Supplement to Journal of Nuclear Cardiology

Abstracts of Original Contributions ASNC2020 The 25th Annual Scientific Session of the American Society of Nuclear Cardiology Organizing Committee Panithaya Chareonthaitawee, MD, Chair Karthikeyan Ananthasubramaniam, MD, FASNC Rob S.B. Beanlands, MD, MASNC Randall C. Thompson, MD, FASNC Program Committee Terrence D. Ruddy, MD, MASNC, Chair Piotr J. Slomka, PhD, FASNC, Vice Chair

Omar Abou-Ezzedine, MDCM Wael Jaber, MD Niti R. Aggarwal, MD, FASNC Scott D. Jerome, DO, FASNC Cigdem Akincioglu, MD Viet Le, MPAS, PA-C Andrew Arai, MD Saurabh Malhotra, MD, MPH, FASNC Daniel S. Berman, MD, MASNC Edward J. Miller, MD, PhD, FASNC Ron Blankstein, MD, FASNC Robert J.H. Miller, MD Renee Bullock-Palmer, MD, FASNC Rene Packard, MD, PhD Dennis Calnon, MD, MASNC Mi-Ae Park, PhD Panithaya Chareonthaitawee, MD Krishna Patel, MD Benjamin Chow, MD, FASNC Donna M. Polk, MD, MPH, FASNC Paul C. Cremer, MD Mehran Sadeghi, MD Robert A. deKemp, PhD, FASNC Thomas H. Schindler, MD, PhD Andrew J. Einstein, MD, PhD, FASNC Ronald G. Schwartz, MD, MS, MASNC Ernest V. Garcia, PhD, MASNC Nishant R. Shah, MD, MPH, FASNC Fadi Hage, MD, FASNC Albert J. Sinusas, MD, FASNC Edward Hulten, MD, MPH, FASNC Gary R. Small, MBChB, PhD Mark C. Hyun, CNMT, NCT, RT(N), Prem Soman, MD, PhD, MASNC FASNC Brett W. Sperry, MD

Journal of Nuclear CardiologyÒ YOUNG INVESTIGATOR ABSTRACTS

104-02 and LVBP than SUV images. This may improve CS image interpretation, especially in the presence of high residual blood pool activity. GENERATION OF PARAMETRIC KI IMAGES USING FDG PET DUAL-TIME-POINT IMAGING DATA FOR CARDIAC SARCOIDOSIS 104-03 J. Wu*,1 B. D. Young,2 H. Liu,3 M. Sadeghi,1 E. J. Miller,1 C. Liu1; 1Yale University School of Medicine, New Haven, CT, 2Internal CT-FREE ATTENUATION CORRECTION FOR DEDICATED Medicine, Yale University School of Medicine, New Haven, CT, CARDIAC SPECT USING A 3D DUAL SQUEEZE-AND- 3Internal medicine (cardiology), Yale University School of Medicine, EXCITATION RESIDUAL DENSE NETWORK New Haven, CT X. Chen*, B. Zhou, L. Shi, R. Wang, E. J. Miller, A. Sinusas, C. Liu; Introduction: FDG PET is used in the diagnosis and monitoring of School of Medicine, Yale University, New Haven, CT patients with cardiac sarcoidosis (CS). The net uptake rate (Ki) obtained Introduction: Attenuation correction for cardiac SPECT is challenging using kinetic modeling is the gold standard quantification index for FDG for SPECT-only systems without CT. This study proposed a CT-free PET. This study aimed to evaluate an approach to generate Ki images for attenuation correction method for GE dedicated cardiac SPECT systems CS using FDG PET dual-time-point imaging data. based on customized 3D dual squeeze-and-excitation residual dense Methods: Fourteen patients referred to FDG PET for suspected CS were network (DuRDN), which incorporates both imaging and non-imaging included. Seven were found to have myocardial FDG uptake consistent information including BMI, gender, and scatter window data. with CS, and seven had no myocardial FDG uptake. In this study, 8-min Methods: Our dataset consists of 176 anonymized clinical myocardial FDG PET/CT scans were obtained at both 90 min and 120 min post perfusion studies using 99mTc-tetrofosmin on a GE Discovery 570c injection (p.i.). The Ki image was generated from the two PET images hybrid SPECT/CT scanner, with 108 for training and 68 for testing. Each using a simplified dual-time-point Patlak approach that was previously study includes attenuation-corrected (AC) and non-attenuation-corrected developed and validated by our group. For quantitative analyses, the (NC) images from photopeak window (133–148 keV), scatter (SC) cardiac maximum SUV (SUVmax), the left ventricular blood pool images from 3 scatter windows (55–80 keV, 80–105 keV, 105– (LVBP) SUV, and the target-to-blood ratio (TBRmax = SUVmax/LVBP 130 keV), along with the patient BMI and gender. The NC, SC, BMI, SUV) were calculated in the SUV images, while the cardiac maximum and gender image volumes are encoded and concatenated as the network Ki (Ki_max) and the LVBP Ki were calculated in the Ki images. input with AC image as label. Our DuRDN consists of Residual Dense Results: The Ki_max values of the FDG-positive patients were signifi- Block (RDB), Dual Squeeze-and-Excitation (DuSE), and U-Net back- cantly higher than those of the FDG-negative patients (17.6 ± 16.4 lL/ bone architecture. The results are evaluated using polar maps, min/cm3 vs. 2.66 ± 1.44 lL/min/cm3, p \ 0.05), concordant with the normalized mean square error (NMSE), normalized mean absolute error SUVmax results used clinically (4.27 ± 2.21 g/mL vs. 0.92 ± 0.35 g/mL (NMAE), and peak signal-to-noise ratio (PSNR), by comparing the at 90 min p.i., p \ 0.05). The correlation between Ki_max and TBRmax network predicted AC with the ground truth of scanner AC. was stronger than that between Ki_max and SUVmax (R2 = 0.96 vs. Results: DuRDN baseline (only NC input) achieved more accurate AC R2 = 0.87, p \ 0.05). Compared to the SUV images, a substantially as compared to traditional 3D U-Net. A progressive performance higher contrast between the myocardium and LVBP was observed in the improvement of DuRDN is observed as scatter data, BMI, and gender Ki images as the LVBP Ki values were close to zero were added as the inputs. In contrast, adding such information did not (6.8 9 10-17 ± 7.0 9 10-16 lL/min/cm3). substantially improve the AC performance using traditional 3D U-Net. Conclusions: Feasibility of generating Ki images using FDG PET dual- Conclusions: Our customized DuRDN is able to efficiently incorporate time-point imaging data was demonstrated in patients with CS. Ki both imaging and non-imaging information (BMI, gender, scatter win- images showed substantially higher contrast between the myocardium dows) to improve the performance of CT-free attenuation correction for dedicated cardiac SPECT systems.

104-04 DEVELOPMENT AND VALIDATION OF A DIAGNOSTIC MODEL FOR TRANSTHYRETIN CARDIAC AMYLOIDOSIS S. Bukhari*,1 S. Malhotra,2 Y. S. Eisele,3 D. Shpilsky,1 R. Nieves,1 Z. Bashir,1 W. Follansbee,1 P. Soman1; 1UPMC, Pittsburgh, PA, 2Cardiology, Cook County Health, Chicago, IL, 3UPMC Heart & Vascular Inst., Pittsburgh, PA Introduction: Referral for Tc-99m pyrophosphate (PYP) imaging is generally based on a combination of clinical, electrocardiographic (ECG) and echocardiographic (echo) features which are individually non-spe- cific. We aimed to derive a clinical score to predict a positive PYP study. Methods: Demographic, clinical, ECG and echo data were recorded for patients who underwent PYP imaging between 06/2015 and 01/2020. Patients were randomly divided into derivation (n = 300) and validation (n = 140) cohorts. Independent predictors of a positive PYP study were identified from the derivation cohort by multivariable regression analy- sis. Presence/absence of these variables was assigned a score of 1/-1, respectively, which was then weighted by the regression coefficient (RC). Weighted values were summed to derive an Amyloidosis Predic- tion Score (APS). Receiver operating characteristic (ROC) curve was used to describe the predictive value of the APS for a positive PYP study in the validation cohort.

Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

Results: Among the 440 patients studied (age = 75 ± 11 years, 71% men, 81% Caucasian) a positive PYP was present in 126 (28.6%). Bilateral carpal tunnel syndrome (RC = 0.58), lumbar spinal stenosis (RC = 0.16), atrial fibrillation (RC = 0.07), low QRS voltage (RC = 0.13), pseudo-infarct pattern (RC = 0.13) and left ventricular hyper- trophy C 1.4 cm (RC = 0.13) were independent predictors of a positive PYP study in the derivation cohort. APS ranged from - 1.2 to ? 1.2 and predicted a positive PYP in the validation cohort with an area under the curve of 0.96 (figure). An APS value of C-0.42 conferred a sensitivity and specificity of 95% and 91% for predicting a positive PYP study, respectively, with a positive likelihood ratio of [ 10. Conclusion: A combination of clinical, ECG and echo features can be used to derive an APS which, in this pilot validation study, has high predictive accuracy for a positive PYP study. This score should be prospectively validated in a larger study to determine if it will increase the efficiency of resource utilization for the diagnosis of transthyretin cardiac amyloidosis.

Journal of Nuclear CardiologyÒ 104-05 In this study, we investigated the potential of TSPO-targeted PET imaging for assessing aging-associated cardiac abnormalities. MYOCARDIAL FDG SUPPRESSION IN PATIENTS Methods: Leptin receptor heterozygotes Zucker rats (fa/?) fed a high fat diet WITH SUSPECTED CARDIAC SARCOIDOSIS: EFFECT were used in this study either as young (12–16 weeks old) or aged (35– OF TIMING AND IMMUNOTHERAPY IN MONITORING 52 weeks old) animals. Cardiac function was evaluated by echocardiography THERAPY RESPONSE in 5 young and 7 aged rats. The animals were injected intravenously with 1 1 2 2 3 C. Rojulpote*, U. Salam, M. Vidula, S. Selvaraj, K. Patterson, 15.2 ± 7.8 MBq of [11C]-PBR28 (specific activity: 149 ± 171 MBq/nmol). 3 3 3 1 4 M. Rossman, L. Goldberg, J. Dubroff, C. Ligon, P. E. Bravo ; In two animals (22–24 weeks), samples of blood and heart tissue were col- 1 2 University of Pennsylvania, Philadelphia, PA, Cardiology, Hospital lected and used to evaluate the presence of [11C]-PBR28 metabolites by radio 3 of the University of Pennsylvania, Philadelphia, PA, Hospital of the high performance liquid chromatography (HPLC). PET/CT imaging (Inveon 4 University of Pennsylvania, Philadelphia, PA, Radiology, Univer- PET/CT, Siemens) was performed in 4 young and 6 aged animals either as a sity of Pennsylvania, Philadelphia, PA dynamic PET scan from 0 to 40 min post injection (p.i., n = 5)orastaticPET Background: Patients with suspected cardiac sarcoidosis (CS) fre- acquisition from 20 to 40 min p.i. (n = 5). Radioactivity in the heart was quently undergo FDG-PET imaging to assess disease activity at baseline quantified on the PET images and expressed as standardized uptake values and after treatment initiation. However, the assessment of treatment (SUV). All animals were euthanized at the end of the imaging procedure or at response has not been systematically investigated, in particular the 30 min p.i. for the group dedicated for metabolite analysis. Myocardial timing of repeat imaging and the effect of different immuno-regimens to samples were collected and deep-frozen, and TSPO and catalase protein achieve complete myocardial suppression (CMS) of FDG. expression were analyzed by western blotting. Methods: We analyzed 123 patients with suspected CS (54.5 ± 9.6 years, Results: Aged animals exhibited mild diastolic dysfunction as evidenced 28.5% females, 47.2% history of biopsy confirmed sarcoidosis) from a by a 30% increase in isovolumic relaxation time (p \ 0.05) in the absence database registry of 1321 patients who had undergone PET imaging for of significant changes in systolic function. Radio-HPLC analysis of blood cardiac sarcoidosis at the Hospital of the University of Pennsylvania samples and heart tissue demonstrated the absence of [11C]-PBR28 between 2008 and 2020. Our study sample was selected if they met the metabolites in the heart tissue, while the parent compound represented following inclusion criteria: (1) patient did not receive treatment at time of only 29% of the radioactivity in the plasma at 30 min p.i. Dynamic PET first PET scan; (2) myocardial inflammation was present on first PET scan; images showed rapid blood clearance and uptake of [11C]-PBR28 in the (3) patient had a follow up PET scan to monitor disease activity. Baseline myocardium. Cardiac uptake of [11C]-PBR28 at 20–40 min p.i. was history prior to first scan was noted; 35.8% had ventricular tachycardia, higher in aged compared to young rats (SUV: 9.1 ± 1.9 vs. 5.9 ± 2.4, 19.7% had heart failure admissions, 20.3% had complete heart block, and p \ 0.05). Western blot analysis revealed higher expression of TSPO 52.5% had existing pacemaker/implantable cardioverter defibrillator. monomer and catalase, a marker of oxidative stress, in aged myocardium. Follow-up scans were analyzed at different intervals and were reported as Conclusions: Older rats challenged with a high-fat diet show mild CMS if myocardial FDG was similar or lower than blood pool. We also diastolic functional impairment. This is associated with increased cardiac investigated the effect of different immuno-regimens in achieving CMS. A oxidative stress and increased expression of TSPO, which can be Pearson Chi-square was employed for statistical purposes. detected by [11C]-PBR28 PET imaging. [11C]-PBR28 PET may detect Results: Overall, 30.14% of patients showed CMS at the time of follow- MD in age-related cardiomyopathy. up PET scan (median 6.8 months [IQR 4.8–9.4]). CMS was achieved in 31%, 36%, and 25% of patients at 2–3, 4–5, and 6–7 months follow-up, respectively (p = 0.664). Prednisone alone (69% of patients), prednisone in combination (26% of patients), or non-prednisone immuno-regimens (5% of patients) showed similar CMS rates (31% vs. 33%, vs. 33%; p = 0.9). However, in the prednisone only group, greater CMS rates appeared to be attained at a dose of B 20 mg vs. C 30 mg daily (45% vs. 24%; p = 0.024) during follow-up. Conclusion: The proportion of suspected CS patients that showed CMS of FDG on PET was not found to be significantly different with delayed interval of follow-up scans, nor higher doses of prednisone. These findings have significant clinical implications for patient management and will need to be confirmed in future studies.

104-06 TSPO-TARGETED PET IMAGING IN AGING HEART Jakub Toczek1, Gunjan Kukreja1, Kiran Gona1, Jiasheng Zhang1, Krista Fowles2, Michael Kapinos2, Ming-Qiang Zheng2, Yunpeng Ye2, Yiyun Huang2, Richard E. Carson2, John Hwa3, Fadi G. Akar3, Mehran M. Sadeghi1; 1Yale University & VACT Healthcare System, New Haven, CT, United States; 2Yale PET Center, New Haven, CT, United States; 3Yale Cardiovascular Research Center, New Haven, CT, United States Background: Aging is associated with structural and functional deterio- rations of the heart. Mitochondrial dysfunction (MD) promotes oxidative stress, and is a common feature of aging, metabolic disorders and car- diomyopathy. The 18 kDa mitochondrial translocator protein (TSPO) is expressed in the outer mitochondrial membrane. Several TSPO-targeted PET radiotracers, including [11C]-PBR28, have been developed to image microglial activation. However, TSPO is also upregulated in several dis- eases associated with MD, suggesting that TSPO may be a marker of MD.

Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

104-07 Results: 190 patients underwent Rb-82 PET between May 2017 and August 2019 (43% women, mean age 65 ± 11.8 years). 60% (116/190) INTEGRATION OF RUBIDIUM-82 POSITRON EMISSION had stress-induced regional perfusion defects (mean 24% ± 19) and 41% TOMOGRAPHY (PET) DERIVED REGIONAL MYOCARDIAL (77/190) had resting perfusion defects ([ 15% of LV). Mean regional BLOOD FLOW (MBF) QUANTIFICATION IN THE DIAGNO- MFR per vessel was reduced in all vascular territories: LAD median 1.75 SIS OF CORONARY ARTERY DISEASE (IQR 1.40–2.19), RCA median 1.76 (IQR 1.36–2.27), LCx median 1.70 1 2 1 1 1 C. Gallegos*, C. Trejo-Paredes, E. Posada, Y. Saito, Y. Liu, E. (IQR 1.30–2.16). Stress MFR and MBF were mildly predictive of 1 3 1 Spatz, E. J. Miller ; Yale School of Medicine, New Haven, CT, obstructive CAD by QCA in the LAD territory (OR = 0.36, CI = 0.17– 2,3 Yale University, New Haven, CT 0.74, p = 0.006); (OR = 0.45, CI = 0.23–0.89, p = 0.023), respectively, Introduction: Global Rb-82 PET MFR predicts cardiovascular events, and RCA territory (stress MBF; OR = 0.29, CI = (0.15–0.57), but less is known about the physiologic significance and prognostic p \ 0.001), but not the LCX territory (stress MBF and MFR: OR = 0.53, impact of regional MFR, particularly if reductions in regional MBF CI = 0.23–1.21, p = 0.136 and OR = 0.57, CI = 0.23–1.40, p = 0.227, correlate with angiographically defined CAD lesion severity. We com- respectively). Correlation was weak between regional MFR and pared per vessel MFR and MBF to CAD lesion characteristics measured obstructive lesion diameter in all three vessels: LAD (R = 0.2, by quantitative coronary analysis (QCA) in patients with abnormal Rb-82 p = 0.005), RCA (R = 0.23, p = 0.001) and LCx (R = 0.21, p = 0.003), PET. with an increased odds of a significant lesion when MFR was \ 1.5. Methods: Cardiac Rb-82 PET results and QCA data were compared Conclusion: To our knowledge, this is the first large study to show the from subjects referred for coronary angiography following abnormal relationship between per vessel MBF, MFR, relative perfusion, and PET studies. Global and regional MBF and MFR were derived using the coronary stenosis by QCA. Regional MBF was only modestly associated Lortie Fixed DV model for each coronary territory. Angiographic lesions with significant stenosis, particularly in the LAD and RCA, but not in the were quantitatively assessed by QCA using QAngio XA (Version 7.3, LCX, suggesting discordance between regional quantitative flow and Medis Medical Imaging System BV). Significant stenosis was defined QCA, likely as a result of other pathophysiologic processes such as as [ 50% of luminal obstruction. Correlation of QCA derived mea- stenosis location, concomitant microvascular disease, presence of col- surements with MFR was analyzed using linear regression. Logistic laterals, or downstream stenoses from other vessels. While an MFR regression was performed to assess the association between MBF and of \ 1.5 is suggestive of obstructive disease, we found significant MFR with angiographic stenosis. We also assessed the correlation heterogeneity in this association, suggesting MFR and MBF are overall between MFR and QCA lesion characteristics; cubic spline function was poor indicators of obstructive CAD. used to account for outlier values of MFR.

