress than physical exercise Gate-spect allows simultaneous assessment both of Gate-spect allows simultaneous assessment both of

myocardial perfusion, function and assessment of myocardial perfusion, function and assessment of myocardial viability myocardial viability

Gamma camera coincidence imaging systemGamma camera coincidence imaging system Myocardial metabolic imagingMyocardial metabolic imaging

Diagnosis & prognosisDiagnosis & prognosis Risk stratificationRisk stratification Medical vs. surgical Medical vs. surgical

treatmenttreatment Efficiency of managementEfficiency of management

Clinical applicationsClinical applications

• CAD• Acute and post MI• Cardiomyopathy• Valvular disease and Shunts• Cardiotoxicity• Aneurysms• Transplants

Stress-rest Tl-201 and Tc-99m labeled agents has been widely used in the diagnosis and assessment of coronary artery disease

MPI still an important position in clinical practiceonly 1/3 of symptom-free men with exercise induced ST segment depression had coronary angiographic lesions > 50% diameter stenosis

MPI has been proposed to improve the accuracy and risk assessment of exercise testing in patients with suspected CAD

Sensitivity 74% - 96%, specificity 65% -97% 

Cardiac stress testCardiac stress testPhysical exercisesPhysical exercises Exercise has to be adequate to produced the heterogenity Exercise has to be adequate to produced the heterogenity

in blood flow to achieve high detection sensitivityin blood flow to achieve high detection sensitivity TreadmilTreadmil ErgocycleErgocycle

PharmacologicalPharmacological Pharmacological stress test become important, since Pharmacological stress test become important, since

many patients are unable to exercisemany patients are unable to exercise

Pharmacological stress agents largely remove the need Pharmacological stress agents largely remove the need for patient cooperation and motivation, and enable a for patient cooperation and motivation, and enable a confident assessment of cardiac function in virtually all confident assessment of cardiac function in virtually all casescases DipyridamoleDipyridamole DobutamineDobutamine AdenosineAdenosine

Image interpretationImage interpretation

I. DefectsI. Defects LocationLocation ExtentExtent SeveritySeverity Reversible or fixedReversible or fixed Quantitative or semi quantitative Quantitative or semi quantitative

analysisanalysis

II. Other informationII. Other information Transient ischemic dilationTransient ischemic dilation Lung uptakeLung uptake

Case 1 Case 1 55 years old male with atypical 55 years old male with atypical

Chest pain and No risk factors.Chest pain and No risk factors.

ECG, Echo, Cardiac Enzymes are ECG, Echo, Cardiac Enzymes are NormalNormal

What Next?What Next? PET MPI using Rubidium 82PET MPI using Rubidium 82

Case 2 Case 2 70 years old lady with AF, DM, HTN, 70 years old lady with AF, DM, HTN,

IHD Previous PCI to RCA.IHD Previous PCI to RCA.

Came with Exertional Chest pain, Came with Exertional Chest pain, ECG and Echo are NormalECG and Echo are Normal

PET MPI using Rubidium 82PET MPI using Rubidium 82

This is a 61 yr old male who is k/c of This is a 61 yr old male who is k/c of type II DM. He has sustained acute type II DM. He has sustained acute Anterior wall myocardial infarction 2 Anterior wall myocardial infarction 2 days ago and was admitted in Affif days ago and was admitted in Affif hospital, where given thrombolytic hospital, where given thrombolytic therapy. Then he signed DAMA and therapy. Then he signed DAMA and came here for further manangement.came here for further manangement.

Echo EF 35-40%, Akinetic LAD area, Echo EF 35-40%, Akinetic LAD area, No significant Valvular pathologyNo significant Valvular pathology

Second Case Second Case 56 years old male with DM, HTN, 56 years old male with DM, HTN,

CVA Recovered .CVA Recovered .

Had occasional Exertional CP, ACS Had occasional Exertional CP, ACS Ruled Out in ER, Given appointment Ruled Out in ER, Given appointment for PET /CT Stress as OP for PET /CT Stress as OP

67 years old male with Recent 67 years old male with Recent anterior MI from another hospital.anterior MI from another hospital.

In MCICU he had Multiple and In MCICU he had Multiple and Recurrent VF/VT.Recurrent VF/VT.

EP labelled him as ischemic VF/VTEP labelled him as ischemic VF/VT

Cardiac surgery insisted on Viability Cardiac surgery insisted on Viability Before CABGBefore CABG

Case (1) 42 Male with DM, Case (1) 42 Male with DM, Prior Liver transplant, CKD Prior Liver transplant, CKD

Referred for Pre OP Referred for Pre OP Clearance(Normal studyClearance(Normal study) )

Case 2 63 F with DM, DLP Case 2 63 F with DM, DLP and CKD for Pre Op and CKD for Pre Op

Workup Workup (Normal (Normal study)study)

79 male with S/P CABG , 79 male with S/P CABG ,

Moderate Inferolateral defect with Moderate Inferolateral defect with Moderate partial peri-infract Moderate partial peri-infract ischemia ischemia

66 years old female 4 Preop 66 years old female 4 Preop ClearanceClearance

LBBB in SinusLBBB in Sinus

Booked for calcium score + Booked for calcium score + Persantin PET/CT Persantin PET/CT

Calcium Score showed Mid LAD mild Calcium Score showed Mid LAD mild calcificationcalcification

No obvious reversible ischemic No obvious reversible ischemic defect .defect .

Mild fixed defect at the apex Mild fixed defect at the apex represent apical thining represent apical thining

MPI(Myocardial perfusion imaging) has been widely used MPI(Myocardial perfusion imaging) has been widely used and an important position in the diagnosis and assessment and an important position in the diagnosis and assessment of CAD Sensitivity 74% - 96%, specificity 65% -97%of CAD Sensitivity 74% - 96%, specificity 65% -97%

Summary Summary

• Nuclear cardiology separates high risk patient who need invasive and expensive procedures from low risk patient who do not.

• Acts as a ”Gate - Keeper” for referral to angiography.

Cost of management strategies using MPI are cheaper and equally effective when compared with strategies without MPI with same outcome.

Nuclear cardiology separates persistent defect with LV dysfunction but viable myocardium from scar tissue