IMAGING AND INTERVENTION IN CARDIOLOGY

Developments in Cardiovascular Medicine

VOLUME 173

The titles published in this series are listed at the end of this volume.

Imaging and Intervention in Cardiology

Edited by

CHRISTOPH A. NIENABER Department of Cardiology, University Hospital Eppendorf, Hamburg, Germany

and

UDO SECHTEM Klinik III fur Innere Medizin, University of Cologne, Cologne, Germany

Kluwer Academic Publishers Dordrecht / Boston / London

Library of Congress Cataloging-in-Publication Data Imaging and intervent i on in cardiology I edited by Christoph A.

Nienaber and Udo Sechtem p . cm. -- (Developments in cardiovascular medicine; v. 173)

Includes indexes. ISBN-13: 978-94-010-6538-2 1. Myocardial infarction--Radionucl ide imaging.

revascularization. 3. Radiology, Interventional . therapy. I. Nienaber, Chr i stoph A. I I. Sechtem, III. Series .

2. Myocardial 4. ThrombolytiC Udo.

[DNLM, 1. Myocardial Ischemia--diagnosis. 2 . Diagnostic Imaging--methods. 3. Myocardial Revascularization. W1 DE997VME v. 173 1995 I WG 300 I31 1995] RC685.I6I46 1995 616.1'237'0754--dc20 DNLM/DLC for Library of Congress 95-34054

ISBN-13 : 978-94-010-6538-2 e-ISBN-13: 978-94-009-0115-5 DOl: 10.1007/978-94-009-0115-5

Published by Kluwer Academic Publishers , P.O. Box 17, 3300 AA Dordrecht, The Netherlands.

Kluwer Academic Publishers incorporates the publishing programmes of D. Reidel, Martinus Nijhoff, Dr W. Junk and MTP Press.

Sold and distributed in the U.S.A . and Canada by Kluwer Academic Publishers, 101 Philip Drive, Norwell , MA 02061, U .S.A .

In all other countries, sold and distributed by Kluwer Academic Publishers Group P.O. Box 322, 3300 AH Dordrecht, The Netherlands.

Printed on acid-free paper

All Rights Reserved © 1996 Kluwer Academic Publishers Softcover reprint of the hardcover I st edition 1996. No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical , including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner .

Table of contents

Foreword by Michel E. Bertrand

Preface by C.A. Nienaber and U. Sechtem

List of Contributors

Part One: Thrombolysis

1. Serial myocardial perfusion imaging with Tc-99m-Iabeled myocardial perfusion imaging agents in patients receiving

IX

Xl

XV

thrombolytic therapy for acute myocardial infarction 1 Frans J. Th. Wackers

2. Contraction-perfusion matching in reperfused acute myocardial infarction 13 Timothy F. Christian

3. Metabolic characteristics in the infarct zone: PET findings 29 Morten Bf/Jttcher, Johannes Czernin and Heinrich R. Schelbert

4. Assessment of myocardial viability with positron emission tomography after coronary thrombolysis 43 Patricia J. Rubin and Steven R. Bergmann

5. Postthrombolysis noninvasive detection of myocardial ischemia and multivessel disease and the need for additional intervention George A. Beller and Lawrence W. Gimple

Part Two: Coronary revascularization: Assessment before intervention

6. Imaging to justify no intervention Christoph A. Nienaber and Gunnar K. Lund

53

75

VI Table of contents

7. Interpretation of coronary angiograms prior to PTCA: Pitfalls and problems 93 Rudiger Simon

8. Diagnostic accuracy of stress-echocardiography for the detection of significant coronary artery disease 105 Frank M. Baer and Hans J. Deutsch

9. Perfusion imaging with thallium-201 to assess stenosis significance 121 Edna H.G. Venneker, Berthe L.F. van Eck-Smit and Ernst E. van der Wall

10. Perfusion imaging by PET to assess stenosis significance 135 Gunnar K. Lund and Christoph A. Nienaber

11. Contrast enhanced magnetic resonance imaging for assessing myocardial perfusion and reperfusion injury 149 Leonard M. Numerow, Michael F. Wendland, May them Saeed and Charles B. Higgins