Journal of Nuclear CardiologyÒ ePOSTERS: NEW TECHNOLOGIES

301-01 301-02 PREDICTIVE VALUE OF LEFT VENTRICULAR PHASE PREDICTING IMAGE DEGRADATION DUE TO MOTION ANALYSIS FOR CANCER THERAPY RELATED CARDIAC IN RUBIDIUM-82 MYOCARDIAL PERFUSION IMAGING DYSFUNCTION USING METRICS DERIVED FROM A NOVEL DATA- K. A. Jones*, S. A. D. Small,1 D. J. Hamilton,1 S. Ray,1 W. Martin,2 DRIVEN MOTION CORRECTION ALGORITHM 1 1 2 1 J. Robinson,1 N. E. R. Goodfield,1 C. A. Paterson1; 1NHS Greater M. J. Memmott*, I. S. Armstrong, C. Hayden, P. Arumugam ; 1 Glasgow & Clyde, Glasgow, United Kingdom, 2University of Glas- Manchester University Hospitals NHS Foundation Trust, Manch- 2 gow, Glasgow, United Kingdom ester, United Kingdom, Siemens Healthineers, Knoxville, TN Background: Anthracycline/trastuzumab based chemotherapy regimens Introduction: Static myocardial perfusion data are acquired over a period have been associated with increased risk of cardiovascular disease. of minutes, a time window great enough to allow significant cardiac dis- Accurate diagnostic tools to identify patients at risk of cancer therapy placement to take place and ultimately degrade the reconstructed image related cardiac dysfunction (CTRCD) are critical. quality. We have previously demonstrated the benefit of a high temporal Approximate Entropy (ApEn) is a regularity statistic that quantifies resolution (1 s) data-driven motion correction (DDMC) algorithm for unpredictability of fluctuations in data. It has not previously been widely rubidium-82 relative perfusion PET images [1]. By utilizing the motion investigated for assessing ventricular contraction. The aim of this work is vector from this algorithm we sought to derive metrics which are predictive to determine if ApEn calculated from RNVG phase images can identify of image degradation due to motion, prior to reconstruction. subclinical cardiac abnormalities and identify patients who are at higher Methods: Rest and stress relative perfusion images from 300 consecutive risk before treatment starts. patients (181 male; stress agent: 266 adenosine, 34 regadenoson) were Methods: Phase analysis was retrospectively carried out on sequentially reconstructed with and without DDMC. Patients were administered acquired baseline RNVG studies of 177 breast cancer patients before 740 MBq of Rb-82 for each acquisition with images acquired on a Bio- they received cardiotoxic chemotherapy. Using in-house R code, ApEn graph Vision (Siemens Healthineers, Knoxville, TN, United States) and was calculated from the baseline RNVG phase images. reconstructed with OSEM ? PSF ? TOF. The 600 image pairs (corrected Results: A significant difference (p \ 0.05) in ApEn at baseline was and non-corrected) were blinded and shown to two observers who gave a found between the group who maintained a normal LVEF during treat- visual difference score (VDS) of 0, 1 or 2 as such: 0—no difference per- ment (n = 166) and those who had an LVEF decline of more than 10% to ceivable; 1—subtle difference perceivable and 2—a clear difference below 50% (n = 11). Improved discrimination between the groups was perceivable. Metrics were derived from the motion vector: namely the sum achieved by combining the LVEF and ApEn from the baseline assess- of the absolute motion vector, XAMV, distance traveled, XDT, standard ment. The results suggest that patients with a lower LVEF and higher deviation of the vector, XSTD, and the fraction of time the vector dwelled ApEn at their baseline RNVG (lower right quadrant in the figure below) in a central spatial window, XDWELL. Receiver operating characteristic are more likely to have an LVEF drop to below 50% during treatment. (ROC) curves were created for each metric and the area under the curve The figure shows LVEF vs ApEn for breast cancer patients prior to (AUC) determined for discrimination between a VDS of 0 or 2 and receiving cardiotoxic chemotherapy. VDS [ 0. Varying widths and locations of the window for XDWELL were Conclusion: Patients who have a normal LVEF before treatment may evaluated and parameters chosen which maximized the AUC. have subtle phase abnormalities which can be detected at the baseline Results: The optimal width and location for XDWELL were found to be ± RNVG. The results of this study suggest that ApEn combined with the 4 mm, centered on the location which maximized the modal time spent in that baseline LVEF could potentially predict which patients are at a higher window. For discriminating between a VDS of 0 (n = 327)and2(n =36),the risk of developing CTRCD. This may help identify those at highest risk AUC values for all metrics except XDT were [ 0.99. For discrimination of CTRCD and allow commencement of protective therapy and more betweenaVDSof0and1or2(n = 273), i.e., detecting any degradation, the focused follow up. AUC values were 0.90 (± 0.01), 0.77 (± 0.02), 0.92 (± 0.01) and 0.94 (± 0.01) for XAMV, XDT, XSTD and XDWELL, respectively. Conclusions: Subtle image degradation can be predicted from a motion vector derived from list-mode events. The optimal metric was found to be the dwell fraction in a spatial window of ± 4 mm, dependent on scanner resolution and time-of-flight capabilities. As the metric could be created in near real time during acquisition, this creates a unique quality control measure indicative of patient motion and resultant image quality prior to motion correction and reconstruction. [1] Armstrong IS, Hayden C, Memmott MJ, Arumugam P. A preliminary evaluation of a high temporal resolution data-driven motion correction algorithm for rubid- ium-82 on a SiPM PET-CT system. J Nucl Cardiol. 2020 In press.

301-03 HIGH-FREQUENCY QRS ANALYSIS TO SUPPLEMENT ST-ANALYSIS FOR MYOCARDIAL ISCHEMIA: MULTI- CENTER PROSPECTIVE COHORT T. R. Patel*,1 J. M. Bourque2; 1University of Virginia, Charlottesville, VA, 2University of Virginia Health Systems, Crozet, VA Background: Exercise testing is a well-known noninvasive assessment method for myocardial ischemia in patients with suspected coronary artery disease (CAD). Stress electrocardiography (ECG) alone is underutilized in this population despite guideline recommendations in part due to poor diagnostic accuracy. High frequency QRS analysis (HF- QRS) is a novel tool to supplement standard ST-analysis during stress ECG and has been shown in single-center retrospective analyses to identify any and substantial ischemia with high diagnostic accuracy. We Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

sought to compare the diagnostic accuracy of HF-QRS? standard ST- Methods: This study comprised 171 patients who underwent rest/stress analysis compared to standard ST-analysis alone for the identification of 82Rb PET on a 3D PET/CT system using a full dose (FD) protocol with moderate to severe myocardial ischemia by exercise SPECT MPI. available correlating invasive angiography within 6 months. HfD and Methods: The study population included 388 consecutive patients who QD reconstructions were obtained by reducing events from the FD list- underwent exercise SPECT MPI at the Cleveland Clinic Foundation, mode files. Stenosis diameter of C 70% in the three major coronary Minneapolis Heart Institute Foundation, and the University of Virginia arteries was considered obstructive. Total perfusion defects for rest and Health System, respectively. An ischemic HF-QRS pattern was defined stress and ischemia (iTPD = sTPD – rTPD) were quantified. Diagnostic as an absolute reduction of C 1 lV and a relative reduction of C 50% accuracy CAD was compared with area under the receiver operating between maximal and minimal values of the mean root square of the characteristic curve (AUC). Contrast to noise ratios (CNR) was reported 150–250 Hz band signal in C 3 leads. HF-QRS data were processed at to check for changes in the images caused by the dose-reductions. In University of Virginia. The diagnostic accuracy of HF-QRS ? ST- addition, noise in the images were calculated as the coefficient of vari- analysis was compared with ST-analysis alone for moderate to severe ation in the blood pool. myocardial ischemia using Chi-square analysis and semi-quantitative Results: Patients with weights of 180.8 ± 47.2 lbs. were injected with gated SPECT MPI as the gold standard. The incremental diagnostic value doses of 31.5 ± 5.1 mCi (FD), with simulated doses of 15.7 ± 2.6 mCi of HF-QRS was assessed by logistic regression analysis. The likelihood for HfD and 7.9 ± 1.3 mCi for QD. For sTPD, FD and HfD protocols of any ischemia by number of leads positive for HF-QRS was also had similar AUC (FD = 0.807, HfD = 0.802, p = 0.108), whereas QD determined. had reduced AUC (0.786, p = 0.037). No differences in AUC was Results: The study cohort was 71% male and 84% Caucasian with a reported for ITPD among the three protocols (AUC: FD = 0.831, mean age of 58.3 ± 11.8 years. ST- and HF-QRS analyses were positive HfD = 0.835, QD = 0.831, all p C 0.805). Bland–Altman plots revealed in 96 (24.7%) and 121 (31.2%) of patients, respectively. HF-QRS had a that sTPD were comparable for FD and HfD, while a bias of 3% was substantially higher sensitivity than ST-analysis for moderate-severe observed between FD and QD (Figure 1). CNR was found comparable ischemia (66.7% vs. 40.0%, p \ 0.003). There was no statistically sig- across the three reconstruction protocols (FD = 11.0, HfD = 10.7, nificant difference in specificities for HF-QRS vs ST-analysis for QD = 9.7, all p [ 0.19), though noise in the images were increased for moderate-severe ischemia. (70.5% vs 75.7%, p = 0.08). There was a the dose-reduced reconstructions (FD = 0.12, HfD = 0.14, QD = 0.15, stepwise increase in ischemia as number of positive HF-QRS leads all p \ 0.0001). increased (p = 0.0004). HF-QRS provided significant incremental diag- Conclusions: Half-dose injection protocols do not affect the accuracy of nostic value when added to clinical variables and ST-analysis 82Rb PET. Based on these findings, we recommend that dose reductions (p = 0.006). of 50% should be applied in static perfusion 82Rb studies. Conclusions: This multicenter, prospective study expands the literature showing the benefit of HF-QRS analysis. HF-QRS analysis substantially improves detection of moderate-severe ischemia over ST-analysis and clinical risk factors in patients undergoing exercise stress ECG. This noninvasive adjunct may improve CAD risk stratification and encourage use of stress ECG without imaging, reducing costs and radiation exposure.

301-04 LOW-DOSE 82RB PET MYOCARDIAL PERFUSION: COM- PARISON OF A FULL-DOSE AND SIMULATED HALF-DOSE AND QUARTER DOSE PROTOCOLS M. Lassen*,1 Y. Otaki,1 P. Kavanagh,1 R. Miller,2 D. S. Berman,1 P. Slomka1; 1Cedars-Sinai Medical Center, Los Angeles, CA, 2Univer- sity of Calgary, Calgary, AB, Canada Introduction: Quantification of myocardial perfusion imaging (MPI) using Rubidium-82 (82Rb) PET is key in the assessment of coronary artery disease (CAD). Current recommended injected doses 82Rb are 30–40 mCi. We investigated the effect on static image quality and diagnostic performance of 82Rb PET MPI of half-dose (HfD) or quarter dose (QD) protocol.

Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

301-05 Results: 2247 patients (63%) had obstructive CAD. The AUC by DL with tenfold repeated testing (0.84 [0.83–0.85]) was higher than stress CLINICAL DEPLOYMENT OF EXPLAINABLE DEEP TPD (0.79 [0.78–0.81]) (p \ 0.0001). In external testing, AUC by DL LEARNING FOR DIAGNOSIS OF OBSTRUCTIVE COR- (555 patients from 3 left out sites) (0.79 [0.76–0.83]) was higher than ONARY DISEASE FROM MYOCARDIAL PERFUSION stress TPD (0.74 [0.70–77]) (p \ 0.01). The sensitivity of DL (86.6%) SPECT was higher than visual diagnosis (82.4%) and stress TPD (81.8%) 1 1 1 12 Y. Otaki*, A. Singh, P. Kavanagh, R. Miller, B. K. Tamarap- (p \ 0.001 for all), with equivalent specificity. 1 3 4 5 6 poo, T. Sharir, A. J. Einstein, M. B. Fish, T. D. Ruddy, Conclusion: The diagnostic performance of the DL model developed for 7 8 8 9 P. A. Kaufmann, A. J. Sinusas, E. J. Miller, T. M. Bateman, both conventional and solid-state SPECT-MPI systems significantly 10 10 1 1 1 S. Dorbala, M. Di Carli ; S. Cadet, J. X. Liang, D. Dey, surpasses quantitative analysis and visual diagnosis. D. S. Berman,1 P. J. Slomka,1; 1Cedars-Sinai Medical Center, Los Angeles, CA, 2University of Calgary, Calgary, AB, Canada, 3Israel and Ben Gurion University of Negev, Beer Sheba, Israel, 4Columbia University Medical Center, New York, NY, 5Oregon Heart and Vascular Inst., Springfield, OR, 6Ottawa Heart Inst., Ottawa, ON, Canada, 7University Hospital Zurich, Zurich, Switzerland, 8Yale Univ. School of Medicine, New Haven, CT, 9Cardiovascular Imag- ing Technologies, Kansas City, MO, 10Brighan & Women’s Hospital, Boston, MA Purpose: We developed and tested a novel explainable deep learning (DL) approach for the detection of coronary artery disease (CAD) in patients undergoing SPECT myocardial perfusion imaging (MPI). Methods: 3578 patients without known CAD from nine centers with invasive angiography performed within a 6-month interval, from MPI performed with solid-state (n = 2059) or conventional SPECT (n = 1519). DL model used automatically obtained stress perfusion, motion and thickening polar maps, age, sex, and cardiac volumes and outputted per-vessel probability of CAD. The models were evaluated with tenfold repeated hold-out and external testing. The Grad-CAM method was used to highlight the regions in the polar map which con- tribute to the prediction (Figure). The diagnostic thresholds of DL and stress TPD were set to match the specificity of abnormal visual diagnosis. The area under the receiver operating characteristics curve (AUC) and sensitivity by DL were compared to visual diagnosis and stress TPD.

Journal of Nuclear CardiologyÒ ePOSTERS: MYOCARDIAL PERFUSION AND FUNCTION IMAGING UTILIZATION: AUC, COST EFFECTIVENESS, COMPARATIVE EFFECTIVENESS

302-01 302-02 PATIENT REPORTED SYMPTOMS AND AGREEMENT QUALITATIVE ASSESSMENT OF FACTORS RELATED WITH CLINICIAN DOCUMENTATION PRIOR TO TO UNNECESSARY NONINVASIVE IMAGING MYOCARDIAL PERFUSION STUDIES D. E. Winchester*,1 L. J. Shaw,2 C. Helfrich,3 R. J. Beyth1; D. E. Winchester*, C. Schwartz; University of Florida, Gainesville, 1University of Florida, Gainesville, FL, 2Weill Cornell Medicine, FL New York, NY, 3University of Washington, Seattle, WA Background: Clinicians are responsible for documenting patients’ Background: Multiple lines of evidence have consistently demonstrated symptoms in the medical record and use those symptoms to develop that a substantial proportion of noninvasive imaging is unnecessary. While plans of care. In some cases, miscommunication or differing interpre- several plausible contributing factors have been identified, qualitative tations can result in patient symptoms being incorrectly recorded. We assessment seeking additional unknown factors has not been performed. sought to measure the extent to which patient-reported and clinician- Methods: An interview guide was developed to probe physician opinions documented symptoms differ and what effect this would have on about unnecessary noninvasive imaging including definitions, contributing appropriateness of myocardial perfusion imaging (MPI). factors, sources of pressure to order, response to these pressures, and unique Methods: We conducted a prospective cohort study of patients referred characteristics of the Veterans Health Administration (VHA) care environ- for myocardial perfusion imaging between November 2017 and July ment. Interviews were conducted confidentially, in private, and audio- 2019. After providing consent, patients completed a structured assess- recorded for transcription. Interviews were coded using a rapid analysis ment of their symptoms in a research database. Data on symptoms were qualitative method with agreement by consensus among the authors as to the extracted from the clinician note in which MPI was ordered. Appropri- relevant responses pertaining to each domain. ateness of MPI was determined based on both the patient-reported and Results: Data from 13 subjects have been analyzed. Years in practice clinician-documented symptoms. Disagreements on symptoms and ranged from 3 to 31 (median = 15 years) and multiple specialties were appropriateness were compared by kappa statistic. represented including primary care, emergency medicine, radiology, hos- Results: Of 93 included subjects, median age was 71 and 4.4% were pital medicine, and internal medicine subspecialties. Respondents reported female. Prior MI was reported for 28.9% and 36.7% had diabetes mel- that 3–25% (median = 22.5) of noninvasive tests that they order are litus. Moderate agreement between patients and clinicians was observed unnecessary. Among sources of pressure to order unnecessary tests, a novel for the symptom of chest pain, all others had fair or slight agreement. report was one physician who felt that nurses pressure physicians to order (Figure) AUC ratings were in disagreement for n = 12 (13.3%) of sub- tests, specifically when a patient’s condition worsens or has an unexpected jects, in 3 the disagreement was from appropriate to rarely appropriate. event (e.g. falls). Other contributing factors identified included: ‘‘it’s easier Based on patient report (n = 28, 30.1%) and clinician documentation than doing a physical exam’’, ‘‘[peer review] can make people become (n = 30, 33.3%), the minority of subjects were asymptomatic. In the defensive’’, and concerns about professional liability, missed diagnoses, and absence of symptoms, MPI may be more likely to be rarely appropriate adverse outcomes. In response to the pressure to order, some reported (patient relative risk 1.17 95% confidence interval 0.99–1.34; clinician engaging in discussions with the patient or referring physician/consultant; relative risk 1.23 95% confidence interval 1.04–1.30). one noted that in some cases, an unnecessary test may help reassure a patient Conclusions: Disagreement was common between the symptoms about an anxiety-provoking diagnosis. Physicians identified several con- recorded by clinicians and those reported directly by the patient. As a tributing factors they considered unique to the VHA environment including: result, appropriateness ratings were not consistent for a portion of the higher rates of post-traumatic stress, substance/tobacco abuse, chronic pain, cohort. When no symptoms were documented by the clinician, MPI was and health literacy; the presence of a patient advocate office; and misun- significantly more likely to be rarely appropriate. derstanding about VHA versus the Veterans Benefits Administration. Conclusions: Physicians recognize that a substantial portion of the noninvasive imaging they order is unnecessary. In some cases, a seem- ingly unnecessary test may benefit a patient. The VHA environment may have unique factors that contribute to unnecessary imaging.

