Cardiac CT and Cardiac PET 82 Rb imaging Raymond T Endozo Radiographer
Production of Rubidium-82
Radiotracer Tracer Half Life Production Method Rb-82 76 sec Generator N-13 Ammonia 9.8 min Cyclotron O-15 Water 2.4 min Cyclotron Fluorine 18 (18F) flurpiridaz 110 min Cyclotron
82 RUBIDIUM 13 N-ammonia Product Generator Cyclotron Half Life 76 s 9.96 min Mean Positron n range 2.6 mm 0.7-mm Second study Without delay 30 mins delay Extraction 50%-60% 80%
PET with the use of short-lived radiopharmaceuticals results in substantially lower radiation doses to patients than does SPECT
Recommendations for Reducing Radiation Exposure in Myocardial Perfusion Imaging Cerqueira et al, ASNC information statement, Jnucl Cardiol
Cardiac PET Imaging Perfusion studies (Rubidium 82) Rest-stress perfusion imaging Detection of coronary artery disease and assessing the progression of coronary artery disease May be used in place of or following an equivocal SPECT study 18F-FDG Perfusion-metabolism imaging Identification of tissue that may recover contractile function following revascularization techniques
Cardiac pet (Rubidium) optimizes your clinical environment Faster Imaging, Greater Throughput Ready on Demand,No waiting on delivery A Positive Imaging Experience for Your Patients and Staff PET is suitable for your patients, including those... Result in a suboptimal scan Unable to exercise EMERGENCY
Good Quality Cardiac PET Count density -Poor count ( poor intravenous access, inadequate scan duration) Blood Pool Clearance 90s delay 150s delay Transmission-Emission Misalignment
CT Transmission-PET Emission Misalignment CT Transmission-PET Emission Alignment stress Rest Misregistration Artefact stress Rest Misregistration Corrected Teaching Point: Carefully review all CT transmission and PET RB emission images for adequate registration prior to finalizing the interpretation of the case
List-mode Cardiac PET Acquisition ECG Gated Dynamic LV Function Absolute Quantification
Flow Quantification : How it is changing MPI Macrovascular Perfusion Defect MPI Microvascular Reduced MBF Reserve (ml/min/g) FLOW
79/ M Reassessment CABG 1991 ( 4x graft) LIMA to LAD, SVG to RCA, DIAGONAL and OM
Flow Quantification : How it is changing MPI PET MPI FUSED CCTA and MPI FLOW STRESS REST MPI CT FLOW RCA Normal Occluded Graft-RCA 0.82 LAD Ischemia Occluded Graft -Diag 0.59 CIRC Mild Ischemia 70 % stenosis Graft 0.70
Coronary Calcium score Non-contrast-enhanced, ECG gated Easy-to-perform No preparation Radiation dose is minimal
Calcium score ROI drawn Measured parameters: area=a; density=d CAC score = A x D coefficient Originally developed with EBCT- subsequent MDCT High reproducibility, low radiation exposure Alternative scoring systems Volume scoring Mass scoring
Calcium score 0 1-400 400-1000 >1000 Agaston score
0 calcium score > 400 Tip of the Iceberg Calcium > 400 HU Patterns: - Speckled (unstable) - Fragmented - Diffuse
A Added value of a Calcium score in patients with Normal PET MPI B STRESS REST Total Score- 0 Total Score- 950
Cardiac CT Angiography
There are two scanning modes: Spiral and Axial Prospective ECG triggering Retrospective ECG gating
Prospective ECG Gating in Action 0010110101010110011011000011101010101010100101001010101010101010101001 0101010101010101010101010101010101010101010100010110101010101001010101 01010101010111010011010101010101010101101001001011001010 0010110101010110011011000011101010101010100101001010101010101010101001 0101010101010101010101010101010101010101010100010110101010101001010101 01010101010111010011010101010101010101101001001011001010 0010110101010110011011000011101010101010100101001010101010101010101001 0101010101010101010101010101010101010101010100010110101010101001010101 01010101010111010011010101010101010101101001001011001010 0010110101010110011011000011101010101010100101001010101010101010101001 0101010101010101010101010101010101010101010100010110101010101001010101 01010101010111010011010101010101010101101001001011001010 Prospective ECG-Triggered Acquisition
Spiral CT Scanning in Action 001011010101011001101100001110101010101010010100101010101010101 010100101010101010101010101010101010101010101010101000101101010 001011010101011001101100001110101010101010010100101010101010101 101010010101010101010101011101001101010101010101010110100100101 010100101010101010101010101010101010101010101010101000101101010 100101010101010101010101010101110010110101010101010011010101101 101010010101010101010101011101001101010101010101010110100100101 010101110010101011001101010100101011010101010101100100111010101 100101010101010101010101010101110010110101010101010011010101101 010101010101010010110101010110011011000011101010101010100101001 010101110010101011001101010100101011010101010101100100111010101 010101010101010101001010101010101010101010101010101010101010101 010101010101010010110101010110011011000011101010101010100101001 010001011010101010100101010101010101010111010011010101010101010 010101010101010101001010101010101010101010101010101010101010101 101101001001011001010101010101010101010101011100101101010101010 010001011010101010100101010101010101010111010011010101010101010 100110101011010101011100101010110011010101001010110101010101011 101101001001011001010101010101010101010101011100101101010101010 001001110101010101010101010 100110101011010101011100101010110011010101001010110101010101011 001001110101010101010101010 Selected Phase Retrospective ECG-Gated Reconstruction
Indications 1. Heart rate >65 bpm Contraindications: 1. Asthma or COPD 2. AV Block 2 nd or 3 rd degree 3. Heart failure 4. Active Bronchospasm 5. Allergy to Beta Blocker 6. Systolic BP <100 mm Hg Beta blocker helps image quality 1.Promote a more stable heart rate 2.Better chance of freezing the motion of the heart 3.Better dose optimization
Hiatus hernia Pulmonary embolism lymph nodes Pulmonary nodules Pleural effusion Hepatic cysts Pulmonary infiltrates Interstitial lung disease Incidental findings abound in cardiac CT imaging
Incidental findings in Cardiac CT imaging
Cardiac PET RB82 and Cardiac CT Protocol Adenosine Rb-82 Rb-82 Scout scout Cardiac CT CT-trans Stress-Dynamic Rest Dynamic Cal score 2 min
Case-1 64/F Atypical chest pain Irregular heart beat Hypertensive
CT MPI CATH FUSED-MPI and CT
Case-2 43 /M Presented with chest pain and ECG changes.? RCA anomalous origin
MPI MPI CATH CT
47/M Case-3 Chest pain and SOB on exertion. Hypertension??Anomolous RCA origin coming off the Main Pulmonary artery or L PA CT Coronary angiogram and perfusion scan
CATH MPI CT
Summary Accuracy/ Speed Greater Throughput Positive Experience
Acknowledgements Prof Ashley Groves Prof Peter Ell Dr Jamshed Bomanji Dr.John Dickson Ms Marguerite Meintjes Ms Caroline Towsend