12. Non-invasive visualization of the coronary arteries using magnetic resonance imaging - is it good enough to guide interventions? 167 Warren J. Manning and Robert R. Edelman

13. MRI as a substitute for scintigraphic techniques in the assessment of inducible ischaemia 191 Dudley J. Pennell

14. Assessment of viability by MR-techniques 211 Udo Sechtem, Frank M. Baer, Eberhard Voth, Peter Theissen, Christian Schneider and Harald Schicha

15. Assessment of viability in severely hypokinetic myocardium before revascularization and prediction of functional recovery: Contribution of thallium-201 imaging 237 Jacques A. Melin, Jean-Louis Vanoverschelde, Bernhard Gerber and William Wijns

16. Assessment of myocardial viability before revascularization: Can sestamibi accurately predict functional recovery? 249 Jan H. Cornel, Ambroos E.M. Reijs, Joyce Postma-Tjoa and Paolo M. Fioretti

17. Assessment of viability in noncontractile myocardium before revascularization and prediction of functional recovery by PET 259 Christoph A. Nienaber

Table of contents vii

18. Assessment of viability in severely hypokinetic myocardium before revascularization and prediction of functional recovery: The role of echocardiography 279 Luc A. Pierard

19. Assessment of functional significance of the stenotic substrate by Doppler flow measurements 295 Christian Seiler

Part Three: Coronary revascularization: Assessment after intervention

20. Angiographic assessment of immediate success and the problem (definition) of restenosis after coronary interventions 311 David P. Foley and Patrick W. Serruys

21. Immediate evaluation of percutaneous transluminal coronary balloon angioplasty success by intracoronary Doppler ultrasound 341 Michael Haude, Dietrich Baumgart, Guido Caspari, lunbo Ge and Raimund Erbel

22. Evaluation of the effect of new devices by intravascular ultrasound Dirk Hausmann, Peter 1. Fitzgerald and Paul G. Yock

23. Can restenosis after coronary angioplasty be predicted by

359

scintigraphy? 379 Elizabeth Prvulovich and Richard Underwood

24. Evaluation of immediate and long-term results of intervention by echocardiography: Can restenosis be predicted? 387 Albert Varga and Eugenio Picano

25. Predictors of restenosis after angioplasty: Morphologic and quantitative evaluation by intravascular ultrasound 401 Udo Sechtem, Hans-Wilhelm Hopp and Dirk Rudolph

26. How to evaluate and to avoid vascular complications at the puncture site 429 Franz Fobbe

Part Four: Imaging and valvular interventions

27. Selection of patients and transesophageal echocardiography guidance during balloon mitral valvuloplasty 443 Steven A. Goldstein

Vlll Table of contents

28. Echocardiography for intraprocedural monitoring and postinterventional follow-up of mitral balloon valvuloplasty 459 Lianglong Chen, Linda Gillam, Raymond McKay and Chunguang Chen

Part Five: Intervention in congenital heart disease

29. Preinterventional imaging in pediatric cardiology Gerd Hausdorf

30. The role of ultrasound in monitoring of interventional cardiac

471

catheterization in patients with congenital heart disease 505 Oliver Stumper

31. Follow-up of patients after transcatheter procedures in congenital heart disease using noninvasive imaging techniques 521 Michael Tynan and Gunter Fischer

Colour section

Index

533

543

Foreword

Less than 18 years have passed since the first coronary balloon angioplasty was performed in September 1977 by Andreas Gruntzig. In 1993, 185700 coronary angioplasties were performed in Europe and in many European countries, percutaneous transluminal coronary angioplasty is the most com­mon method of myocardial revascularization, well ahead of coronary bypass surgery. This explosive growth of interventional cardiology results from major technological advances. The balloons have been markedly improved with a better profile, excellent trackability, and good pushability. The steer­able guide wires are excellent and can reach the most difficult and the most distal parts of the coronary tree. The guiding catheters offer excellent support and good back-up in the ostium. Meanwhile, new tools have been proposed and designed for a "lesion specific" approach. Coronary stenting which is the "second wind" of angioplasty has dethroned most of the so-called new tools and stents are currently implanted in 30-60% of cases. Similar develop­ments have occurred in the field of mitral valvuloplasty, ablative techniques in electrophysiology, and in the field of interventions in congenital heart disease.