302-03 SILENT AND SYMPTOMATIC ISCHEMIA IN REVASCULARIZED PATIENTS. A RETROSPECTIVE MULTICENTER REGISTRY J. Erriest*,1 N. A. Vita,2 A. Romero Acun˜a,3 L. Gutierrez,4 M. Redolatti,1 S. Ponce,5 B. Del Corro,5 J. Lotti,2 A. Mele,5 J. Camilletti1; 1Hospital Italiano La Plata, La Plata, Argentina, 2Hospital Italiano Rosario, Rosario, Argentina, 3Instituto de Cardiologı´aRosario, Rosario, Argentina, 4Medicina Nuclear, Instituto de Diagnostico y Resonancia de Mendoza, Mendoza, Argentina, 5Instituto Cardiologı´a La Plata, La Plata, Argentina Introduction: There is conviction in a large number of cardiologists that revascularization means the definitive solution of ischemia and therefore of angina in patients with coronary artery disease (CAD). In both internationally and nationally clinical communities there are data that show that this is not the current reality. Objectives: Establish the percentage of patients with silent and symp- tomatic ischemia post revascularization. Quantify the amount, extent and the degree of severity of ischemia. Methods: We performed a retrospective analysis of the last four years, from the data base of four centers in Argentina. We included

Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

revascularized patients, we analyzed coronary risk factors, past history of microvascular arteries; this can explain the limited specificity, with 4 CAD and the results of the stress test. We divided the patients according patients having normal ICA but impaired MFR potentially due to to the procedure used for their revascularization, percutaneous coronary microvascular dysfunction (diabetes with target organ damage such as interventional (PCI) or a coronary bypass graft surgery (CABG), and proteinuriaÁÁÁ). Only one patient had normal global MFR of 2.68, but grouped them according to whether they had ischemia symptomatic or abnormal ICA with severe stenosis on right coronary artery (inferior asymptomatic, according to the clinic and the results of the myocardial MFR was 1.68). perfusio´n Spect studies (MPIs). We quantify the severity and the extent Conclusions: Global MFR measured during MPI for CAD screening on of the myocardial perfusion defects semiquantitatively according to the CZT camera significantly enhances SPECT diagnostic performances and summed stress score (SSS), summed rest score (SRS) and summed dif- could be a safe exclusion or a strong motivation for asking an ICA. ference score (SDS). Also, left ventricular ejection fraction (EF). Results: We analyzed 20.492 patients, sent to the four centers of nuclear cardiology with or without known CAD, of whom n 6987 (29%) had 302-05 been revascularized, n 1163 (16%) with CABG and n 5815 (84%) with PCI. Characteristics of the population of patients revascularized age IMPROVED DIAGNOSTIC ACCURACY OF PET MYOCAR- 66 ± 9 years, male n 5598 (80.2%), hypertension n 4332 (62%), dys- DIAL PERFUSION IMAGING IN COMPARISON lipidemia n 4526 (64/8%), smokers n 1486 (21.2%), diabetic n 1729 WITH SPECT FOR THE DETECTION OF CORONARY (24.6%), overweight (BMI [ 25) n 3561 (51%). Time elapsed between ARTERY DISEASE IN PATIENTS WITH LEFT BUNDLE the revascularization and the performance of the MPIs PCI BRANCH BLOCK 4.3 ± 4.1 years and CABG 9.2 ± 3.3 years. Patients revascularized M. Vidula*,1 P. Wiener,2 S. Selvaraj,3 C. Rojulpote,4 U. Salam,1 M. whom presented ischemia in the MPIs n 2310 (33%), n 1773 (77%) in the Guerraty,1 H. Julien,1 P. E. Bravo5; 1Hospital of the University of group of patients post PCI and n 537 (23%) in the group of patients post Pennsylvania, Philadelphia, PA, 2Einstein Healthcare Network, CABG. Silent ischemia n 292 (54%) and symptomatic ischemia n 245 Philadelphia, PA, 3Cardiology, Hospital of the University of Penn- (46%) in the post CABG group of patients. Symptomatic Ischemia SSS sylvania, Philadelphia, PA, 4Radiology, Hospital of the University of 9.7 ± 5.5; SRS 4.2 ± 3.4; SDS 5.5 ± 2.9 and EF 53.3 ± 16%; and Silent Pennsylvania, Philadelphia, PA, 5Radiology, University of Pennsyl- Ischemia SSS 8.8 ± 6. SRS 4.7 ± 4.6; SDS 4.1 ± 3.1; EF 51.8 ± 15% in vania, Philadelphia, PA the post CABG group of patients. Silent ischemia n 877 (49.5%) and Introduction: Pharmacologic stress testing is recommended for the symptomatic ischemia n 896 (50.5%) in the post PCI group of patients. evaluation of coronary artery disease (CAD) in patients with left bundle Symptomatic Ischemia SSS 9.1 ± 6.4; SRS 3.8 ± 4.4; SDS 5.3 ± 3.7; EF branch block (LBBB), but the difference in diagnostic accuracy between 53.8 ± 12.8%; and Silent Ischemia SSS 9.2 ± 6.1; SRS 4.5 ± 4.9; SDS PET and SPECT myocardial perfusion imaging (MPI) is unknown. 4.7 ± 2.8; EF 51.5 ± 12.9%, in the post PCI group of patients. Methods: We identified patients with LBBB who underwent either PET Conclusions: A high percentage of revascularized patients are ischemic. or SPECT MPI and subsequent invasive coronary angiography (ICA) at Approximately 50% of patients revascularized with ischemia are an academic center between January 2009 and June 2019. Patients with asymptomatic. The ischemic amount of patients with silent ischemia is known CAD or nonischemic cardiomyopathy were excluded (Fig- moderate to high risk. ure 1A). LBBB-related septal defect was defined as two or more contiguous defects of the anterior septum (AHA segments 2, 8, or 14) in the absence of obstructive CAD involving the left anterior descending 302-04 artery. Obstructive CAD was defined as C 50% stenosis in the left main coronary artery or C 70% stenosis in any other coronary artery on ICA. ADDED VALUE OF MYOCARDIAL FLOW RESERVE MEA- Results: Of the 62 patients who underwent ICA, the mean age was SUREMENT DURING SPECT PERFUSION: CORRELATION 65 years, 52% were female, 40% were black, 76% had hypertension, and WITH INVASIVE CORONARY ANGIOGRAPHY 35% were diabetic. Seventeen patients (27%) underwent PET and 45 M. Bailly*,1 F. Thibault,1 M. Courtehoux,2 G. Metrard,1 D. (73%) underwent SPECT. LBBB-related septal defects were more Angoulvant,2 M. Ribeiro2; 1chr Orleans, Orleans, France, 2CHRU common with SPECT compared to PET (49% vs 8%, p = 0.01). The TOURS, TOURS, France prevalence of obstructive CAD was similar in both SPECT and PET Introduction: Myocardial blood flow (MBF) and flow reserve (MFR) cohorts (22% vs 47%, p = 0.06). PET compared to SPECT demonstrated measurement have been shown to improve diagnostic performances of higher sensitivity (88% vs 60%), higher specificity (56% vs 9%), better coronary artery disease (CAD). Dedicated CZT cardiac cameras provide positive predictive value (64% vs 16%), and better negative predictive accurate evaluation of MBF and MFR. In this pilot study, we correlated value (83% vs 43%) (Figure 1B) to detect obstructive CAD. Receiver the results of SPECT myocardial perfusion imaging (MPI) and MFR operating characteristic (ROC) curves demonstrated superior diagnostic measurement with invasive coronary angiography (ICA) findings. accuracy with PET when compared to SPECT (AUC 0.72 (95% CI 0.50– Methods: Patients referred for dynamic MPI for CAD screening between 0.93) vs 0.34 (95% CI 0.18–0.51), p = 0.007) (Figure 1B). November 2018 and March 2020 and for whom coronary angiography Conclusions: While LBBB-related septal defects were seen with both was performed within 3 months were included. Symptoms and risk PET and SPECT, they were six times more likely with SPECT. Overall, factors were collected. SPECT data were acquired on a CZT-based PET showed superior diagnostic accuracy when compared to SPECT for pinhole cardiac camera using a stress (251 ± 12 MBq)/rest the detection of obstructive CAD in patients with LBBB. (513 ± 25 MBq) one-day Tc-99m-tetrofosmin protocol. Kinetic analysis was done with Corridor 4DMTMsoftware using a 1-tissue-compartment model and converted to MBF using a previously determined extraction fraction correction. ICA was performed upon decision of the referring cardiologist and considered normal if no stenosis [ 30% or with impaired FFR was found. The Results of ICA were compared to global MFR. Results: 35 patients (21 male, 14 female) were analyzed. MPI was visually normal in 25 patients, among them 16 had pathological ICA. Mean global MFR was 1.94 ± 0.77. Global MFR was impaired (\ 2) in 25 patients; among them only 7 patients had abnormal visual MPI. This threshold could be considered as the optimal one and allowed a safe exclusion for asking an ICA: sensitivity 95.5%, specificity 69.2% and negative predictive value 99.3%, area under Receiver-Operator-Charac- teristic curve: 0.83. MFR is related to epicardial coronary arteries and to Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

302-06 302-07 REDUCING STAFF OCCUPATIONAL RADIATION EXPO- VALUE OF STRESS MYOCARDIAL PERFUSION SURE: AN ADDITIONAL BENEFIT OF TRANSITIONING WITH GATED SPECT IN THE PROGNOSIS OF PATIENTS FROM SPECT MPI TO PET MPI IN KIDNEY TRANSPLANT PROTOCOL IN A HIGH CON- R. M. Sanghani, S. Fugar*, J. M. D. Gomez, W. White, M. Malecki, CENTRATION MEDICAL CENTER N. Rana, K. A. Williams; Rush University Medical Center, Chicago, V. Gomez Leiva*,1 A. Puente,2 C. M. Martinez,3 D. Escobedo IL Mercado4; 1ISSS Hospital Medico Quirurgico y Oncologico, San Background: Much has been written about reducing patient exposure to Salvador, El Salvador, 2Cardiology, Centro Medico Nacional 20de radiation in medical imaging but there is little about staff exposure, Noviembre ISSSTE, Mexico, Mexico, 3Medicina Nuclear, Issste, particularly in positron emission tomography myocardial perfusion Benito Jua´rez, Mexico, 4Isste Cmn ‘‘20 de Noviembre’’, Mexico city, imaging (PET MPI). Rush University (Chicago, IL) launched a PET MPI Mexico program in February 2019 with conversion of 80% of our pharmacologic Background. End-stage chronic kidney disease (ES-CKD) increases the stress tests from single-photon computed tomography (SPECT) MPI to risk of silent cardiac events, being its main cause of death. Traditional rubidium-82 PET MPI. The new PET room was designed to optimize the and non-traditionalcardiovascular risk factors increases the risk. The safety principles of time, distance and shielding to reduce staff exposure. prognostic value of the test was determined in this high cardiovascular Our objective was to identify if, and by how much, the transition from risk population, obtaining the incidence of cardiovascular mortality from SPECT only to predominantly PET MPI reduced staff exposure to all causes and MACE at three-year follow-up. radiation. Methods. Retrospective, Observational, Transversal. The records of 170 Methods: This is a single-center, retrospective, observational quality patients with ES-CKD in kidney transplant protocol were reviewed and study. Radiation badges were collected from all staff who work in the followed up for three years (current). Analysis of the data with SPSS (v stress lab area, which includes nuclear medicine technologists (NMTs), 21.0), means and standard deviations, frequencies and percentages. nurses, and echo sonographers. Staff radiation exposure before the Results. Age 43.9 (± 13.2), women 42.4% and men 57.6%. Risk factors: implementation of PET MPI (April 2018 to February 2019) was com- systemic arterial hypertension 80%, type 2 diabetes mellitus 25.3%, pared to after the implementation of PET MPI (March 2019–December smoking 30%, dyslipidemia 40%, family history 16.4% and ischemic 2019). Comparison of whole body deep dose (WBDD) in millirems heart disease 1.8%. According to the post-test risk in result, they were (mrem) was reported as median (25th-75th percentile range) and was grouped in: normal 68% (3% went to angiography), low risk compared using the Mann-U-Whitney Test. Two tailed p value \ 0.05 15.3%(19.2%), moderate risk 13% (50%) or severe 3.7% (100%). Of all defined statistical significance. the groups, 17% were brought to kidney transplant. Overall incidence of Results: A total of 36 staff members worked in the cardiac stress lab non-cardiovascular death and MACE of 4.7% and 5.3%, 3.5% and 4.1% over the study period and had exposure to SPECT and PET MPI radia- for normal-low risk groups, and 1.2% and 1.2% for moderate-severe risk tion. There was a significant reduction in median monthly WBDD for all groups. staff (5.3 mrem to 3.7 mrem; p = 0.04). Subgroup analysis revealed the Conclusions. Stress myocardial perfusion with Gated SPECT in this greatest reduction was seen in the NMT group (28 mrem to 16.5 mrem) population shows good prognostic value as it is related to the low inci- and echo sonographers (3.0 vs 1.3) (Table 1). dence of non-cardiovascular death and MACE due to non-ischemic Conclusions: Staff radiation exposure was significantly reduced in the causes. Increasing its prognostic value by guiding therapeutic interven- year after transitioning from SPECT only to predominantly PET MPI. tions, improving morbidity and mortality during the follow-up. Reduced staff radiation exposure may be an additional benefit of PET MPI that has been under-appreciated and warrants further research.

Table 1. Comparison of median monthly whole- body deep dose radiation in millirem (mrem) before and after the Introduction of a PET MPI Program

Pre Post p value

All staff (n = 36) 5.3 (1.3– 3.7 (1– 0.04 13.7) 12.0) Nuclear medicine 28.0 (16.0– 16.5 (11.8– <0.001 technologists (n = 10) 38.0) 26.0) Echo sonographers 3.0 (0–5.3) 1.3 (0–2.3) <0.001 (n = 14) Nurses (n = 12) 5.0 (0.7– 4.3 (0.7– 0.72 Three-year follow-up and evaluation of mortality and MACE. 10.7) 5.7)

Data presented as median (25th–75th percentile range)

Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

302-08 Results: In our population, 62.0% were male patients, with an age range from 16 to 91 years, weight from 48 to 132 kg and height from 1.47 to MYOCARDIAL PERFUSION IMAGE QUALITY IN CZT 1.89 cm. Related to cardiovascular risk factors, 20.0% had diabetes, VERSUS CONVENTIONAL GAMMA CAMERAS AND IIS 46.9% hypertension and 15.4% already suffered an acute myocardial IMPACT ON MEDICAL ANALYSIS infarction. Regarding to stress test modalities, treadmill test were per- 1 2 1 1 R. W. Lopes*, S. Froede, F. B. P. Alves, D. Boccia, L. E. Mas- formed in 73.8%, and pharmacologic stress in 26..2%, divided in, 23.8% 1 1 2 trocola ; Hospital do Corac¸a˜o, Sa˜o Paulo, Brazil, Paulista dipyridamole and 2.4% dobutamine. Cameras images were randomly University - UNIP, Sa˜o Paulo, Brazil selected, with 36% obtained from CZT, 32..5% from GP an 31.5% from Introduction: Myocardial perfusion scintigraphy (MPS) is used for more CC. The image quality regarding CZT, GP and CC, was excellent in than 40 years to evaluate coronary disease, with extensive and robust 53.2%, 20.8% and 30.5%; good in 28.2%, 39.3%, and 37.8%, the regular literature supporting it. The secret of this longevity may lie in the fact and poor category were grouped due to small numbers, only 2..1% were that its principles have changed little over time, however with techno- considered poor image quality. The agreement proportion of diagnostic logical evolution new equipment has emerged with improvements in its score, according to the used method was, in CZT 70.2%, in CC 63.4%, in construction, engineering, as well as in detector’s materials and recon- GP 66.7% and overall 66.9%, and when at least 3 of 4 examiners had the struction algorithms. Our objective is to assess MPS image quality same agreement in their diagnosis it was, in CZT 89.4%, CC 87.8%, GP acquired in three different equipment generations and it’s possible 83.3%, and overall 86.9%%. The overall agreement between reports was impact on diagnosis. 0.629 by the kappa Fleiss method, which shows that the agreement Methods: Our study consisted of a retrospective, cross-sectional, random between observers was close to what was expected. cohort, which used images from 130 patients acquired from three dif- Conclusions: It’s possible to claim that CZT had a positive impact, ferent equipment’s, from the same manufacturer, GE, a ultra-fast camera allowing better image quality more frequently compared to conventional Discovery MN 530c (CZT), and two conventional cameras, a general cameras and the used camera (CZT, CC, GP) influenced on the per- purpose Discovery NM 630 (GP) and a cardio dedicated, Ventri (CC), ception of image quality, however, it does not seem to have an impact on between November 6th to December 5th, 2015, all studies used radio- the diagnosis. pharmaceutical kits belonging to the same batch. The 130 images were blinded analyzed by 4 experienced nuclear cardiologists, summing 520 images, a score was assigned to each image based on specific criteria, and the quality score was a sum of this criteria scores. We used the quality scores to compare the overall quality in respect to each equip- ment and different examiners, and in parallel to obtaining a diagnostic score.

