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Myocardial Perfusion Imaging with PET

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Myocardial Perfusion Imaging with PET SPECIAL CONTRIBUTION Myocardial Perfusion Imaging with PET Markus Schwaiger Nuklearmedizinische Klinik und Poliklini/çDer Technischen Universitdt Munchen, Klini/wm Rechts der Isar, Munich, Germany SPEC!' (5). PET spatial resolution is superior to that of AlthoughSPECThas become an acceptedimagingtechnique SPECT, resulting in superior image quality and less partial formyocardialperfusionstudies,thereare severaladvantages volume effect (5). Most PET images are processed with a to evaluatingcoronaryarterydisease (CAD)withPET.CADis a spatial resolution of about 6—10mm, as compared with complex, dynamic disease and quantitativemeasurements of 10—15mm for SPECF image reconstruction. myocardialbloodflowby PET can improvethe fUnCtiOnalchar The majoradvantageof PET is its ability to correct for acterizationof CAD.The majoradvantage of PET over SPECT attenuation.Traditionalmyocardialperfusionimagingwith is @rtsabilityto provideattenuation-correctedimages, whichde single-photon radiotracers such as 201'flposes significant creases incidenceof attenuation artifactsand increases spea challenges in avoiding or identifying and correcting for flcfty.Myocardialpertusion imagingwithPET can also provide moreaccurateinformationon localizationofdisease, as wellas attenuation artifacts, particularly those that involve the quantitativeassessment, inabsolutevalues, ofmyocardialblood inferior wall in male patients and the anterior wall in female flow.The measurement ofregionalflowreserve allowsforphys patients (6,7). iologiccharacterizationof stenosis severity, and may provide Unquestionably, attenuation correction provides more earn, detection of CAD as well as prognostic information. The homogeneous radiotracerdistribution in normal myocar disadvantage of PET, compared to SPECT, is that the equip dium, andimprovedcharacterizationof relativedifferences ment and operationsare more expensive.As more accurate in regional perfusion (8). In addition, attenuation correc diagnosticand prognosticdata lead to improvedpatient man tion improves the accuracy of quantitativeanalysis of de agement,the cost-to-benefitratiosof PETand SPECTin the fect severity since variation within normal segments is clinicalsetting need to be furtheranalyzed to determine which reduced (8). Thus, PET can provide reliable, quantitative diagnostictest is most effiaent in the work-upof patients with assessment of myocardialradiotracerdistribution;whereas suspected orknownCAD. SPECT, without attenuation correction, provides a more KeyWords:myocardialperfusionimaging;coronaryarterydis variable reflection of regional myocardial radiotracerdis ease; SPECT; PET tribution.Such improvement in image quality is expected J NucIMed1994;35:693-698 to result in enhanced diagnostic performance. Validation As new medical technology is introduced,several issues must be addressed. t is well established that tomographicmyocardialperfu One challenge is to validate a new diagnostictechnology sion images provide higher spatial resolution than planar with established tests that are accepted as gold standards. images for evaluatingpatientswith coronaryarterydisease If, for example, coronaty angiography is used to confirm (CAD) (1,2). SPECT is used routinely in the clinical set results of myocardialperfusion studies with PET, referral ting. There are three commercially available radiotracers bias becomes a problembecause only patientswith abnor for myocardial perfusion SPEC!' which have been em mal myocardial perfusion scans are referred for cardiac ployed successfully for the detection and localization of catheterization (9). The selected study population, there CAD (1—4):20―fl,9@9'c-sestamibi and @‘@Tc-teboroxime.fore, may not representthe general patientpopulationthat is referred for myocardial perfusion studies. PET VERSUS SPECT Secondly, it is important to consider which diagnostic In comparison to SPECT, PET can detect radiotracer accuracy is necessary to affect patient management dcci activity with 10 times the sensitivity of state-of-the-art sions. Clinicalexperience shows, for example, that a nor mal201'flstudy, even in the presence of CAD, is associated ReceivedJan.7, 1994;revisIonacceptedJan. 