However, these advances would not have been possible without the con­comitant development of cardiac imaging. For many interventions, cardiac imaging is an necessary pre-requisite: 1. Imaging is mandatory to identify the lesions needing an intervention.

Coronary bypass surgery or angioplasty cannot be performed without prior coronary angiography. However, scintigraphic stress testing is also needed to identify perfusion defects in the area supplied by the diseased artery.

2. Imaging is necessary to guide the interventions. This includes not only coronary angiography but also the new techniques like intracoronary ultrasound or angioscopy. The first technique is especially useful to iden­tify the atherosclerotic mass but also the composition of the plaque and the dissections resulting from balloon dilatation. Angioscopy is the only tool able to adequately identify thrombus, a problem with which the interventional cardiologists has to deal more and more frequently. Finally,

x Foreword

intracoronary Doppler can assess the immediate results in determining coronary flow reserve.

3. Imaging is finally useful to asses the short and long term results of the various interventions. This includes a broad array of procedures from angiography to intracoronary ultrasound but also stress echocardiography, perfusion scintigraphy or positron emission tomography.

Whilst technological advances have rapidly improved interventional tech­niques, imaging technology has also undergone extraordinary development. Nobody can imagine a new catheterization laboratory without digital imag­ing. Digital storage of the data has been harmonized and the DICOM stan­dard will allow us shortly to exchange digitised data not only by sending floppy disks or compact disks but even by transferring the images directly via information highways.

In nuclear medicine camera design has been improved and new tracers are available. New miniaturised imaging catheters provide cross-sectional ultrasound images of the coronary wall. Small guide wires are new tools to measure coronary blood flow velocity using the Doppler technique.

Promising advances have also been achieved with other non-invasive tech­niques such as the CT-scanners which are helpful to diagnose pulmonary embolism, and with magnetic resonance imaging. The interest in latter tech­nique, which is well established in aortic imaging or depiction of complex congenital heart disease, has now been extended to the field of coronary arteries with the challenging goal of identifying the coronary lesions.

No field in medicine has proliferated and developed as extensively as imaging. This book is aimed at helping general cardiologists to get abreast of the latest developments in cardiac imaging. Obviously, each technique more or less competes with another one. This book will not and cannot provide the final answer to which technique is the best one. This is evident when reading the section on stress imaging before interventions. However, this book will provide an excellent opportunity of getting up-to-date with the most recent developments and forging a personal judgement.

The reader will discover that there is no longer competition between the cardiac imaging community and interventional cardiologists but, in contrast, a mutual interest to contribute to a better understanding and management of cardiovascular disease.

Michel E. Bertrand, M.D. Professor of Medicine Head Department of Cardiology University Cardiological Hospital Lille France

Preface

There are two things: science and opinion; the first leads to knowledge, the second to ignorance

Hippocratis

Interventional cardiology and cardiac imaging are closely inter-related sub­jects. Since the early days of catheter-based cardiovascular interventions, imaging techniques have been used to define the necessity of and aid in the performance of interventions, as well as assessing the results of this form of therapy. Within the last 20 years, cardiac imaging as well as interventional catheterization have come a long way.

Although imaging is often defined as noninvasive imaging, invasive x-ray imaging continues to be the most important tool of the interventionalist. Fluoroscopy remains the 'mother of all interventions' and coronary angio­graphy is still the basis of all coronary procedures. X-ray imaging has wit­nessed immense progress towards higher image quality at lower radiation exposure. Today, radiation exposure from thallium scintigraphy is higher than that of a state-of-the-art diagnostic cardiac catheterization including coronary angiography using digital image acquisition technology.