Journal of Nuclear CardiologyÒ ePOSTERS: MYOCARDIAL PERFUSION AND FUNCTION IMAGING METHODS (SPECT AND PET): PROTOCOLS, STRESSORS, TRACERS

303-01 303-02 DETERMINATION OF [N-13] AMMONIA EXTRACTION COMPARISON OF DYNAMIC SPECT MYOCARDIAL BLOOD FRACTION IN PATIENTS WITH CAD BY CALIBRATION FLOW AND FLOW RESERVE WITH REGADENOSON TO INVASIVE PHYSIOLOGICAL MEASUREMENTS OF CFR AND DIPYRIDAMOLE AND FFR WITH NORMAL IMR M. Bailly*,1 Q. Brana,1 F. Thibault,1 M. Courtehoux,2 G. Metrard,1 J. A. Nye*,1 M. Piccinelli,1 D. Hwang,2 C. D. Cooke,1 J. Lee,3 S. D. Angoulvant,2 M. Ribeiro2; 1CHR Orleans, Orleans, France, Cho,4 R. Folks,1 H. H. Bom,4 B. Koo,2 M. Haber,2 E. V. Garcia,1; 2CHRU Tours, Tours, France 1Emory University, Atlanta, GA, 2Seoul National University Introduction: Regadenoson is a recent selective A2A adenosine receptor Hospital, Seoul, Korea, Republic of, 3Heart Vascular Stroke Insti- agonist. It is currently unclear if the absolute stress flow increase differs tute, Seoul, Korea, Republic of, 4Nuclear Medicine, Chonnam between pharmacological stress agents. We compared dipyridamole and National University Hospital, Gwang-ju, Korea, Republic of, 5Dept. regadenoson Myocardial Blood Flow (MBF) and Myocardial Flow of Biostatics and Bioinformatics, Emory University, Atlanta, GA Reserve (MFR) values obtained with dynamic Cadmium Zinc Telluride Introduction: The goal of our NIH funded (R01 HL143350-02) (CZT) SPECT Myocardial Perfusion Imaging (MPI), to evaluate if they DEMYSTIFY study (NCT04221594) is to use measures of myocardial could induce the same level of hyperemia. blood flow (MBFPET) from dynamic PET to predict invasive physiolog- Methods: Patients referred for dynamic MPI for Coronary Artery Dis- ical parameters that drive revascularization. Usually MBFPET is obtained ease (CAD) screening between November 2018 and March 2020 were by correcting the calculated tissue uptake (K1) by the Renkin-Crone flow- retrospectively analyzed. SPECT data were acquired on a CZT camera, dependent extraction fraction (EF = 1 - e-PS/MBF, PS = permeability- using 1-day stress/rest 99mTc-tetrofosmin dynamic protocol. All analysis surface area product) derived from radiotracer and microsphere experi- was performed using Corridor 4DM. To rule out confounding factors, ments in animal models. For [N-13] ammonia, at least 4 EF models are used patients with prior cardiac disease, ischemia or infarction and diabetes that present differences in MBFPET from calculated tissue uptake. Using 4 were excluded in a subgroup analysis. The remaining patients were kinetic models, we developed and compared novel EF correction formulas matched for clinical characteristics (age, gender, BMI, cardiovascular for [N-13] ammonia calibrated to invasive measures of coronary flow risk factors) and compared in terms of stress MBF and MFR. reserve (CFR) and fractional flow reserve (FFR) in CAD patients with Results: 162 patients stressed with dipyridamole were compared with 66 normal index microcirculatory resistance (IMR). patients stressed with regadenoson. Global MFR wasn’t different Methods: Measurements of CFR, FFR and IMR were obtained from a between regadenoson and dipyridamole groups (2.46 ± 0.87 vs. total of 30 vessels in 19 subjects. The same cohort underwent an 8-min 2.64 ± 1.02 respectively for dipyridamole and regadenoson, p = 0.36) duration [N-13] ammonia rest/adenosine stress dynamic PET imaging. but stress MBF was higher in regadenoson group (1.71 ± 0.73 vs. The LV blood input function and tissue time-activity curves for each 1.44 ± 0.55 ml/min/g respectively for regadenoson and dipyridamole, vascular territory were extracted from automatically determined regions p \ 0.05). When potential pathological patients were excluded, two of interest. The 4 dynamic PET kinetic models applied to estimate tissue groups of 41 patients comparable in terms of age, gender, BMI, resting uptake were: (1) 2-tissue, 3-rate constant (Hutchins), (2) 1-tissue, 2-rate left ventricular ejection fraction, cardiac risk factors and cardiovascular constant (DeGrado), (3) 1-tissue, retention model (Yoshida) and (4) 1- treatments at the time of evaluation (p = 0.2 at least) were analyzed. tissue, 1 rate constant (microsphere analog) (Votaw). EF values were Mean global MFR wasn’t different between the two groups: 2.62 ± 0.77 obtained for each vessel by equating CFR = MFRPET and FFR = and 2.46 ± 0.76 respectively for dipyridamole and regadenoson RFRPET, assuming that EF = 1 at rest yielding the relationship EFs- (p = 0.88). Stress MBF wasn’t significantly different between dipyri- tress = (FFR 9 K1 stress)/(CFR 9 K1 rest), where MFRPET is the damole (1.57 ± 0.56 ml/min/g) and regadenoson patients myocardial flow reserve and RFRPET is the relative flow reserve. Each (1.61 ± 0.62 ml/min/g) (p = 0.88). of the four EF corrections based on their respective PET model were fit Conclusions: Regadenoson showed higher stress MBF values in our to the Renkin-Crone flow-dependent extraction fraction equation. global results, but dipyridamole and regadenoson induced equivalent MBFPET was determined from the calculated tissue uptake and each of hyperemia with similar global stress MBF and MFR when confounding the four EF models. Agreement between MFRPET for each PET model factors were ruled out. These Results should be confirmed on a large, and measured CFR were assessed using the concordance correlation prospective and randomized study. coefficient (constraining: slope = 1, y intercept = 0). Results: Concordance coefficients for each of the four models were 1): 0.31 (Hutchins), 2) 0.25 (DeGrado), 3) 0.18 (Yoshida), 4) 0.10 (Votaw). These preliminary data suggest that a 2-tissue, 3-rate constant model that incorporates tracer efflux and glutamine metabolism agrees best with invasive CFR measures following EF correction. Conclusions: We present the first data deriving EF corrections based on invasive measures of CFR and FFR in human subjects yielding the best CFR concordance using a 2-tissue, 3-rate constant model (Hutchins). Future enhancements to improve correlations are being pursued such as motion correction and specific vessel rather than vascular territory calibration.

Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

303-03 treat adverse effects of vasodilator stress agents. We have evaluated the safety and effectiveness of a buccal caffeine strip (BCS) which is rapidly 13 N-AMMONIA REGADENOSON LOW-DOSE REST/HIGH- absorbed, inexpensive, readily available and simplifies caffeine DOSE STRESS PET/CT MPI: THE IMPACT OF PERSISTENT administration. CAFFEINE BLOOD LEVELS ON MYOCARDIAL BLOOD Methods: All patients (pts) undergoing regadenoson stress SPECT MPI FLOW METRICS over 6 weeks at Hartford Hospital were assessed with a questionnaire U. A. Mahmood*, W. Yap, J. Donald, A. Diliberto, B. Press, M. J. during testing. Presence, severity (1–10), and duration of adverse Feldkamp, T. Rosamond; The University of Kansas Health System, symptoms with BCS and need for rescue IV caffeine were assessed. Kansas City, KSU. A. Mahmood*, W. Yap, J. Donald, A. Diliberto, Patients who requested optional reversal of adverse symptoms received B. Press, M. J. Feldkamp, T. Rosamond; The University of Kansas 100 mg BCS (Elite Ops Energy Strips), 3 min after tracer injection. Health System, Kansas City, KS Rescue IV caffeine (60 mg) was offered 10 min later if clinically Background: The quantification of myocardial blood flow (MBF) and indicated. myocardial flow reserve (MFR) utilizing 13 N-ammonia regadenoson Results: Of 77 pts enrolled (53.2% male, age 66.0 ± 12.2 years), 49 pts low-dose rest/high-dose stress MPI provides additional diagnostic value reported adverse symptoms (63.6%), 20 patients (26.0%) requested BCS, for detection of CAD. Patients are typically instructed to avoid caf- and 2 patients (10% of BCS pts, 2.6% total enrolled pts) received IV feinated beverages for at least 12 h prior to the study. The impact of rescue caffeine. A total of 68 different symptoms were reported (average persistently measurable caffeine in the blood on MBF and MFR quan- of 1.4 distinct symptoms per symptomatic pt); the most common tification with 13 N-ammonia, despite this period of supervised symptoms were dyspnea (45.6%) and headache (13.2%). Pts treated with abstinence, remains uncertain. BCS had higher initial severity of symptoms (5.9 ± 2.1 vs 4.6 ± 1.8, Methods: 76 consecutive inpatients admitted with chest pain (64% p \ 0.01) and longer duration of symptoms (312 ± 170 s vs 159 ± 79 s, female, age 66 ± 11 years, BMI 30.2 ± 8) underwent a regadenoson p \ 0.01). Average time from BCS to symptom termination was low-dose rest/high-dose stress MPI protocol with a fully digital PET/CT 181 ± 165 s. No side effects or adverse clinical events were reported hybrid scanner, having had their blood caffeine level checked immedi- with BCS. No pts in this series experienced a major adverse cardiac ately prior to the study. All had been placed on a caffeine-free diet for event such as high degree conduction block, respiratory distress, or 12-18 h prior to the exam under supervision. MBF and MFR were cal- hypotension requiring intervention. culated using proprietary software and adjusted to the resting heart rate x Conclusion: Buccal caffeine strip is a safe, well tolerated and effective systolic blood pressure product and motion correction methodology. initial strategy to reverse adverse effects of vasodilator stress in the Patients with measurable caffeine in their blood were compared to caf- minority of patients who request it. Buccal caffeine alone or with IV feine-free matched controls. The study readers were blinded to caffeine rescue caffeine was highly effective in reversing adverse effects and was levels and interpreted the studies by consensus between physicians from free of major adverse clinical event. Cardiology and Radiology. Results: Eight (6 female) of 76 inpatients (10.5%) had significant blood levels of caffeine in samples drawn just before the PET/CT exam (mean caffeine blood level = 2.6 ± 2.1 lg/mL, range: 1–7 lg/mL). In the caf- feinated group, the average age was 70 ± 9 years (range: 55–84 years), mean resting global MBF = 0.83 ± 0.11 ml/min/g, mean stress global MBF = 2.64 ± 0.83 ml/min/g and mean global MFR = 3.12 ± 0.64. Four of the eight patient studies with residual blood caffeine were read as ischemic by standard MPI qualitative and quantitative imaging criteria. For matched caffeine-free normal controls, the mean age was 62 ± 9.8 years, mean global resting MBF = 0.73 ± 0.27 ml/min/g, mean global stress MBF = 2.87 ± 0.44 ml/min/g and mean global MFR = 3.57 ± 0.86; not significantly different than in the caffeine group. The normal and caffeine group’s rest and stress LVEFs were also not sig- 303-05 nificantly different. (One-way ANOVA, Tukey–Kramer Test: LSD Matrix analysis and Student’s t Test, assuming both equal and unequal ORAL VS. INTRAVENOUS CAFFEINE ADMINISTRATION variances). AS AN INITIAL STRATEGY FOR REVERSAL OF ADVERSE Conclusion: A significant percentage of inpatients that are supervised EFFECTS OF REGADENOSON DURING ROUTINE CLINI- regarding caffeine abstinence for at least 12 h prior to a MPI exam still CAL SPECT MPI have detectable blood caffeine levels. At these levels, however, global K. H. Abdulla*,1 J. A. Doran,2 J. Bote,3 W. L. Duvall,4 R. G. MBF metrics are not meaningfully impeded when using 13 N-ammonia Schwartz5; 1University of Rochester Medical Center, Rochester, NY, low-dose rest/high-dose regadenoson stress protocols. More vigorous 2Cardiology Unit, Department of Medicine, University of Rochester dietary control is needed to prevent unrecognized persistent caffeine School of Medicine and Dentistry, Rochester, NY, NY, 3Hartford blood levels due to surreptitious or accidental intake by inpatients. It is Hospital, Hartford, CT, 4Nuclear Cardiology, Hartford Hospital, likely that this phenomenon is more prevalent in the unsupervised out- Hartford, CT, 5Cardiology and Imaging Sciences, University of patient population. Rochester Medical Center, Rochester, NY Introduction: Due to recurrent shortages of aminophylline, caffeine has emerged as an inexpensive, convenient and effective agent to reverse 303-04 adverse symptoms associated with vasodilator stress testing during rou- tine SPECT and PET MPI. Ubiquitous availability of oral caffeine BUCCAL CAFFEINE STRIPS FOR REVERSAL OF ADVERSE suggests its use; however, its effectiveness compared to IV administra- SYMPTOMS OF VASODILATOR STRESS tion of caffeine (IVAC) requires further evaluation. Our objectives were J. Bote,1 K. H. Abdulla,2 J. A. Doran,3 R. G. Schwartz,4 W. to evaluate the safety, effectiveness and patient satisfaction of orally Duvall*1; 1Hartford Hospital, Hartford, CT, 2University of Roche- administered caffeine (POAC) vs. IVAC. ster Medical Center, Rochester, NY, 3Cardiology Unit, Department Methods: All consecutive patients who had regadenoson stress SPECT of Medicine, University of Rochester Medical Center, Rochester, MPI at the Nuclear Cardiology Laboratory in the Paul N. Yu Heart NY, 4Cardiology and Imaging Sciences, University of Rochester Center of the University of Rochester Medical Center from October 8, Medical Center, Rochester, NY 2019 to March 17, 2020 were evaluated as a quality assurance evaluation Background: Due to recurrent shortages of aminophylline, intravenous of routine caffeine reversal of adverse symptoms. Patients were ran- caffeine has emerged as a commonly used, safe and reliable method to domized to POAC (ad lib intake of brewed coffee or diet cola by patient Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

preference) or IVAC (caffeine citrate 60 mg diluted in 25 cc normal dyssynchronous LV contractions might affect changes in LV functional saline and administered over 60–90 s) in a prespecified 3:2 ratio. Patients parameters. were offered caffeine reversal at 3 min post tracer injection. For patients with persistent symptoms, optional rescue IVAC was offered at 13 min. Patients randomized to POAC who experienced severe regadenoson-in- 303-07 duced adverse reactions were crossed over into the IVAC group. The presence, severity (1–10) and duration of symptoms and patient satis- EVALUATION OF IMAGE QUALITY, RADIATION DOSE faction scores (1–5) were recorded. The composite primary clinical AND QUANTIFICATION OF MYOCARDIAL BLOOD USING outcome endpoint included death, MI, high-grade AV block (Mobitz II or A WEIGHT-BASED, CONSTANT ACTIVITY RB-82 INFUSION 3rd-degree block), sustained VT, or hospitalization. SYSTEM Results: Out of 261 patients (56.7% male, average age J. A. Case*,1 S. A. Courter,1 E. Moloney,2 T. M. Bateman3; 1Car- 65.3 ± 11.7 years), 241 (92.3%) received regadenoson reversal inter- diovascular Imaging Technologies, Kansas City, MO, 2CVIT, vention (POAC = 91, IVAC = 150). Of those, 32 (13.3%) required a Kansas City, MO, 3St. Luke’s Mid America Heart Institute, Kansas second rescue dose of IV caffeine. A minority of 38 patients (28.4%) City, MO randomized to POAC required crossover to IVAC. Complete resolution Introduction: Weight-based infusion protocols offer the potential to of symptoms was similar in the POAC (n = 61, 67.0%) and IVAC improve image quality without increasing radiation exposure. We (n = 114, 76.0%) groups (p = NS). The average time from caffeine examined the performance characteristics over a one generator cycle administration to symptom resolution was 189 ± 137 s and was similar period from two different Rb-82 infusion systems. in both POAC and IVAC groups. The average patient satisfaction scores Methods: Two cardiac Rb-82 infusion systems (Cardiogen (CG), Bracco for patients receiving POAC (3.7 ± 1.1) and IVAC (3.4 ± 1.3) were Diagnostics and RUBY-FILLÒ (RF), Jubilant Radiopharma) were stud- similar (p = 0.07). No major adverse clinical event of the primary ied in a group of consecutive patients with a flow reserve of greater than composite endpoint occurred. 1.1 over two separate six-week periods. A total of 300 patients Conclusions: Both oral and intravenous methods of caffeine adminis- (N(RF) = 167 patients, N(CG) = 133 patients) were acquired on a 16- tration are safe, effective, and well-tolerated as initial strategies in the slice Siemens Biograph system. The CG system was programmed to reversal of regadenoson-induced adverse effects during routine deliver a 1295 MBq dose per study. The RF system was set to deliver a vasodilator SPECT MPI. In the minority of patients with severe symp- weight -adjusted dose of 10 MBq/kg in a followed by a customizable toms who were considered suboptimal candidates for oral caffeine, IV post-infusion saline flush Studies were acquired in listmode for 7-min- caffeine remains a safe, effective, and well-tolerated reversal agent. utes post-infusion. Dynamic, gated and perfusion datasets were created for listmode data. Studies were evaluated using the ImagenMD (CVIT, Kansas City) quality assessment tool for perfusion study quality (emis- 303-06 sion counts, intra-scan motion). Myocardial blood flow was evaluated using ImageQ (CVIT, Kansas City) for flow study quality (flow frame LEFT VENTRICULAR DYSSYNCHRONY AND 28 DAYS noise, peak to plateau ratio and peak time) and quantitative values. The MORTALITY IN PATIENTS WITH ACUTE ST ELEVATION myocardial to blood pool counts in the perfusion study was also MYOCARDIAL INFARCTION GATED SINGLE-PHOTON evaluated. EMISSION COMPUTED TOMOGRAPHY STUDY Results: The demographics between the two groups were very similar W. M. K. Ahmed*, A. Abdel Bary; Kasr Al Ainy, Cairo, Egypt (51%/55% male, age = 68.0/68.4, SSS = 6.6/7.7, BMI = 29.1/29.8, RF Background: The clinical implications of dyssynchrony after an acute vs CG, respectively). Weight-based dosing also increase the patient dose myocardial infarction (MI) and relationship of LV functional and for higher weight patients (1143 MBq ([ 100 kg) vs 977 MBq dyssynchrony parameters to adverse outcomes have not been fully (B 100 kg).Flow values did not differ for stress myocardial blood flow elucidated (MBF), rest MBF and blood flow reserve (all p [ 0.1). The mean radi- Methods: Acute STEMI patients underwent gated SPECT examination, ation dose which was 29% lower using the RUBY-FILLÒ system to document temporal changes in left ventricular (LV) functional (p \ 10–34). In addition, Counts in the myocardium did not differ at rest parameters (LV volumes and LVEF) and dyssynchrony indices (His- or stress over the entire cohort, however, the additional dose for the togram bandwidth HBW and histogram SD HSD). larger patients did result in a 17% higher myocardial counts at stress for Results: Sixty patients were recruited in our study. Age was 54.0 ± 10.4 patients with a BMI [ 35 kg/m2 (p = 0.033). There was a trend that did (Males 90.0%). Recruited patients included 39 anterior STEMIs (32 not achieve statistical significance (p = 0.1) for higher myocardial counts survived, and 7 died) and 21 inferior STEMIs (all survived). Survivors to background count ratio at stress (4.08) (RUBY-FILLÒ) vs 3.93 showed significant improvement in LV volumes and HSD. However, (CardioGen). non-survivors showed non-significant changes in LV volumes and sig- Conclusions: The use of a weight-adjusted dose along with a constant nificant worsening of LVEF and HSD. Regression analysis showed that activity rate infusion system resulted in a significant reduction in the changes in LV dyssynchrony was a significant predictor of changes in delivered radiation dose without compromising image quality or both LVES and LVEF. Receiver operating curve was examined for cut- changing blood flow measurements. This approach also resulted in offs for LVEF and histogram SD. LVEF B 25% showed sensitivity higher myocardial counts in larger patients. Future studies to investigate 85.7% and specificity 96.2% and histogram SD C 34 Æ showed sensi- myocardial to background counts ratio are needed to establish if contrast tivity 85.7% and specificity 88.7% to predict 28-day mortality. is improved with the RF system. Conclusion: Left ventricular contractility and dyssynchrony parameters could impact 28-day mortality in STEMI patients. Changes in

Journal of Nuclear CardiologyÒ ePOSTERS: MYOCARDIAL PERFUSION AND FUNCTION IMAGING: APPLICATIONS 1