18,1994. with a vety good prognosis (10—12).Therefore, the sensi This paper was presented in part at the AnnualMeetingof the Societyof NudearMedicineon June8, 1993as partof a ContinuingMed@siEducation tivity of 20111 SPEC!' for detection of CAD may be ade Seminarorganizedbythe CardiOvascUlarCouncil quate. However, the specificity of @°@Tlstudies is not suf For correspondence or repñntscont@ Prof. Dr. Maalws Schwaiger, Nuklear medizinischeKilnikundPolknik,DerTechnischenUniversitátMUnchen,KJin@umficiently high, resulting in a reported false-positive rate Rechtsder Isar,IsmaningerStrasse 22, 8000MUnchen80, Germany. ranging from 20% to 50% (13—15).As a consequence, pa MyocardialPerfusionImagingwithPET•Schwaiger 693 tient care may not suffer, but unnecessary additional diag Copper-62-PTSM nostic procedures will be performed, affecting the cost of Copper-62-pyruvaldehyde bin(n-methy-thio-semicarba patient care. zonado) (PThM)is currentlybeing validated as an alterna Thirdly, as diagnostic imaging technology advances, it tive to 82Rbfor myocardialperfusionimaging(24). As with provides new approaches to more sophisticated diagnostic 82Rb,the relation between 62Cu-PTSMand blood flow is challenges. Althoughthe presence of CAD can be detected nonlinear and may therefore lead to an underestimation of adequately with a variety of diagnostic tests, other ques coronaiy flow reserve estimates. Direct comparison of tions—suchas the exact location of stenoses and their 82Rb and 62Cu-PTSM studies are necessaiy to define the hemodynamic significance—requiremore advanced quan future clinical role of this new radiotracer. titative measurements of regionalblood flow. Over recent years, internists and cardiologists have become more ag IMAGEQUALITY gressive in treating CAD and more demanding of docu mented outcomes. The need for noninvasive techniques to Excellent PET image quality is obtainable with 82Rb, monitor therapy is well appreciated. Quantitative measure ‘3N-ammoniaand 6@Cu-VFSM,with a high contrast be ments of regional flow reserve, which PET can provide, tween myocardium and underlying lung tissue or blood may be able to monitor the progression or regression of pool (24,25). Because 82Rb emits a high-energy positron CAD and, thus, allow for guided therapy in patients with a that travels a longer distance before collidingwith an elec high risk for accelerated atherosclerotic disease processes tron to produce two gamma photons, 82RbPET images in primaryand secondary prevention (16). have a lower intrinsic resolution. Figure 1 shows images and polar maps representing the normal distribution of all PET MYOCARDIAL PERFUSION TRACERS three tracers (13). PET images with 82Rbdemonstrate homogeneous dintri There are several positron-emittingradiotracersuseful bution, reflectingthe effect of attenuationcorrection; ‘3N- for myocardialperfusion imaging. ammonia distribution is slightly nonhomogeneous, with re Rubldlum-82 duced radiotraceractivity in the lateralwall (Fig. 1); and Rubidium-82 in a convenient radiotracer because it can 62@p@'5M maps demonstrate some scatter in the inferior be produced by a radionucide generatorsystem (17). Any wall, resulting from its high liver uptake. The low uptake of nuclear cardiac imaging facility with PET, therefore, can ‘3N-anunoniain the lateralwall is a reproduciblefindingin provide 82Rbstudies without the need for an on-site cyclo both rest and stress images. Although the mechanism is tron. With a half-life of 76 5cc, 82Rballows for repeated unknown, it appears to be a regional metabolic alteration in blood flow measurements in short time intervals. The re ‘3N-ammoniatissue retention (26). lation between 82Rbuptake and blood flow is nonlinear with decreasingmyocardialextraction at higherflow rates, PROTOCOLS however, the practicality of the radiotracer offsets thin As a rule, PET studies are obtainedwith short scanning physiologic limitation. Several studies have shown that times. A typical myocardialperfusion study with 82Rbcan 82Rb, in combination with pharmacologic stress, allows be completed in 1 hr. After injection of 82Rb,the protocol accurate detection of CAD (18—21). entails:a 15-mintransmissionscan, a 5-mmrest flow study, Nftrogen-13-Ammonia injection of a pharmacologic stress agent, a second dose of Nitrogen-13-ammonia incyclotron-produced. Its half-life 82Rb and a 5-mm stress study acquisition (17). Similar of 10min requiresa 30- to 40-mmwaiting periodbefore the protocols are followed for myocardial perfusion PET im rest and second stress injection (21). With respect to the aging with ‘3N-ammonia,which requires a waiting period relation between blood flow and radiotraceruptake, ‘3N-for ‘3Ndecay, but can be completed within 1.5 to 2.0 hr ammonia behaves similarly to @°‘Tlin that its uptake is less (8). The short completion times of these PET protocols affected by high flow rates as compared with 82Rb. This offer a distinct advantage over myocardial perfusion stud radiotracerexcels by the excellent image quality and con ies with 20111or @Fc-sestamibi. venient use in a clinical setting (8). Oxygen-15-Water DIAGNOSTiC AOCURACY Oxygen-15-water is used primarily in the research envi Myocardial perfusion studies with PET have been ronment (22,23). Theoretically, this radiotracer is ideal for shown to provide a higher diagnostic accuracy than
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