On the other hand, noninvasive techniques have matured from imperfect substitutes for invasive diagnosis into high quality imaging tools in their own right, often replacing invasive procedures or adding information which cannot be obtained invasively. Echocardiography has probably seen the most striking progress: beginning with the M-mode technique, two- and three-dimensional reconstructions of cardiac anatomy, Doppler assessment of functional par­ameters, and stress imaging as well as the transesophageal approach have been developed. Radionuclide imaging has progressed from planar to tomo­graphic imaging and attenuation correction is now undergoing clinical studies. New imaging modalities such as positron emission tomography (PET) or ultrafast computed tomography have entered the clinical arena. More re­cently, magnetic resonance imaging has established itself as an important new tool for the anatomic diagnosis and functional assessment of cardiovascular disease. Even from within the coronary arteries, new forms of imaging have become available such as intracoronary ultrasound or Doppler measurements of intracoronary flow velocities.

Parallel to this breath-taking speed of development in the imaging field, numerous new cardiac interventions have been introduced and more and

xu Preface

more complex procedures are now possible for diseases which, only a few years ago, were thought to be the exclusive battle-ground of cardiac surgery. Thrombolytic therapy is now firmly established as a means of significantly decreasing infarct mortality and a multitude of catheter-based coronary inter­ventions including balloon aJ!gioplasty and stenting, among others, have proved useful to ameliorate anginal symptoms in patients with coronary disease. Although balloon valvuloplasty has not yielded improved outcome in aortic stenosis, it has proved to be as successful as surgical procedures in mitral and pulmonic stenosis. The recent development of catheter-based curative interventions in congenital heart disease now offers an alternative to surgery or a means of avoiding repeated surgery in a significant number of children or adult patients with congenital heart disease.

What makes imaging such an integral part of all types of interventions? The patient's complaints and a straightforward clinical examination are rarely sufficient to justify an immediate intervention. In our opinion, some form of functional noninvasive cardiac imaging is crucial in many patients to more objectively define the need for an intervention. Undoubtedly, some patients require some form of intervention on an emergency basis solely based on clinical symptoms and others have such impressive abnormalities in their stress ECG that further evaluation would simply be a waste of time and money. However, in current practice these patients constitute only an -albeit sizeable - minority. The majority of coronary patients will profit from some form of noninvasive stress imaging in order to clearly define the need for invasive investigation and intervention. It may, however, be advisable not to have the same physician interpret the results of imaging stress studies and perform the intervention to avoid 'self referral bias'. An objective func­tional assessment of myocardial perfusion or wall motion during stress should counteract the dreaded 'oculo-stenotic' reflex. Managing patients in this way will have a positive impact on the quality of care and at the same time help to contain costs in this era of incessant increase in health-care expenditure.

Today, imaging in the form of angiography is still indispensable in guiding coronary interventions. Recently, new imaging tools such as intracoronary ultrasound or blood flow measurements by Doppler guidewires have become available to the interventionalist and provide additional information for on­line guidance of procedures. Although these new tools may ultimately result in less reliance on noninvasive stress imaging studies, the interventionalist often collaborates with an imaging oriented specialist in the catheterization laboratory for optimal interpretation of images and on-line measurements of luminal areas or flow velocities. Another good example of close collaboration between interventionalist and imaging specialist during an intervention is balloon dilatation of cardiac valves guided by transthoracic or transeso­phageal echocardiography.

Objective documentation of the success or failure of an intervention be­yond the angiographic depiction of the immediate result requires the use of invasive or noninvasive imaging techniques. Again, intracoronary ultrasound

Preface Xlll

may be helpful for the interventionalist in deciding whether the lumen en­largement achieved by the procedure is indeed satisfactory even though the ultrasound image is the less forgiving modality of incomplete dilatation as compared to the angiogram. However, postinterventional imaging stress tests or Doppler assessment of intracoronary blood flow may remain abnormal for some time to become only normal at follow-up angiography weeks to months later. Thus, some caveats remain with respect tq the role of postin­terventional stress imaging.