304-01 Background: In the ISCHEMIA trial, an initial invasive strategy did not reduce death or ischemic events compared to an initial conservative PROGNOSTIC VALUE OF SILENT MYOCARDIAL INFARC- strategy for those with moderate to severe ischemia. However, stress tests TION IN PATIENTS WITH CHRONIC KIDNEY DISEASE of & 26,000 patients (pts) were screened to randomize 5179 pts, of STATUS POST KIDNEY TRANSPLANTATION which 2555 (49.3%) underwent myocardial perfusion imaging (MPI). J. C. Santana*,1 H. Doppalapudi,1 C. W. Ives,1 D. V. Rizk,1 V. The core lab mean summed difference score (SDS) and number of Kumar,1 A. E. Iskandrian,2 F. G. Hage1; 1University of Alabama at infarcted segments in this cohort were low at 9.4 (13.4% myocardium) Birmingham, Birmingham, AL, 2Medicine/CV division, University and 0.6, respectively. The large number of pts screened and the low SDS of Alabama at Birmingham, Birmingham, AL suggests some pts with particularly large perfusion defects were not Introduction: Patients with advanced kidney disease have an increased referred for randomization. Only 18% of pts were from low and lower cardiovascular disease (CVD) risk. We have previously shown that silent middle-income countries where pts often present with greater myocardial myocardial infarctions (SMIs) are associated with increased CVD risk in ischemia and scar. Thus, we sought to compare ischemia and outcomes patients awaiting renal transplantation (RT) and that screening myocar- in a consecutive cohort of stable outpatients in Cairo, Egypt (a lower dial perfusion imaging (MPI) provides prognostic data post-RT. In this middle-income country) who underwent medical therapy (MT) or study, we evaluated the prevalence of SMI in patients undergoing RT and revascularization (REV) following exercise MPI. its prognostic value after RT. Methods: We retrospectively reviewed MPI studies of 1914 consecutive Methods: We identified consecutive patients who underwent RT at the pts with a summed stress score (SSS) [ 10% and SDS [ 8%. Propensity University of Alabama at Birmingham between 2008 and 2012. MI was score matching was used to adjust for non-randomization factors. Risk determined by automated analysis of 12-lead ECG obtained at time of adjusted Cox regression analysis was performed to identify predictors of transplant evaluation. SMI was defined as ECG evidence of MI without a the composite endpoint of cardiac death (CD) and non-fatal myocardial history of clinical MI (CMI). The primary outcome was a composite of infarction (MI). CVD death, non-fatal MI and coronary revascularization after RT. Results: 201 pts met criteria and were followed for a mean of Results: Of the 1189 patients who underwent RT, a 12-lead ECG was 43 ± 17 months. Mean SSS was 19 ± 7.9% and SDS 15.5 ± 5.8%. CD available in [ 99% (median age 51 years, 56% male, 34% diabetes, 95% or MI occurred in 12 pts (9.7%) and 35 pts (45.5%) in the REV vs. MT hypertension, 83% on dialysis at time of evaluation, 60% underwent groups, respectively (Figure). After propensity matching, the adjusted cadaveric transplant). MI by ECG was present in 13% of the cohort (56% hazard ratio (HR) for REV vs. MT was 0.13 (95% CI = 0.06–0.32, SMI). During a median follow-up of 4.6 years, 147 (12%) experienced p \ 0.0001). Results were consistent among the 55 pts who had under- the primary outcome (8% CVD death, 4% MI, 4% coronary revascu- gone intervention (PCI or CABG) prior to index MPI (HR = 0.14 (95% larization) and 12% died. Both SMI and CMI were associated with CI = 0.04–0.57, p = 0.0057) and the 85 pts who had not (HR = 0.07 increased risk of CVD events (Figure, left panel) and all-cause deaths. In (95% CI = 0.02–0.30, p = 0.0004). a multivariable adjusted Cox regression model, both SMI (adjusted Conclusion: In this observational study of pts with defect sizes larger hazard ratio 1.99, [1.24–3.20], p = 0.004) and CMI (2.13 [1.22–3.70], than those in the ISCHEMIA trial, pts who underwent REV had a lower p = 0.007) were independently associated with the primary outcome. In rate of CD and MI compared to those treated medically. the subset of patients (n = 633) who had normal MPI, the prognostic significance of SMI and CMI was maintained (Figure, right panel). Conclusions: SMI detected by ECG on pre-transplant evaluation is associated with increased risk of CVD events after RT. The risk is maintained even in the subset of patients with normal MPI.

304-02 THE EGYPTIAN ISCHEMIA STUDY: REVASCULARIZA- TION IMPROVES PROGNOSIS IN PATIENTS WITH STABLE ISCHEMIC HEART DISEASE AND LARGE MYOCARDIAL PERFUSION DEFECTS M. Hakimi*,1 A. E. Yahia,2 A. Reda,3 M. A. Mandour Ali,4 A. 304-03 Sadek,4 C. J. Rowan,5 R. C. Thompson,6 N. D. Wong,7 G. S. Thomas,8 A. H. Allam4; HORUS Research Team; 1University of THE ASSOCIATION BETWEEN HIGH-SENSITIVITY TRO- California Irvine, ORANGE, CA, 2Alfa Scan Radiology Center, PONIN AND POST EMERGENCY DEPARTMENT Cairo, Egypt, 3Menoufia University, Al Minufiyah, Egypt, 4Al Azhar DISCHARGE STRESS SPECT MYOCARDIAL PERFUSION Medical University, Cairo, Egypt, 5Renown Hospital, Reno, NV, IMAGING IN PATIENTS WITH LOW TO INTERMEDIATE 6University of Missouri Kansas City, St Luke’s Mid America Heart RISK CHEST PAIN Institute, Kansas City, MO, 7University of California Irvine, Irvine, L. Lee*, A. R. Patel, R. Ward; University of Chicago Medicine, CA, 8Long Beach Memorial Medical Center, Long Beach, CA Chicago, IL

Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

Background: Patients (pts) with low to intermediate risk chest pain (CP) prospectively and compared between groups by Kaplan–Meier (KM) ruled out for acute coronary syndromes (ACS) in the emergency survival analysis. department (ED) are often referred for early post discharge stress testing Results: 114 (41.3%) had NNCAs or nonobstructive CAD and 162 for further risk stratification. High-sensitivity troponin (HST) testing has (58.7%) had obstructive CAD. Patients with NNCAs or nonobstructive recently gained widespread use, has high negative predictive value in CAD were often younger than those with obstructive CAD (median age excluding active ACS, and is associated with low prevalence of rever- 60.6 vs 65.7, p = 0.002), female (53.5% vs 38.3%, p \ 0.001), and had sible ischemia in stable CP pts. Whether HST can predict results of post lower baseline ASCVD risk scores (61.3% with risk score [ 7.5 vs ED discharge stress testing is unknown. We sought to assess the ability 84.4%, p \ 0.001). KM analysis showed a difference in outcomes in of ED HST levels to predict results of single-photon emission computed those with \ 50% stenosis and those with obstructive CAD, but no tomography myocardial perfusion imaging (SPECT-MPI) early after ED difference in long-term outcomes in patients with NNCAs or nonob- discharge. structive CAD (Figure 1). Of the patients who underwent nuclear MPI Methods: From August 2018 to January 2019, consecutive adult ED pts with LV ischemia data available, 24.7% had [ 10% LV ischemia. In presenting with CP who were deemed appropriate for ED discharge via patients with \ 50% stenosis, 15.8% had [ 10% LV ischemia; however, an institutional ACS pathway and subsequently underwent early, post ED % LV ischemia was not a predictor of long-term cardiac events (Cox discharge SPECT-MPI, were eligible for this retrospective study. HSTs proportional analysis, p = 0.14). and HEART scores were considered in the ACS algorithm. Pts were Conclusions: Our study showed that patients with positive stress testing offered SPECT-MPI stress testing within 72 h of ED visit. Abnormal found to have NNCAs or nonobstructive CAD on ICA had few long-term SPECT-MPI (ABN-MPI) was defined as sum stress score (SSS) C 4, left cardiac events compared to those with obstructive CAD, despite high ventricular ejection fraction (LVEF) \ 50%, and/or transient ischemic baseline ASCVD risk and substantial LV ischemia. dilation (TID). A composite endpoint of cardiac hospitalization, revas- cularization, and death from any cause at 1 year was assessed. Results: 115 consecutive patients (mean age 56.5 years, 68% women) who completed post ED discharge stress SPECT-MPI were studied. Mean ED HEART score was 3.2, 86% of pts had normal HST (\ 14 ng/ L in women; \ 22 ng/L in men), and 51% had very low HST (B 6 ng/ L). Overall, 10% pts had ABN-MPI. Only 3% of pts with very low HST had ABN-MPI versus 18% with HST [ 6 ng/L (p = 0.01). Of 16 pts with abnormal HST, 25% had ABN-MPI, compared to only 8% with normal HST (p = 0.04). Pts with both HEART score [ 3 and abnormal HST had highest rates of ABN-MPI (31%), (vs 8% without both, p = 0.01). A HEART score [ 3 trended toward more ABN-MPI (17% vs 7%, p = 0.06). Of 97 (84%) pts with available long-term follow up, 5 (5%) had a composite endpoint at 1 year (0 death, 3 hospitalization/ revascularization, 2 non-ST elevation myocardial infarction); all had ABN-MPI and none had HST B 6 ng/L. Pts with normal stress tests had no events at 1 year. Conclusion: ED pts with low to intermediate risk CP who rule out for ACS and are referred for early post ED discharge SPECT-MPI have low rates of ABN-MPI, suggesting ED ACS algorithms are effective. HST use in the ED effectively stratifies the likelihood of an abnormal post ED discharge SPECT-MPI. A HST B 6 is associated with very low rates of ABN-MPI, suggesting a post ED discharge stress test may not be needed. The combination of normal HST and negative SPECT-MPI is predictive of excellent outcomes. Further study is needed to test a clinical pathway 304-05 in which HST is used to select ED patients for post discharge SPECT- THE IMPACT OF CORONARY CALCIUM SCORE ADDED MPI. TO MYOCARDIAL PERFUSION IMAGING IN ALTERING CLINICAL MANAGEMENT (ICCAMPA TRIAL) P. Jayadeva*,1 J. Vitola,2 R. Cerci,3 J. Yao,4 S. Stowers,5 B. Elison,6 304-04 N. Better7; 1Royal Melbourne Hospital, Park ville, Australia, 2Quanta Diagnostico & Terapia, Curitiba, Brazil, 3Quanta Diag- LONG-TERM OUTCOMES OF PATIENTS UNDERGOING no´stico e Terapia, Curitiba, Brazil, 4Royal Melbourne Hospital, CORONARY ANGIOGRAPHY FOLLOWING POSITIVE STRESS Parkville, Australia, 5Palmerston North Hospital, Palmerston North, TESTING: FOCUS ON PATIENTS WITH NONOBSTRUCTIVE New Zealand, 6Wollongong Hospital, Wollongong, NSW, Australia, CAD 7 1 2 2 2 Nuclear Medicine, Royal Melbourne Hospital, Parkville, Victoria, E. Lu*, C. A. Hanson, G. A. Beller, S. S. Ghumman, J. M. Australia Bourque2; 1University of North Carolina Medical Center, Chapel 2 Introduction: CT derived coronary calcium score can be used as a Hill, NC, University of Virginia Health System, Charlottesville, VA prognostic tool in isolation or as an adjunct with myocardial perfusion Background: A significant proportion of patients referred to invasive imaging (MPI). coronary angiography (ICA) after abnormal stress tests are found to have Aim: To evaluate the impact on management of coronary artery calcium normal/near-normal coronary arteries (defined as B 20% stenosis, (CAC) score, performed during CT attenuation correction, when co-re- NNCAs) or nonobstructive CAD (21–49% stenosis). We assessed long- ported with MPI in patients without a history of coronary artery disease. term outcomes of such patients compared to those with obstructive CAD Methods: A prospective multicenter international trial using a stan- (C 50% stenosis). dardized oral questionnaire to evaluate changes in management Methods: We performed analysis of a consecutive cohort of 276 patients determined from an MPI result alone and compared to management from who underwent ICA at the University of Virginia for positive stress MPI plus the addition of a CAC-derived Shemesh score. testing (211 nuclear MPI, 51 echo, 6 ECG alone, 8 with cardiac PET/ Results: 253 patients were enrolled from Australia, New Zealand and CMR). Median time of follow up was 6.0 years. We compared baseline Brazil. Median age was 65 years (IQR 25%–75%: 57–62). Management characteristics between those with NNCAs or nonobstructive CAD and was altered in 121/253 patients (47.8%, p = 0.0001) with the addition of those with obstructive CAD via T-test and Chi-square analysis. Cardiac CAC score. This was most significant in patients with a negative MPI. In death, non-fatal MI, and late revascularization were gathered Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

patients with positive CAC, the most common management change was initiation of statin therapy (70/105, 68%). Observed mortality in HVM segments group Vs Predicted Management change (MC) with CAC (using Fisher’s exact test) Mortality by Euroscore II (Table 1). Conclusion: The addition of CAC score to MPI yielded statistically More than 4 Less than 4 significant changes in management, particularly in the subset of patients hibernating hibernating with a negative MPI and positive CAC. viable segments viable segments

Mean Euroscore II 2.66 2.77 predicted mortality Table 1. Proportion of patients in MPI negative and MPI positive Mean observed mortality 2.4 18.2 groups with management change (MC) positive or negative CAC Mortality risk change by No change :557 assessment of viability MPI negative (N = 192) MC/CAC? MC/CAC- p value 71/121 15/71 0.0001 MPI positive (N = 61) MC/CAC? MC/CAC- p value 34/55 1/6 0.075

304-07 MISCLASSIFICATION OF SEVERE ISCHEMIA ON SPECT VERSUS PET MYOCARDIAL PERFUSION IMAGING: 304-06 RESULTS FROM A SAME-PATIENT SIMULTANEOUS IMAGING PROTOCOL F18-FDG PET/CT CARDIAC VIABILITY RISK STRATIFICA- F. S. Patel*,1 K. K. Patel,2 A. McGhie,3 J. A. Spertus,4 S. A. TION IN COMPARISON WITH EUROSCORE II Courter,5 J. A. Case,5 K. F. Kennedy,1 T. M. Bateman3; 1Saint FOR REVASCULARIZATION IN PATIENTS WITH LEFT Luke’s Mid America Heart Institute, Kansas city, MO, 2Cardiology, VENTRICULAR DYSFUNCTION Saint Lukes’ Mid America Heart Institute, Kansas City, MO, 3St. B. Y. Thangamuthu*, S. Simon, I. Muthukrishnan, S. Imhaneni; Luke’s Mid America Heart Institute, Kansas City, MO, 4UMKC Apollo Hospitals, Chennai, India School of Medicine, Kansas City, MO, 5Cardiovascular Imaging Background: To predict peri-operative mortality with hibernating viable Technologies, Kansas City, MO myocardial (HVM) segments in comparison with Euroscore II in patients Background: Measurement of ischemia may not be comparable across with left ventricular (LV) dysfunction undergoing coronary artery bypass modalities. PET MPI has greater diagnostic accuracy than SPECT but grafting (CABG) surgery. was not commonly used in the ISCHEMIA Trial to define its study Methods: This prospective observational study includes 75 patients of population (C 10% ischemia). The extent to which this difference may ischemic coronary artery disease (CAD) with ejection fraction (EF) less lead to misclassification of severe ischemia is not known. than or equal to 40%. Each patient was subjected to rest Technetium (Tc) Methods: A total of 322 patients with known CAD and suspected 99 m methoxyisobutylisonitrile (MIBI) myocardial perfusion single- ischemia had near-simultaneous pharmacologic 99mTc AC SPECT and photon emission computed tomography (SPECT/CT) and fluorine18- 82Rb PET MPI between 06/2009 and 08/2013. Perfusion images were fluorodeoxyglucose positron emission computed tomography (F18-FDG quantitated using automated software. Ischemia was categorized into PET/CT). All patients were risk stratified based on Euroscore II. These none (0), mild (1–2), moderate (3–6), and severe (C 7, * 10%) based patients were followed for post CABG 30-day mortality. Mortality on Summed Difference Score (SDS). Presence of obstructive disease observed by HVM segment groups were compared with Euroscore II (any epicardial stenosis C 70%), and multivessel disease (C 2 epicardial predicted mortality. stenoses C 70%, MVD) on patients referred for catheterization within Results: Receiver operating curve (ROC) analysis was constructed 6 months post-MPI were compared among those with severe ischemia on between HVM segments and Euroscore II for 30-day mortality prediction PET vs. SPECT. showed cut off of \ 4 HVM segments (AUC -0.7) had sensitivity of 85% Results: Of 322 patients, 94 (29%) had severe ischemia by PET vs. 31 whereas Euroscore II (AUC-0.4) had only 28.6% sensitivity. In patients (10%) by SPECT. Of those with severe ischemia on PET, only 19% were with more than 4 viable segments, Euroscore II predicted and observed identified as having severe ischemia by SPECT. Conversely, of those mortality was similar. But observed mortality in patients in less than 4 with severe ischemia on SPECT, 42% had less than severe ischemia on viable segments was significantly higher than the Euroscore II predicted PET (p \ 0.0001; Fig). The obstructive disease was present in 45 (74%) mortality. Euroscore II underestimated perioperative risk in patients with out of 61 patients referred for angiography. Of those, 30 (67%) had less than 4 viable segments, wherein five times higher risk was observed severe ischemia with PET vs. 9 (20%) with SPECT (p \ 0.0001). Of in these patients. those with obstructive disease and severe ischemia on PET, 73% (22/30) Conclusion: Hibernating viable myocardial segments established by did not have severe ischemia on SPECT. MVD was present in 24 (39%) F18-FDG PET/CT had independently predicted mortality postopera- patients, of these 17 (70%) had severe ischemia with PET vs. 5 (21%) tively. Hence including F18-FDG PET/CT for viability assessment along with SPECT (p = 0.001). Again, 71% (12/17) of patients with severe with Euroscore II in preoperative risk assessment for revascularization by ischemia on PET and MVD did not have severe ischemia on SPECT. CABG in patients with left ventricular dysfunction provided better risk Conclusions: Among patients with severe ischemia on PET perfusion, stratification. 80% did not have severe ischemia on SPECT. High risk CAD on

Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

subsequent invasive testing would have been missed in 75% of these among patients with primary ST abnormality (HR, 1.64; 95% CI, 0.87– patients if severe ischemia on SPECT was the sole criteria for invasive 3.06; P = 0.124) or T-wave inversion (HR, 1.15; 95% CI, 0.62–2.16; referral. P = 0.658) as compared to those with normal ECG. Abnormal MPI was not associated with higher MACE among patients with secondary ST abnormality (HR, 1.18; 95% CI, 0.31–4.58; P = 0.808), while it was associated with higher MACE among patients with primary ST abnor- mality (HR, 4.50; 95% CI, 1.44–14.10; P = 0.005) and T-wave inversion (HR, 3.74; 95% CI, 1.20–11.68; P = 0.015), Bottom Fig. Conclusion: While secondary ST-changes are associated with higher MACE, abnormal MPI does not add further prognostic information in this group of patients. T-wave inversion and primary ST changes do not seem to have higher MACE risk; however, abnormal MPI in these patients correlates with higher MACE.