Imaging and intervention belong together and it is important that special­ists in each field understand the concepts and the potential, the capabilities and the shortcomings of the other field. However, the increasing complexity of a multitude of new developments makes it increasingly difficult for the individual physician to keep pace and gain or retain sufficient knowledge in both fields. Therefore, the intention of this book is to provide clinical cardiologists and interventionalists with an up to the minute overview on the use of cardiac imaging techniques in combination with modern interventional procedures such as thrombolysis, nonsurgical coronary revascularization, val­vuloplasty, and interventions in congenital heart disease. Each section of the book contains several chapters describing how imaging techniques can be used before, during, and after intervention to select the optimal interven­tional strategy including the choice of simply continuing medical therapy. However, imaging can also be helpful to understand the interaction between disease and interventional therapy, and this aspect is also reflected in the book.

Some readers may miss certain topics such as the role of electron beam CT in the diagnosis and prognostic assessment of coronary artery disease. However, the idea of the book was to select a number of frequently used interventions and imaging techniques rather than producing an encyclopedia which would combine all possible imaging modalities with every type of cardiac intervention. Unavoidably, there will be some bias in some chapters written by recognized and enthusiastic experts in the topic. The competition between nuclear cardiologists and stress echocardiography proponents is likely to exist even between the staff members in many cardiology depart­ments and to some extent merely reflects the positive experiences each investigator has made with his favourite imaging tool. "Imaging and interven­tion" will provide the reader with an opportunity to study the competing techniques in detail and develop his or her own personal preference on how to use the various options most efficiently. For the interventional cardiologist, this book will be useful to learn more about the many ways cardiac imaging can be of assistance to him in the catheterization laboratory. It cannot be overemphasized that the exclusive reliance on good old coronary angiography may result in suboptimal treatment and an unnecessary risk to the patient.

The book is structured around a number of interventional procedures with special emphasis on the clinically relevant problems. For instance, imaging in conjunction with thrombolysis is focused on the assessment of the risk

xiv Preface

zone, on the evidence of postinfarct viability, and on prognostic evaluation. This structure should help the reader to quickly find the information per­taining to a given clinical problem. Since the main focus of the book is on imaging, there is a large number of carefully selected colour and black and white figures illustrating the key points of each chapter to the reader. The bibliographies contain up-to-date references as well as the classic quotations on the topic. Therefore, we hope that this book may also be useful for the reader who would like to study certain aspects in more detail.

We gratefully acknowledge the excellent work of the many contributors to the book who helped us to capture the dynamic developments in both fields. Nettie Dekker, Monique Pagels, and Helen Liepman at Kluwer de­serve our grateful recognition for their patience and support during the planning and the production phase of the project. We are also obliged to many friends and colleagues at our institutions for all their constructive criticism.

Christoph Nienaber Udo Sechtem

List of contributors

FRANK M. BAER Klinik III fUr Innere Medizin, University of Cologne, Joseph-Stelz­mannstrasse 9, D-50924 Cologne, Germany Co-author: Hans J. Deutsch

GEORGE A. BELLER Cardiovascular Division, P.O. Box 158, Univerisity of Virginia, Health Sciences Center, Charlottesville, VA 22908, USA Co-author: Lawrence W. Gimple

MORTEN B<Z>TTCHER Positron Emission Tomography Center (PET), Building 10 (1OC), Aarhus Kommunehospital, DK-8080 Aarhus C, Denmark Co-authors: Johannes Czernin and Heinrich R. Schelbert

CHUNGUANG CHEN Echocardiography Laboratory, Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA Co-authors: Lianglong Chen, Linda Gillam and Raymond McKay

TIMOTHY F. CHRISTIAN Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA

JAN H. CORNEL Thoraxcenter, Ba 350, Erasmus University, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands Co-authors: Ambroos E.M. Reijs, Joyce Postma-Tjoa and Paolo M. Fioretti

XVI List of contributors

FRANZ FOBBE Department of Radiology, Klinikum Steglitz, Free University Berlin, Hin­denburgdamm 30, D-12200 Berlin 45, Germany

DAVID P. FOLEY Thorax Center, Bd 416, Erasmus University, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands Co-author: Patrick W. Serruys