304-08 THE PROGNOSTIC VALUE OF NON-SPECIFIC ST-T WAVE ABNORMALITIES IN PATIENTS UNDERGOING REGADE- NOSON STRESS SPECT MYOCARDIAL PERFUSION IMAGING A. Arif,1 M. Khan,1 F. H. Iskander,1 M. H. Iskander,2 R. Doukky*2; 1Cook County Health and Hospitals System, Chicago, IL, 2Cardi- ology, Cook County Health and Hospitals System, Chicago, IL Background: The prognostic implications of non-specific ST-T wave (NS-STT) abnormalities in patients undergoing stress SPECT myocardial perfusion imaging (MPI) are not well defined, leading to frequent use of stress MPI to investigate a potential underlying coronary artery disease (CAD). Methods: This was a single-center, retrospective cohort study of con- secutive patients who underwent regadenoson stress SPECT-MPI. Patients with missing MPI, missing ECG, paced rhythm, left bundle branch block, prior myocardial infarction or CAD, atrial flutter, and intraventricular conduction delay were excluded. Patients were catego- rized as having primary ST abnormality, secondary ST abnormality, T- wave inversion or normal ECG. The primary outcome was major adverse cardiac events (MACE) defined as the composite of cardiac death or MI. Results: Among 6059 included, 1912 (18.1%) patients had NS-STT abnormalities. During a mean follow-up of 2.3 ± 1.9 years, the incidence of MACE was significantly higher among patients with secondary ST abnormality as compared to those with normal ECG (HR, 2.05; 95% CI, 1.04–4.05; P = 0.039). No significant difference in MACE was observed

Journal of Nuclear CardiologyÒ ePOSTERS: MYOCARDIAL PERFUSION AND FUNCTION IMAGING: APPLICATIONS 2

305-01 305-02 COMPARISON WITH THREE COMMERCIALLY AVAIL- PROGNOSTIC VALUE OF CORONARY VASCULAR DYS- ABLE SOFTWARE PACKAGES FOR MEASUREMENT FUNCTION ASSESSED BY HYBRID RUBIDIUM-82 PET/CT OF MYOCARDIAL BLOOD FLOW AND FLOW RESERVE IMAGING IN PATIENTS WITH RESISTANT HYPERTEN- STUDIED BY N-13 AMMONIA PET/CT; QPET VS CORRIDOR SION 4 DM VS SYNGO MBF V. Gaudieri*,1 T. Mannarino,1 A. D’Antonio,1 R. Assante,1 E. K. Kiso*,1 E. Tateishi,2 A. Imoto,1 Y. Terakawa,1 S. Higuchi,1 H. Zampella,1 P. Buongiorno,1 C. Nappi,1 P. Arumugam,2 W. Horinouchi,1 T. Nishii,1 Y. Ota,1 T. Fukuda1; 1National Cerebral Acampa,1 A. Cuocolo1; 1Department of Advanced Biomedical Sci- and Cardiovascular Center, Suita, Japan, 2Department of Radiology, ences - University of Naples Federico II, Naples, Italy, 2Nuclear National Cerebral and Cardiovascular Center, Suita, Japan Medicine Centre, Manchester Royal Infirmary, Manchester, United Introduction: N-13 ammonia PET imaging is widely utilized for the Kingdom assessment of myocardial perfusion for the diagnosis of not only Introduction: Patients with treatment-resistant hypertension (RH) have ischemic heart disease but also underlining disease of heart failure. One higher risk of hypertension-mediated organ damage and a Framingham of the major advantages of ammonia PET imaging is quantitative mea- coronary risk score [ 20% compared to patients with controlled hyper- surement of myocardial blood flow (MBF) and myocardial flow reserve tension (CH). Aim of this study is to evaluate if coronary vascular (MFR). Recently, calculation of MBF and MFR has been capable with dysfunction, assessed by Rubidium-82 (82Rb) PET/CT imaging, helps to several commercially available software packages. However, differences predict adverse outcome in patients with RH and without known coro- among these applications are not well-known. Therefore, in this study, nary artery disease (CAD). we compared the results of MBF and MFR between three packages such Methods: A total of 517 hypertensive patients without overt CAD and as QPET (Version 2015; QP), Corridow-4DM (version 2017; 4D), and normal myocardial perfusion (summed stress score \ 3) at stress-rest syngo MBF (version VB15; Sy), and investigated the differences and 82Rb PET/CT imaging were studied. Hypertension was defined as features of them. resistant when the concurrent use of three different antihypertensive Methods: We enrolled consecutive 53 patients, who were referred for drugs failed to control blood pressure. Coronary artery calcium (CAC) adenosine stress and rest MPI with N-13 ammonia for the diagnosis of score was categorized into 4 groups (0, 0.1–99.9, 100-399.9, C 400). ischemic heart disease. Dynamic scan data for 10 min acquired from N- Baseline, hyperemic myocardial blood flow (MBF) and myocardial 13 ammonia injection (370 MBq) were studied by PET/CT system and perfusion reserve (MPR) were measured. MPR, defined as the ratio of was analyzed by each application. We compared global MBF on stress hyperemic to baseline MBF, was considered reduced when \ 2. The and at rest, and MFR which was calculated by stress MBF/rest MBF. endpoints of cardiac events were cardiac death, non-fatal myocardial Results: In MBF analysis, both stress and rest MBF showed statistically infarction, coronary revascularization and heart failure. significant and good correlations between three packages (r = 0.76–0.97, Results: Over a median of 38 months (interquartile range 26 to p \ 0.0001 each). Moreover, in MFR analysis, there were significant and 50 months), 21 cardiac events (4.1% cumulative event rate) occurred. strong correlations between QP vs. 4D (r = 0.88, p \ 0.0001), QP vs. SY Patients with RH compared to those with CH were slightly older (r = 0.84, p \ 0.0001), and 4D vs. Sy (r = 0.96, p \ 0.0001). Especially, (63 ± 13 vs. 60 ± 12 years, p \ 0.05), had lower hyperemic MBF and correlation between 4D and Sy was superior than other comparisons in MPR values (2.2 ± 0.8 vs. 2.7 ± 0.8 and 2.2 ± 0.6 vs. 2.7 ± 0.7, both MBF and MFR (see figure). One of the reasons of strong correlation respectively, both P \ 0.001). CAC scores and baseline MBF were not between 4D and Sy is presumed to be ‘‘motion correction,’’ which is different between RH and CH patients group. At multivariable Cox programed into these two applications for MBF calculation, but not into regression analysis, age (P \ 0.01), RH (P \ 0.05), and reduced MPR QP. (P \ 0.05) were independent predictors of events. In patients with CH no Conclusions: Commercially available applications for MBF/MFR mea- statistically significant differences in annualized event rates (AER) were surement; QP, 4D, and Sy are comparable for clinical use. Especially, observed comparing those with and without reduced MPR (1.1% vs correlation between 4D and Sy, in which motion correction algorithm 0.5%, respectively, p = 0.16); differently RH patients with reduced MPR was programed for MBF calculation, was excellent. showed a significant higher AER compared to RH patients with normal MPR (3.7% vs. 1.7, respectively, P \ 0.05). Moreover, in the presence of normal MPR, RH patients showed a higher AER compared to CH group (1.7% vs. 0.5%, respectively, P \ 0.005); similarly, in patients with reduced MPR, higher AER was observed in RH group (3.7% vs. 1.1%, respectively, P \ 0.05). Event-free survival was lower in patients with RH and reduced MPR compared with those with CH and reduced MPR (P \ 0.05). Using a parametric model, RH patients with reduced MPR showed the highest risk of events and the greatest risk acceleration over time, with a time to achieve a cumulative cardiac risk level of [ 3% of 12.5 months. Conclusions: Coronary vascular dysfunction by 82Rb PET/CT in patients with RH and no overt CAD can help in identify a higher risk of cardiovascular events. Thus, MPR could be useful in the risk assessment and for patients management, guiding alternative therapeutic strategies aimed to improve MPR.

Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

305-03 (ICA) performed within 3 months were included. DSPECT were acquired on a CZT camera using Stress-Rest one-day 99mTc-tetrofosmin SPECT MYOCARDIAL BLOOD FLOW AND CALCIUM protocol. Kinetic analysis was done with Corridor 4DM software using 1- SCORING MEASUREMENT IN PATIENTS REFERRED tissue-compartment model and converted to Myocardial Blood Flow FOR CORONARY ARTERY DISEASE SCREENING (MBF) using a pre-determined extraction fraction. CRI method is applied 1 1 2 1 M. Bailly*, F. Thibault, M. Courtehoux, G. Metrard, D. subsequently. CAD diagnostic values (MBF and CRI) were computed: 2 2 1 2 Angoulvant, M. Ribeiro ; chr Orleans, Orleans, France, chru ‘‘cut-point’’ separating normal/abnormal values is 2.0 for MBF, and 3.0 1 1 2 Tours, Tours, FranceM. Bailly*, F. Thibault, M. Courtehoux, G. for CRI. 1 2 2 1 Metrard, D. Angoulvant, M. Ribeiro ; chr Orleans, Orleans, Results: Among 25 patients, 15 had significant CAD (stenosis [ 30%): 2 France, chru Tours, Tours, France 3-vessels disease in 3 patients, 2-vessels in 8 and 1-vessel in 4. For Introduction: Aim/Introduction: Dedicated CZT cardiac cameras pro- DSPECT: 14 True Positives (TP), 7 True Negatives (TN), 1 False vide accurate measurements of absolute myocardial blood flow (MBF) Negative (FN), and 3 False Positives (FP) probably with abnormal and flow reserve (MFR). PET MBF studies using either Rb-82 or N-13- micro-circulation (patients with diabetic retinopathy, proteinuria,ÁÁÁ): ammonia have shown that MFR was predictive of major adverse car- Sensitivity (SENS) 93%, Specificity (SPE) 70%, Positive Predictive diovascular (CV) events. Coronary calcium score (CCS) is also Value (PPV) 82% and Negative Predictive Value (NPV) 88% For CRI predictive of CV events, especially in diabetic patients. In this study, we method: 15 TP, 7 TN, 0 FN and 3 FP : SENS 100%, SPE 70%, PPV 83% evaluated the Results of SPECT global MFR measurement and CCS and NPV 100%. ROC AUC = 0.78 for both methods. 21/25 patients evaluation in patients referred for Coronary Artery Disease (CAD) were well classified with DSPECT, 22/25 with CRI. 3 FP DSPECT screening. patients are normal with CRI. Methods: Patients referred for Myocardial Perfusion Imaging (MPI) for Conclusion: Both methods are efficient to evaluate CFR, with similar CAD screening between November 2018 and March 2020 were included performance. DSPECT seems more sensitive to abnormal micro-circu- in a prospective trial (CFR-OR). Clinical and CV risk factors were lation flow reserve. CRI method can be performed any time after a collected to classify patients in 3 groups: moderate, high and very high routine Stress-Rest SPECT without additional acquisition. This CRI risk. HeartScore (SCORE) according to the European Society of Cardi- method can be used with conventional camera as well as with CZT ology was calculated. SPECT data were acquired on a CZT-based camera. pinhole cardiac cameras in listmode using a stress (251 ± 11 MBq)/rest (512 ± 23 MBq) one-day Tc-99m-tetrofosmin protocol. Kinetic analysis was done with Corridor4DMTMsoftware using a 1-tissue-compartment model and converted to MBF using a previously determined extraction fraction correction. Low-dose thoracic CT was acquired on the same day using another SPECT/CT camera in the same position and used for CCS evaluation. Results: 136 patients (60 male, 76 female) were included and classified in 3 clinical CV risk groups: 50 moderate, 36 high and 50 very high risk. Mean SCORE was 4 ± 3.1%. Mean global MFR was 2.50 ± 0.74; 34 patients had impaired CFR (using a threshold of 2). MFR wasn’t sig- nificantly different between the three groups of CV risk (p = 0.09), but MFR was significantly reduced in high and very high risk patients (p = 0.05). CCS was not different according to risk categories (p = 0.32). There was a significant inverse correlation between MFR and SCORE (p = 0.009) and gender (p = 0.026). Significant correlation was also found between CCS and SCORE (p = 0.001) and gender (p = 0.05). MFR was not correlated to CCS (p = 0.61). Regarding CV risk factors, CCS was significantly higher in smokers (p = 0.05), but no other sig- nificant correlation was found between MFR or CCS and dyslipidemia, hypertension, diabetes or family history of coronary artery disease (p at least 0.41). Conclusions: CCS and MFR measured during MPI for CAD screening are significantly correlated with SCORE and gender. MFR was signifi- cantly reduced in high and very high risk patients. CCS and MFR however weren’t correlated together. 305-05 305-04 USE OF CORONARY FLOW RESERVE TO GUIDE TREAT- MENT OF ANGINA IN A CASE OF BILATERAL CORONARY ASSESSMENT OF CORONARY FLOW RESERVE BY ROU- FISTULAS TINE 99MTC-TETROFOSMIN-SPECT: COMPARISON J. Badlani*, S. Thangavel, A. Khalif, V. Srinivasan; Allegheny WITH DYNAMIC 99MTC SPECT RESULTS OBTAINED General Hospital, Pittsburgh, PA IN THE SAME PATIENTS Introduction: Coronary fistulas are a rare cause of angina, with current L. Philippe*,1 M. Bailly,2 Y. EL Yaagoubi,1 C. Prunier-Aesch1; treatment unclear. We present a rare case of bilateral coronary to pul- 1Medecine Nucleaire Tourangelle, Chambray-les-Tours, France, monary artery fistulas causing angina and a novel use of cardiac PET to 2Me´decine Nucle´aire, Chr Orleans, Orleans, France guide treatment. Background: Our aim was to validate Coronary Flow Reserve (CFR) Methods: A 60-year-old gentleman with history of hypertension and values from routine 99mTc-Tetrofosmin SPECT by comparison with hyperlipidemia presented with five months of exertional angina. He ‘‘Dynamic SPECT’’ (DSPECT). noted debilitating, substernal chest pressure which occurred during Methods: CFR evaluation is usually performed by PET or by DSPECT walking or exercise. The pain was associated with shortness of breath on CZT-camera. We compared for each patient DSPECT with a method and relieved by rest. He noted the pain had been increasing in intensity previously described (ASNC 2019), using short-axis slices of routine over the past few weeks. He had a negative stress echocardiogram two 99mTc-tetrofosmin SPECT, obtaining a Coronary Reserve Index (CRI). years prior. Given the crescendo nature of his symptoms, he was taken 25 Patients referred for DSPECT with Invasive Coronary Angiography Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

for cardiac catheterization, which showed no evidence of atherosclerotic ICA, 51 patients had visual estimation of the Calcium Score (vCS), 6 disease, but did show prominent coronary artery fistulas from the LAD to patients having both ICA and vCS. To evaluate coronary calcium, vCS the pulmonary artery and the RCA to the pulmonary artery (Figure 1). was performed using a 3 grades scale: normal (0), low to intermediate Anatomy was confirmed with CTA. (1), important to severe (2). This evaluation was performed by means of Results: The patient was started on anti-anginal medications, including the low-dose CT used for attenuation correction (not sufficient for a beta blocker, calcium channel blocker, and nitrates with his angina quantitative score). We used only non-attenuation corrected Short axis attributed to a coronary steal phenomenon from the bilateral fistulas. The SPECT slices for CRI computation. patient had subsequent resolution of his symptoms. In order to determine Results: The 57 ICA indicated, for an optimal discrimination between if anatomical correction was warranted, a cardiac PET scan with coro- normal and CAD patients, a 3.0 CRI cut-off. Using this value, we nary flow reserve was performed; it demonstrated normal global flow observe 92% Sensitivity, 75% Specificity, 98% Positive Predictive value, reserve. The patient continued on medical therapy. and 43% Negative Predictive Value. Area under ROC curve is 0.73. The Conclusion: Coronary Fistulas are rare (incidence of \ 0.1%), with comparison of CRI and the 51 vCS shows a decrease of CRI when the bilateral fistulas being extremely rare (incidence unknown). We present a vCS increases:(mean CRI ± 1 SD) Grade 0: 3.28 ± 1.29 Grade 1: case that is unique both due to the presence of large bilateral coronary 3.00 ± 1.25 Grade 2: 2.62 ± 1.52. The differences are not significant, fistulas causing angina and the novel use of PET imaging to confirm mainly due to the small number of patients in each group and to the adequate blood flow. insufficient accuracy of vCS grading. Conclusion: CRI computed with routine 99mTc-tetrofosmin-SPECT is of value for CAD diagnosis. This assessment can be performed sys- tematically, routinely, for each patient, without additional time, and without additional dose activity injected. Perfusion, function, CRI mea- sure and vCS may improve efficiency and reliability of the SPECT report.

305-06 CORONARY FLOW RESERVE EVALUATED BY PROCESS- ING OF ROUTINE 99MTC-TETROFOSMIN SPECT ASSOCIATED WITH VISUAL CALCIUM SCORE: A WAY TO INCREASE EFFICIENCY AND RELIABILITY OF THE SPECT REPORT? L. Philippe*, Y. El Yaagoubi, C. Prunier-Aesch; Medecine Nucleaire Tourangelle, Chambray-les-Tours, France Introduction: We evaluate the diagnostic value of routine 99mTc- tetrofosmin-SPECT method, to assess Coronary Flow Reserve (CFR). Methods: CFR is evaluated by computation of myocardial stress/Rest counts-ratio corrected by 5 factors, the algorithm being slightly improved since its previous description (ASNC 2019). This 5 steps processing produces a Coronary Reserve Index (CRI). CRI was calculated in a series of 102 patients addressed to our institution for routine myocardial stress/ rest perfusion SPECT. Among these patients, 57 patients underwent also

Journal of Nuclear CardiologyÒ ePOSTERS: MYOCARDIAL PERFUSION AND FUNCTION IMAGING: APPLICATIONS 3