STEVEN A. GOLDSTEIN Noninvasive Cardiology, Washington Hospital Center, 110 Irving St. NW, Suite 4B-14, Washington, DC 20010-2975, USA

MICHAEL HAUDE Cardiology Department, University of Essen, Hufelandstrasse 55, D-45122 Essen, Germany Co-authors: Dietrich Baumgart, Guido Caspari, Junbo Ge and Raimund Erbel

GERD HAUSDORF Charite, Department of Pediatric Cardiology, Humboldt-University Berlin, Schumannstrasse 20-21, D-10117 Berlin, Germany

DIRK HAUSMANN Department of Cardiology, Hannover Medical School, Konstanty­Gutschow-Strasse 8, D-30625 Hannover, Germany Co-authors: Peter J. Fitzgerald and Paul G. Y ock

GUNNAR K. LUND Department of Cardiology, University Hospital Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany Co-author: Christoph A. Nienaber

WARREN J. MANNING Cardiovascular Division, Beth Israel Hospital, 330 Brookline Avenue, Boston, MA 02215, USA Co-author: Robert R. Edelman

JACQUES A. MELIN Department of Nuclear Medicine, University of Louvain Medical School, Avenue Hippocrate 10/2580, B-1200 Brussels, Belgium Co-authors: Jean-Louis Vanoverschelde, Bernhard Gerber and William Wijns

List of contributors XVll

CHRISTOPH A. NIENABER Department of Cardiology, University Hospital Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany Co-author: Gunnar K. Lund

LEONARD M. NUMEROW c/o Foothills Hospital, Department of Radiology, 1403 29 Street NW, Calgary, Alberta, Canada Co-authors: Michael F. Wendland, May them Saeed and Charles B. Higgins

DUDLEY 1. PENNELL Magnetic Resonance Unit, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK

LUC A. PIERARD Service de Cardiologie, CHU du Sart-Tilman, B-4000 Liege, Belgium

ELIZABETH PRVULOVICH Institute of Nuclear Medicine, Middlesex Hospital, Mortimer St., London WIN 8AA, UK Co-author: Richard Underwood

PATRICIA 1. RUBIN Cardiovascular Division, Washington University School of Medicine, P.O. Box 8086, 660 S. Euclid Ave., St. Louis, MO 63110, USA Co-author: Steven R. Bergman

UDO SECHTEM Klinik III fUr Innere Medizin, University of Cologne, loseph-Stelzmannstrasse 9, D-50924 Cologne, Germany Co-authors Chapter 14: Frank M. Baer, Eberhard Voth, Peter Theissen, Christian Schneider and Harald Schicha Co-authors Chapter 25: Hans-Wilhelm Happ and Dirk Rudolph

CHRISTIAN SEILER Department of Internal Medicine, University Hospital Bern, Freiburg­strasse, CH-3010 Bern, Switzerland

RUDIGER SIMON Klinik fUr Kardiologie, I. Medizinische UniversiHits-Klinik, Christian-AI­brechts-University Kiel, Schittenhelmstrasse 12, D-24105 Kiel, Germany

OLIVER STUMPER Heart Unit, Birmingham Childrens Hospital, Ladywood Middleway, Birmingham B16 8ET, UK

xviii List of contributors

MICHAEL J. TYNAN Department of Paediatric Cardiology, 11th Floor Guy's Tower-Guy's Hos­pital, St. Thomas' Street, London SE1 9RT, UK Co-author: Gunter Fischer

ALBERT VARGA 2nd Department of Medicine, Albert Szent-Gyorgyi University Medical School, P.O. Box 480, 6701 Szeged, Hungary Co-author: Eugenio Picano

EDNA H.G. VENNEKER Department of Cardiology, University Hospital Leiden, Building 1, C5-P25, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands Co-authors: Berthe L.F. van Eck-Smit and Ernst E. van der Wall

FRANSJ.TH.WACKERS Department of Diagnostic Radiology and Medicine, Yale University School of Medicine, 333 Cedar Street, TE-2, P.O. Box 208042, New Haven, CT 06510-8042, USA