306-01 Peak Stress Flow (PSF) and Rest Flow (RF) between heart transplant recipients with and without CAV. MENTAL BIOFEEDBACK TRAINING IMPROVES MENTAL Methods: From 8/2017 to 9/2019 heart transplant recipients referred for MYOCARDIAL BLOOD FLOW RESERVE IN PATIENTS routine vasodilator stress myocardial perfusion imaging (MPI) at our WITH PET-DETECTED MICROVASCULAR DYSFUNCTION center underwent dynamic imaging on the DSPECT camera. Vasodilator M. Piccinelli*,1 A. J. Shah,1 D. J. Bremner,1 A. Quyyumi,1 stress, and Tc-99m sestamibi (MIBI) injection were performed with the V. Vaccarino,1 E. V. Garcia,2 P. Raggi3; 1Emory University, Atlanta, patient under the camera. The protocol consists of 9 mCi and 30 mCi of GA, 2Radiology, Emory University Hospital, Atlanta, GA, MIBI in 2 ml saline for the rest and stress studies, respectively, with the 3Mazankowski Alberta Heart Inst., Edmonton, AB, Canada tracer injection performed 50 s after regadenoson stress using an auto- Introduction: The role of psychological stress and mental-stress induced mated injector, followed by a 40 mL saline flush. Data acquired in list myocardial ischemia (MSIMI) on cardiovascular health has been mode were processed on the Cedars platform. Significant adjustments investigated for decades. While MSIMI underlying mechanisms have not were routinely made to the ROI position in each frame for input and been clarified yet, studies have pointed to coronary microvascular myocardial activity curve derivation. Rate pressure product and residual vasoconstriction as one of the major players in precipitating MSIMI. subtraction corrections were applied. A diagnosis of CAV was deter- Concurrently, stress-reduction therapies have been suggested as a mined by review of coronary angiography by two Heart Failure promising approach to alleviate MSIMI occurrence with mixed Results. specialists blinded to the SPECT Results. The objective of this study was to quantify by means of PET-derived Results: Thirty-eight patients had complete SPECT flow and catheteri- myocardial blood flow (MBF), flow reserve (MFR) and relative flow zation data, of whom 8 patients (21%) were diagnosed with CAV. Global reserve (RFR) the impact of biofeedback mental training (BMT) in MFR and RF were different between patients with and without CAV improving MFR during challenging mental tasks. (2.33 vs 2.86, p = 0.009; 0.921 vs 0.741, p = 0.021, respectively), but Methods: 17 patients were selected from the Emory MIPS[1] database of not PSF (2.21 vs 2.04, p = 0.202). A receiver operator characteristics subjects with known MSIMI and underwent rest/mental stress 82Rb PET curve demonstrated an optimal MFR cutoff of 2.5 which yields a sen- studies at baseline (bas) and after * 9 weeks (fu). The subjects were sitivity of 62.5%, false positive rate of 30%, and specificity of 70%. In randomized to a training group (TG, n = 11), who received BMT this cohort of patients, the sensitivity for dobutamine echo (31 patients) between PET tests, and a control group (CG, n = 6). Ten subjects (7 in and relative myocardial perfusion imaging were 20% and 37.5%, TG, 3 in CG) also received a traditional rest/pharmacological stress 82Rb respectively. PET study at bas and fu. Mental stress tasks consisted of arithmetic Conclusions: Myocardial flow quantification with dynamic SPECT is problems and a public speech. The Emory Cardiac Toolbox was used to feasible and may represent an additional tool for the evaluation of CAV. extract PET-derived MBF, MFR and RFR from all studies; rate pressure Refinements in image processing and larger prospective studies are product (RPP) was used to correct resting flows. By combining MFR and needed. RFR (as noninvasive proxy for CFR and FFR) from pharmacological PET studies[2], subjects with microvascular dysfunction (lVD) were identified in TG and CG. A positive change in mental MFR between bas 306-03 and fu was used as an index for improved response to mental stress. Results: All PET studies were quantified; 8 subjects with lVD were CORRELATION OF CORONARY MICROVASCULAR DIS- identified. Changes in mental MFR between bas and fu were: from EASE AND COGNITIVE IMPAIRMENT ASSOCIATED 0.88 ± 0.22 to 0.95 ± 0.23 in TG (p \ 0.05); from 0.99 ± 0.34 to WITH CEREBROVASCULAR MICROVASCULAR DISEASE 1.03 ± 0.44 in CG (p = NS); mental rest MBF significantly decreased in BASED ON MULTI-MODALITY IMAGING TG. Among lVD patients changes in mental MFR between bas and fu G. Nair,1 J. M. Gomez*,1 J. M. Du-Fay-De-Lavallaz,1 N. T. were: from 0.80 ± 0.21 to 0.96 ± 0.29 in TG (p \ 0.001); from Aggarwal,1 R. Doukky,2 K. A. Williams,1 A. S. Volgman,1 R. M. 0.71 ± 0.21 to 0.66 ± 0.28 in CG (p = NS); mental rest MBF signifi- Sanghani1; 1Rush University Medical Center, Chicago, IL, 2Cardi- cantly decreased in TG; both rest and stress MBF significantly decreased ology, Cook County Health and Hospitals System, Chicago, IL in CG. Introduction: Cognitive impairment (CI) is increasing in prevalence Conclusions: BMT might improve mental stress MFR change in patients with our aging population. Suboptimal control of risk factors for CI such with MSIMI and particularly in those with PET-detected lVD, sug- as hypertension and atherosclerosis also predispose patients to ischemic gesting a quantifiable role for coronary microvasculature in MSIMI heart disease. Microvascular disease is an increasingly recognized phe- mechanisms. [1] Hammadah M et al. Psych Med, 2017,79:311–17. [2] notype of both ischemic heart disease and CI. The purpose of this study Johnson NP et al. JACC Cardiovasc Imag, 2012, 5:193–202. was to correlate coronary microvascular disease (CMD), diagnosed by low myocardial flow reserve (MFR) on positron emission tomography (PET) stress myocardial perfusion imaging (MPI), and CI associated 306-02 with cerebral microvascular disease. Methods: This was a single center, retrospective, observational SPECT MYOCARDIAL BLOOD FLOW IN ALLOGRAFT chart review study. Electronic records were used to identify memory VASCULOPATHY clinic patients with a diagnosis of CI who also had PET MPI. They were R. A. Nieves*,1 S. M. Bukhari,2 J. Dietz,1 K. Hyanl,1 R. Sriwat- compared to an age and sex matched control group who had no CI and tanakomen,1 G. Hickey,1 M. Keebler,1 P. Soman1; 1University of normal cognitive testing. Demographic characteristics, cardiovascular Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, risk factors, CI level assessed by Montreal Cognitive Assessment PA, 2Nuclear Cardiology, University of Pittsburgh Medical Center (MoCA) tool, and presence of cerebral microvascular disease on brain Heart and Vascular Institute, Pittsburgh, PA computed tomography or magnetic resonance imaging were noted. An Introduction: Myocardial flow reserve (MFR) by positron emission experienced nuclear cardiologist reviewed the PET MPI images. T-test tomography has established value for the noninvasive evaluation of for means and ANoVA were used to compare variables using SPSS cardiac allograft vasculopathy (CAV). Myocardial blood flow quantifi- software. cation by Cadmium-Zinc -Telluride (CZT) single-photon emission Results: Eleven patients with cognitive dysfunction were included in the computed tomography (SPECT) is an evolving technique with the study (median age 75 years, 91% female, 45% Black). Eleven age and potential for widespread application. Accurate noninvasive detection of sex matched patients included in the control group (median age 73 years, early CAV may obviate the need for periodic invasive evaluation after 91% female, 45% White). Comorbidities included hypertension (90% vs. heart transplantation. In this study, we compared SPECT-derived MFR, Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

90%), dyslipidemia (100% vs. 100%), and diabetes (64% vs. 45%). In 306-05 the study group, median MoCA score was 18/30 (interquartile range 13– 19, normal C 24). The clinical cognitive diagnoses included mild cog- PROGNOSTIC VALUE OF PERICORONARY ADIPOSE TIS- nitive impairment (45%), Alzheimer’s dementia (36%), and mixed SUE AND CORONARY VASCULAR FUNCTION BY 82RB (vascular & Alzheimer’s) dementia (18%). Transient ischemic dilation PET/CT IN PATIENTS WITH SUSPECTED CORONARY suggestive of left main or severe multivessel coronary artery disease was ARTERY DISEASE AND NORMAL MYOCARDIAL PERFU- present in both groups (50% vs. 22%, p = 0.492). All patients in the CI SION IMAGING 1 1 1 1 group had evidence of coronary artery calcification, while 33% of the V. Gaudieri*, E. Zampella, C. Nappi, R. Assante, T. Mannar- 1 1 1 1 2 controls had none. In the study group, 55% had myocardial perfusion ino, D. Adriana, G. Alessia, W. Acampa, P. Arumugam, A. 1 1 abnormalities (83% mild, 17% moderate-severe) compared to 45% in the Cuocolo ; Department of Advanced Biomedical Sciences, Univer- 2 control group (50% mild, 25% moderate, 25% moderate-severe). sity Federico II, Naples, Italy, Nuclear Medicine Centre, Abnormal myocardial flow reserve, present in both groups, was not Manchester University Hospitals, Manchester, United Kingdom significantly different (55% vs. 67%, p = 0.927). Introduction: Pericoronary adipose tissue, due to its proximity to Conclusions: A higher proportion of patients with CI had evidence of coronary arteries, has been proposed contribute to the progression of coronary artery calcification and myocardial perfusion abnormalities coronary atherosclerosis. The aim of this study was to evaluate the compared to matched controls, signifying a trend to significance. There prognostic value of pericoronary fat thickness (PCFT), coronary artery was no correlation between MFR and CI seen in this pilot study. Further calcium (CAC) score and myocardial perfusion reserve (MPR) by hybrid investigation of the association of CMD and cognitive impairment is 82Rubidium (82Rb) PET/CT imaging in patients with suspected coro- warranted using a larger population. nary artery disease (CAD) and normal myocardial perfusion imaging (MPI). Methods: A total of 616 patients without overt CAD and with normal 306-04 rest-stress 82Rb PET/CT MPI were studied. PCFT was calculated on CT images as the maximum fat thickness (mm) between heart surface and THE PROGNOSTIC VALUE OF AN ABSENT LEFT VEN- visceral epicardium surrounding the main coronary arteries. CAC score TRICULAR EJECTION FRACTION RESERVE was categorized as 0, \ 400 or C 400. MPR was considered reduced WITH REGADENOSON SPECT MYOCARDIAL PERFUSION when \ 2. Endpoints events were cardiac death, non-fatal myocardial IMAGING infarction and coronary revascularization. P. A. Smith*,1 A. Farag,1 P. Bhambhvani,1 A. E. Iskandrian,2 F. G. Results: During a follow-up of 42 ± 13 months, 29 events occurred Hage3; 1University of Alabama in Birmingham, Birmingham, AL, (cumulative event rate 5%). Patients with events were older (66 ± 13 vs. 2Medicine/CV division, University of Alabama at Birmingham, 60 ± 13 years, p \ 0.01), had higher PCFT (13 ± 2 vs 11 ± 2 mm, Birmingham, AL, 3University of Alabama at Birmingham, Vestavia, p \ 0.001), higher prevalence of CAC score C 400 (48% vs. 21%, AL p \ 0.01), and lower MPR (2.1 ± 0.7 vs. 2.7 ± 0.7, p \ 0.001) com- Background: An absent left ventricular ejection fraction (LVEF) reserve pared to those without. A higher prevalence of MPR \ 2 was observed in with vasodilator stress on PET cardiac imaging has been shown to pro- patients with events (48% vs. 18%, p \ 0.001) compared to those vide significant independent and incremental value to the perfusion without. Patients with reduced MPR had higher PCFT compared to those images for prediction of future cardiovascular adverse events. However, with normal MPR (12 ± 2 vs. 11 ± 1 mm, p \ 0.01). A PCFT value of the prognostic value of LVEF reserve has not been well characterized on 11.2 mm was the best trade-off between sensitivity and specificity to SPECT myocardial perfusion imaging (MPI). detect a reduced MPR. Event rate was higher in patients above this Methods: We studied 858 consecutive patients with normal and abnor- threshold compared to those below (8% vs. 1.5%, p \ 0.001). At Cox mal perfusion pattern on regadenoson SPECT MPI. Change in LVEF was univariate analysis, age (p \ 0.05), PCFT [ 11.2 mm (p \ 0.001), CAC calculated as post-stress LVEF – rest LVEF. Absent LVEF reserve was score C 400 (p \ 0.01), and MPR \ 2(p \ 0.001) were predictors of defined as a drop in LVEF by 5% or more on the post-stress images. The events. At multivariate analysis, only PCFT [ 11.2 mm and MPR \ 2 primary outcome was a composite of cardiac death, non-fatal myocardial were independent predictors of events (both p \ 0.01). At incremental infarction and late coronary revascularization. analysis, adding PCFT [ 11.2 mm to a model including clinical data and Results: An absent LVEF reserve was more common in patients with MPR \ 2 increased the global Chi-square from 26 to 35 (p \ 0.01). abnormal vs. normal MPI (31% vs. 19%, p = 0.001). During a median Classification tree analysis produced 3 terminal groups. For patients with follow-up of 32 months, the primary outcome was experienced by 31% MPR \ 2, no further split was needed (event rate 12% vs. 3%, of the study population. An absent LVEF reserve was not associated with p \ 0.001). On the contrary, patients with MPR C 2 were further strat- an increased risk of the primary outcome in patients with normal (hazard ified by PCFT (event rate 7% in patients with and 0.3% in those without ratio 1.1, 95% CI 0.4–2.7, p = 0.8) or abnormal (0.75, 0.56–1.00, (p \ 0.001) PCFT [ 11.2 mm. p = 0.05) MPI (Figure 1). There was no significant correlation between Conclusions: In patients with suspected CAD and normal stress MPI, extent of ischemia and post-stress change in LVEF (Pearson r = -0.072, coronary vascular dysfunction and high PCFT are associated with p = 0.07). increased cardiac risk. PCFT could help in identifying patients at higher Conclusions: In patients undergoing regadenoson SPECT MPI, absent risk of events. Combined evaluation of anatomical and functional vas- LVEF reserve is not associated with worse cardiac outcomes. Thus, cular abnormalities by 82Rb PET/CT might allow a better risk routine reporting of both post-stress and rest LVEF measurements in this stratification. setting is not necessary.

Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

306-06 QUANTIFICATION OF INTRAMYOCARDIAL BLOOD VOL- UME USING SPECT/CT IN HUMAN STUDIES H. Yousefi*,1 L. Shi,2 A. Soufer,3 V. Tsatkin,3 W. Bruni,3 R. Avendano,3 S. Thorn,3 E. J. Miller,4 A. J. Sinusas,5 C. Liu6; 1Department of Radiology and Biomedical Imaging, Yale Univer- sity, New Haven, CT, 2Department of Biomedical Engineering, Yale University, New Haven, CT, 3Department of Internal Medicine (Cardiology), Yale University, New Haven, CT, 4Department of Radiology and Biomedical Imaging, Department of Internal Medi- cine (Cardiology), Yale University, New Haven, CT, 5Department of Radiology and Biomedical Imaging, Department of Biomedical Engineering, Department of Internal Medicine (Cardiology), Yale University, New Haven, CT, 6Department of Radiology and Biomedical Imaging, Department of Biomedical Engineering, Yale E306-07 University, New Haven, CT Introduction: Intramyocardial blood volume (IMBV), a fraction of EVALUATION OF CORONARY DISEASE USING MYOCAR- myocardium volume that is occupied by blood, is a promising index to DIAL PERFUSION SCINTILOGRAPHY COMBINED measure microcirculatory functions. In this study, we report the data WITH THE CALCIUM SCORE IN A BRAZILIAN POPULA- processing methods and results of the first-in-human pilot of three TION SPECT/CT studies for quantification of IMBV using 99mTc-labeled Red R. W. Lopes*,1 L. E. Mastrocola,1 I. M. F. Pinto2; 1Hospital do Blood Cell (RBC). Coracao - HCor - Sao Paulo - Brazil, Sa˜o Paulo, Brazil, 2Instituto Method: Each subject underwent rest and adenosine-induced stress Dante Pazzanese de Cardiologia - Sao Paulo - Brazil, Sa˜o Paulo, 99mTc-RBC SPECT/CT on a dedicated cardiac SPECT system with a Brazil 64-slice CT. Both non-contrast and contrast-enhanced CT were acquired. Introduction: Coronary arteries calcifications are markers of coronary Images were reconstructed with corrections of attenuation (AC), scatter atherosclerosis, but do not correlate well with ischemia or with the (SC), respiratory and cardiac gating, and partial volume correction degree of stenosis. This study aims to evaluate the combined approach of (PVC), facilitated by a fully automatic unsupervised Otsu multi-thresh- myocardial perfusion scintigraphy (SPECT) with calcium score (CS) old detection method for organ segmentation and SPECT-CT using multiple detector computed tomography (MDCT) in a Brazilian registration. Then the blood pool (BP) and myocardium ROIs defined on population with suspected coronary disease (CAD). contrast CT were mapped to all eight SPECT gated in both stress and rest Methods: Among patients with SPECT and MDCT between 2003 and conditions. The IMBV was calculated by the ratio between the mean 2009 we selected those whose interval between studies was equal to or activity of left ventricle myocardium and blood pool ROIs in SPECT. less than 90 days. Of 8131 patients who did both methods, 2183 had Results: The accuracy of automatic organ segmentation was 0.81 and done it within 90 days. We selected the year 2009, as at that time a new 0.76 in terms of Dice coefficients. The IMBV across all subjects were 64-detector MDCT was installed. We retrospectively analyzed 413 0.37 ± 0.043 for the end-diastolic and 0.25 ± 0.025 for the end-systolic candidates with SPECT and MDCT, being able to retrieve the complete phase. IMBV decreased by 0.07 on average after PVC. The cycle-de- data from 303, of which 177 met the absence of known CAD criteria. pendent changes in IMBV between systolic and diastolic phases were The CS was defined automatically and the Agatston score was calculated 30.5 ± 3.4%. The mean IMBV across all subjects were 0.309 ± 0.047 for semi-automatically. SPECT was assessed by semi-objective visual rest and 0.373 ± 0.058 for stress studies. The averaged voxel-wise IMBV quantification. Associations between test results and clinical variables standard deviation within the myocardium across patients are 0.17 and were analyzed. Statistical analysis: Data were analyzed descriptively, 0.19 for end-systolic and end-diastolic phases, respectively. The aver- categorical variables in absolute and relative frequencies and numerical aged LV wall thickness at end-diastolic phase derived from CTA were variables calculated in average, Min, Max and standard deviation. The 9.9 ± 3.1 mm for rest and 12.5 ± 3.9 mm for stress studies. existence of an association between two categorical variables were Conclusion: It is feasible to quantify IMBV in resting and stress con- verified using the Chi-square test, or Fisher’s exact test. For statistical ditions for all cardiac cycles in human studies using SPECT/CT with tests, a significance level of 5% was used and the statistical packages 99mTc-RBC. SPSS 17.0 and Stata 12.0 were used. Results: We included 177 patients without known CAD (71.2% men, mean age 55.6 ± 10.6 years, ranging from 33 to 79 years. Normal SPECT was observed in 84.7% and 45.2% of them had coronary calcium (CAC) with normal SPECT. Those with perfusion defects in SPECT and CAC showed a higher occurrence of diabetes (DM), CS equal to or greater than the 75th percentile according to MESA trial; and CS [ 400. In patients with normal perfusion and CAC, a higher percentage of dyslipidemia was observed (42.5%). Conclusions: Patients with normal SPECT may have coronary calcium on MDCT. This combination was associated with dyslipidemia. Also, DM, CS [ 400 and CS above 75% percentile according to MESA Trial were associated with altered SPECT and CAC in MDCT.

Journal of Nuclear CardiologyÒ ePOSTERS: BEYOND PERFUSION: MOLECULAR IMAGING OF INFILTRATIVE HEART DISEASE, CALCIFICATION, INFLAMMATION, INFECTION 1

307-01 ASSESSING AORTIC AND CORONARY ARTERY CALCIFI- CATION IN HEALTHY SUBJECTS, ANGINA PECTORIS PATIENTS, AND PROSTATE CANCER PATIENTS WITH NAF-PET/CT W. Y. Raynor*,1 A. J. Borja,1 E. Kothekar,1 V. Zhang,1 T. J. Wer- ner,1 P. Hoilund-Carlsen,2 A. Alavi,3 M. Revheim4; 1University of Pennsylvania, Philadelphia, PA, 2Odense University Hospital, Odense, Denmark, 3Radiology, University of Pennsylvania, Philadelphia, PA, 4Oslo University Hospital, Oslo, Norway Background: The nature of the association between cancer and atherosclerosis is an expanding area of research. The aim of this study was to assess and compare NaF uptake in the coronary arteries and aorta in healthy subjects, angina pectoris patients, and prostate cancer patients. Methods: Thirty-three prostate cancer patients were retrospectively compared to 33 healthy subjects and 33 patients with angina pectoris from the CAMONA study conducted at Odense University Hospital in Denmark. NaF-PET/CT imaging was performed 90 min after radiotracer injection. Regions of interest (ROIs) were manually delineated around the cardiac silhouette to measure global coronary artery uptake as well as the aortic wall to measure uptake in the ascending aorta, arch of aorta, and descending aorta. SUVmean and target-to-background ratio (TBR) were calculated, and unpaired t-tests assessed differences in means between groups. Results: Angina pectoris patients were observed with higher SUVmean compared to healthy subjects in the ascending aorta (p = 0.01) and arch of aorta (p = 0.02) as well as higher TBR in the arch of aorta (p = 0.04). Compared to that of healthy subjects, both SUVmean and TBR of prostate cancer patients were increased in the coronary arteries 307-02 (p \ 0.001 and p = 0.01, respectively), ascending aorta (p \ 0.001 and p = 0.03, respectively), arch of aorta (p \ 0.001 and p = 0.04, respec- IMPORTANCE OF NUCLEAR MEDICINE IN THE DIAGNOS- tively), and descending aorta (p \ 0.001 and p = 0.02, respectively). TIC WORKUP OF INFECTIVE ENDOCARDITIS Additionally, prostate cancer patients were observed with higher SUV- S. Pacella*; Post Graduate School in Nuclear Medicine, University of mean compared to angina pectoris patients in the coronary arteries Milano Bicocca, Milan, Italy (p \ 0.001), ascending aorta (p = 0.004), arch of aorta (p = 0.02), and Introduction: Infective Endocarditis (IE) is still a disease with a high descending aorta (p \ 0.001), but no significant differences in TBR were morbidity and mortality rates. The 2015 European Society of Cardiology observed between angina pectoris and prostate cancer patients. (ESC) guidelines for management of IE demonstrated that nuclear Conclusion: The Results show greater uptake in the coronary arteries imaging techniques can improve diagnostic accuracy in prosthetic valve and all segments of the aorta in prostate cancer patients compared to endocarditis and device-related infections. The purpose of our study was healthy subjects as assessed by both SUVmean and TBR, suggesting to evaluate the role of nuclear medicine exams in patients with suspected increased microcalcification due to atherosclerosis. IE and inconclusive echocardiography. Methods: 40 patients hospitalized with suspected IE in our hospital from January 2015 to December 2016 and with inconclusive echocardiography underwent nuclear medicine exams to exclude or confirm IE: 34 patients underwent 18F-FDG PET/CT, 4 were subjected to radiolabeled leucocyte scintigraphy and 2 to both techniques. All cases were classified as ‘‘pos- sible IE’’, ‘‘definite IE’’ or ‘‘rejected IE’’ according to the ESC 2015 criteria for the diagnosis of IE. For each one a definitive diagnosis was made based on both clinical aspects and nuclear imaging (current IE, resolved IE, no IE). Patients were finally reevaluated after 4 months, assessing their clinical conditions and verifying that who received a final diagnosis of ‘‘no IE’’ or ‘‘resolved IE’’ did not develop IE in the meantime. Results: Among the total number, 8 ‘‘possible IE’’ and 6 ‘‘definite IE’’ cases were found to have positive nuclear imaging (12 18F-FDG PET/CT and 2 radiolabeled leucocyte scintigraphy), 23 ‘‘possible IE’’ cases had negative nuclear imaging (21 18F-FDG PET/CT and 2 radiolabeled leucocyte scintigraphy), and 3 cases (1 ‘‘possible IE’’, 1 ‘‘rejected IE’’ and 1 ‘‘definite IE’’) resulted to have a doubtful 18F-FDG PET/CT, which is why in 2 out of 3 cases both nuclear methods had to be used. Patients with positive nuclear imaging were then confirmed to have a ‘‘current IE’’ (14) while patients with negative or doubtful nuclear imaging were reclassified into a ‘‘no IE’’ subgroup (18) or a ‘‘resolved IE’’ subgroup (8). After a follow-up of 4 months, only 1 out of 18 patients with definitive rejected diagnosis of IE had developed the infection and none of the 8 patients who received a ‘‘resolved IE’’ Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

definitive diagnosis had a reoccurring of the illness; in the 2 subgroups of 307-04 ‘‘current IE’’ and ‘‘resolved IE’’ patients, respectively 7 out of 14 and 1 out 8 cases showed echocardiographic evidences of the previous IE. VISUAL ASSESSMENT OUTPERFORMS SEMIQUANTITA- Conclusions: Nuclear imaging, in particular 18F-FDG PET/CT, has TIVE ANALYSIS OF 18F-FDG PET/CT IN THE DIAGNOSIS proven to be a valuable technic to rely on when both clinical and OF INFECTIVE ENDOCARDITIS 1 2 1 1 1 echocardiography evaluation do not provide enough evidence to diag- C. P. Primus*, T. Clay, K. Wong, R. Uppal, S. Ambekar, S. 1 1 1 1 1 nose IE or to exclude it for sure. Das, S. Bhattacharyya, L. Davies, S. Woldman, L. Menezes ; 1Barts Heart Centre, London, United Kingdom, 2University College London, London, United Kingdom 18 307-03 Aim: F-FDG PET/CT is increasingly used to diagnose infective endocarditis (IE). We assessed PET performance in native (NVE) and PRECLINICAL DEMONSTRATION OF PET IMAGING prosthetic (PVE) IE. USING [18F]AS3504073-00 FOR MITOCHONDRIAL FATTY- Methods: Retrospective audit of suspected IE, 01/2010–12/2018. Cases ACID OXIDATION IN RODENT AND MONKEY HEART were classified as confirmed/probable/rejected pre and post-PET using FAILURE MODELS—NEW INSIGHT INTO METABOLIC modified Duke Criteria (mDC). Incremental benefit was assessed vs REMODELING IN CARDIOMYOCYTE actual diagnosis (surgical specimen or IE Team (MDT) consensus. Net H. Fushiki*, Y. Murakami; Astellas Pharma Inc., Tsukuba, Ibaraki, Reclassification Index (NRI) assessed PET performance. Semi-quanti- Japan tative analysis was assessed by ROC curves. Introduction: Myocardial energy metabolism is mainly dependent on Results: PET was used in 71 cases, 59 following inception of the MDT in Fatty Acid Oxidation (FAO) in ATP production, however, FAO alter- 10/2015 (male = 50; mean age 60.6 y). At discharge, 27/39 (69%) had ation in cardiac dysfunction is still unclear. We reported confirmed NVE and 21/32 (66%) confirmed PVE; 30/71 (42%) required [18F]AS3504073-00 ([18F]AS) as a novel PET probe for FAO with good surgery. 22/71 (31%) were culture negative, making a firm diagnosis by mDC property on higher uptake in heart (Murakami et al., SNMMI2020) and challenging. PET sensitivity, specificity, PPV & NPV were 75%, 92%, 94% higher selectivity to mitochondrial FAO (Ohshima et al. SNMMI2020). & 69% in NVE, and 87%, 86%, 91% & 80% in PVE. PET successfully Here we report preclinical demonstration of PET imaging using [18F]AS reclassified cases of both NVE (NRI 0.89) and PVE (NRI 0.9) (Table 1). in rodent and monkey heart failure models. There was no diagnostic cut-off for SUVmax or SUVmean (Table 2). Methods: [18F]AS was synthesized in house. J2N-k and -n hamsters Conclusion: Visual assessment of PET has incremental value above were used as cardiomyopathic model and normal control, respectively. mDC. Routine semi-quantitative analysis does not add further benefit, PET imaging with [18F]AS was demonstrated to monitor the FAO status though alternative methods (e.g. donut ROI) may improve upon this. of heart in both animals from 8 weeks to 15 weeks after the birth. Heart infraction model in monkeys was established by occluding left anterior descending coronary artery (LAD). PET imaging with [18F]AS and [13 N] ammonia in acute (1-week) and subchronic (1-month) phase were conducted in LAD occlusion models. Results: In J2N-k cardiomyopathic hamster model, less uptake of [18F]AS in heart was observed compared to that in J2N-n normal hamster at least 8-week after the birth, when there was no abnormal phenotype on the ejection fraction in both animals. [18F]AS and [13 N]ammonia visualized in the ischemic region at acute and sub- chronic phases. Although the comparable accumulation of [13 N]ammonia was observed in non-ischemic heart region in both phases, the higher uptake of [18F]AS was observed in non-ischemic heart region at subchronic phase rather than that at acute phase. These observations might reflect the metabolic dysfunction and the remodeling in cardiomyopathy and ischemic heart disease, respectively. Conclusions: [18F]AS, a PET probe for mitochondrial FAO, is shown to be a potential tool of illustrating myocardial dysfunction and regional FAO status in heart failure. PET imaging with [18F]AS could bring us to clarify the mechanism of metabolic remodeling in heart failure.

Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

307-05 307-06 PRESENTATION AND DIAGNOSTIC IMAGING PATTERNS SIMULTANEOUS ACQUISITION PET MRI FOR EVALUAT- OF CARDIAC SARCOIDOSIS AT A TERTIARY CARE CEN- ING CARDIAC SARCOIDOSIS: EARLY EXPERIENCE TER FROM INDIA K. Kassar*,1 R. Schorr,1 M. Nellayappan,1 M. Popeck,1 A. Tho- V. Somasundaram*, P. Pavithran, M. Sarma, R. Kannan, P. Shan- sani,1 A. Raina,1 R. Biederman,1 I. Poornima2; 1Allegheny General mugasundaram; Amrita Institute of Medical Sciences and Research Hospital, Pittsburgh, PA, 2Pittsburgh, PA Center, Kochi, India Background: Diagnosis of cardiac sarcoidosis (CS) remains challenging Background: Stand-alone cardiac MRI (cMRI) and cardiac FDG PET given the low sensitivity of biopsy, the non-specific imaging patterns, are well-established procedures with niche indications in clinical cardi- and the variability in institutional referral and testing protocols. We ology. In this study, we attempt to assess the emerging technology of sought to define imaging characteristics and follow-up of patients diag- simultaneous cardiac PET MRI (cPET-MRI) as a cost-effective one-stop nosed with CS. shop in the evaluation of cardiac sarcoidosis. Methods: We conducted a retrospective review on patients who under- Methods: 45 consecutive patients with clinical suspicion of active car- went multimodality imaging for CS at our tertiary care, regional referral diac sarcoidosis were enrolled. Simultaneous cPET-MRI with 18F-FDG center, nuclear and cardiac MRI laboratories between 2016 and 2019 and as PET tracer was performed on a Siemens Biograph mMR 3T PET MRI were followed in our Heart failure/EP clinics. system. Patients pre-prepared with a high-fat diet and iv heparin injection Results: Study population included 66 patients (mean age 52 ± 12 years; to suppress physiological FDG uptake in myocardium. Besides routine 22% non-Caucasian, 68% male) that were positive for CS- by FDG-PET T2 and post-contrast sequences, T1 & T2 mapping was also performed. (48%) and CMRI (44%) and by both (8%) and had longitudinal follow- On a separate day 99 mTechnetium SestaMIBI myocardial perfusion up. Dyspnea, syncope and palpitations were the most common presenting SPECT imaging (MPI) was performed to identify underlying infarcts. symptoms (Fig 1). Focal FDG uptake was noted on 36/64 (56%) with MRI images interpreted using Lake Louise criteria, while focal/diffuse anteroseptal (42%) and inferoseptal (19%) walls being most commonly FDG uptake, especially corresponding to perfusion defects on MPI, was involved and mean SUV was 3.0. Diffuse FDG uptake pattern that was interpreted as PET positive for active sarcoidosis. nondiagnostic was noted in 6 patients, 4 of whom had LVEF \ 35%. Results: cMRI findings of 13 patients were interpreted as suspicious for Matched scar and inflammation noted in 18/56 (32%) and unmatched sarcoidosis/infiltrative disease. However only 5 among them showed scar and inflammation 33/56 (59%). 48 CMRI studies were performed on FDG PET positivity. All PET positive patients were positive on cMRI & 66 patients 41/48 had evidence of LGE suggestive of CS in any wall, showed corresponding perfusion defects on MPI. Among the remaining with anteroseptal 20/41 (49%), anterior 18/41 (44%) and inferolateral 18/ patients, 5 were identified to have old (inactive) scars on cMRI, 8 41(44%) walls most commonly showing LGE. In the subgroup that patients showed hypertrophic cardiomyopathy changes, while the rest underwent PET and MRI, 19/25 were positive by PET only, and 10/25 had normal PET-MRI and MPI studies. In our study, only the PET were positive by both modalities (Table). Over mean follow-up of positive patients were considered positive for cardiac sarcoidosis and 15 ± 6 months, there were 4 deaths, 34 device implantations (32ICD and managed accordingly. 2 pacemakers) and no heart failure admissions. Only 31% ICD implan- Conclusion: Considering the fact that FDG PET and cMRI are indicated tations were for secondary prevention. 57/66 (86%) were on an and often separately performed for evaluation of cardiac sarcoidosis; this immunosuppressive regimen. No correlation was observed with pacing initial experience of ours suggests that simultaneous cPET-MRI is indeed needs and medical treatment of CS (p = 0.3). a cost-effective alternate to existing methods, with lower radiation risk Conclusion: CS has a varied presentation, high index of mortality and (compared to separate PET-CT), and may well become a standard in morbidity and accurate diagnosis by multimodality and specifically management of cardiac sarcoidosis. FDG-PET can dictate further management.

Journal of Nuclear CardiologyÒ ePOSTERS: BEYOND PERFUSION: MOLECULAR IMAGING OF INFILTRATIVE HEART DISEASE, CALCIFICATION, INFLAMMATION, INFECTION 2

308-01 studies. Presence of the following red flags for cardiac ATTR was evaluated: (i) age [ 65 years in males or [ 70 years in females, (ii) left POSITIVE TC-99M PYROPHOSPHATE SCINTIGRAPHY ventricular hypertrophy (LVH; [ 1.4 cm), (iii) low voltage ECG, (iv) PREDICTS THROMBOEMBOLIC RISK IN ATRIAL FIBRIL- apical sparing strain pattern and (v) chronic troponin elevation. The LATION prevalence of other suggested red flags- heart block (10%), dysautono- S. Bukhari*,1 A. Barakat,1 S. Jain,1 A. Brownell,1 Y. S. Eisele,1 R. A. mia or polyneuropathy (7%) and bilateral carpal tunnel syndrome (2%), Nieves,2 W. Follansbee,1 S. Saba,1 P. Soman1; 1University of Pitts- was very low and were not considered in our analysis. burgh Medical Center, Pittsburgh, PA, 2Internal Medicine, Results: In this referral population (78 ? 12 years; 81% African University of Pittsburgh Medical Center, Pittsburgh, PA American; 47% males), cardiac ATTR was diagnosed in 31 (36%) Introduction: Tc-99m pyrophosphate scintigraphy (PYP) has unmasked a patients. There was a sequential increase in the prevalence of cardiac high community prevalence of wild-type transthyretin amyloid cardiomy- ATTR with increasing number of red flags (p \ 0.0001)—from 0 to 5: opathy (ATTRwt-CA). ATTR-CA is thought to increase the risk of atrial 0%, 0%, 0%, 23%, 57% and 86%, respectively. ROC curve analyses fibrillation (AF) and thromboembolism. Our study was aimed to determine showed an AUC of 0.87 for a combination of all 5 red flags (figure), the prevalence of AF in ATTRwt-CA and compare the incidence of which was similar to a combination that excluded chronic troponin thromboembolism in AF patients with and without ATTRwt-CA. elevation. However, exclusion of apical sparing strain pattern, resulted in Methods: We studied patients who underwent PYP between 06/2015 a lower diagnostic accuracy (AUC = 0.77). and 06/2019. Those with positive PYP (defined as Perugini grade C 2 Conclusions: A combination of simple clinical and diagnostic ‘‘red and heart-to-contralateral lung ratio of C 1.5 on a planar image and flags’’, with or without chronic troponin levels, confers good diagnostic diffuse myocardial tracer uptake on SPECT imaging), negative serum accuracy for cardiac ATTR. These features can be easily evaluated in an studies for AL amyloidosis and no TTR gene mutation were diagnosed ambulatory setting and can inform referral for confirmatory PYP with ATTRwt-CA. We compared the prevalence of AF in patients with imaging. and without ATTRwt-CA and the incidence of thromboembolism (stroke, transient ischemic attack or systemic embolism) in AF patients with ATTRwt-CA (AF-ATTR) and without (AF-controls). Results: Of 277 patients referred for PYP (mean age 78.4 ± 8.0 and 83% men), 77 (28%) had ATTRwt-CA. The prevalence of AF was markedly higher in patients with ATTRwt-CA (n = 68, 88%) compared to patients with negative PYP (n = 77, 39%, p \ 0.01). Compared to AF-controls, AF-ATTR patients had similar age (79 ± 7 vs. 79 ± 8 years, p = 0.9) and anticoagulation status (96% vs 94%, p = 0.58), lower CHA2DS2- VASc (4.7 ± 1.4 vs. 5.4 ± 1.2, p = 0.001), thicker interventricular sep- tum (1.67 ± 0.27 vs 1.50 ± 0.15, p \ 0.001) and lower left atrial indexed volume (LAVI) (46 ± 17 vs. 61 ± 35 ml/m2, p = 0.003). Despite a lower CHA2DS2-VASc, the incidence of thromboembolism was higher in AF- ATTR compared to AF-controls (37.3% vs. 19.5%, p = 0.02; OR 2.46, 95% CI 1.16–5.21, p = 0.02). On multivariable logistic regression analysis adjusting for CHA2DS2-VASc, interventricular septal thickness and LAVI, ATTRwt-CA was an independent predictor of thromboem- 308-03 bolism (OR 6.6, 95% CI 2.23–19.69, p \ 0.001). The incidence of TOWARDS A DIAGNOSIS OF CARDIAC AMYLOIDOSIS: hemorrhagic stroke (p = 0.3), intracranial hemorrhage (p = 0.9), major SINGLE CENTER EXPERIENCE WITH TC-99M PYROPHOS- bleeding (p = 0.7), and all-cause death (p = 0.4) did not differ between PHATE SCAN IN THE WORKFLOW the 2 groups. M. Saleem*,1 B. Sadat,1 M. Van Harn,1 K. Ananthasubramaniam2; Conclusions: ATTRwt-CA is a strong predictor of thromboembolism in 1Henry Ford Health System, Detroit, MI, 2Division of Cardiology, patients with AF, independent of CHA2DS2-VASc score, interventric- Henry Ford Hospital, Detroit, MI ular septal thickness or left atrial size. These findings may have Introduction: Technetium-99 m pyrophosphate (PYP) scan has changed important implications for anticoagulation in patients with ATTRwt-CA. the landscape of diagnosis of transthyretin cardiac amyloidosis (TTR- CA) with a very high diagnostic accuracy. Primary goal of this single center analysis of PYP scans done at our institution to assess workflow 308-02 after intermediate PYP scans (PYPI) on diagnostic workup for CA and to EFFECTIVENESS OF THE NUMBER OF DIAGNOSTIC RED perform a quality control re-review PYP scans to identify areas of FLAGS IN PREDICTING TRANSTHYRETIN CARDIAC improvement. AMYLOIDOSIS Methods: Retrospective study with independent re-review of all PYP T. Asif*,1 A. Gupta,2 V. Singh,3 S. Malhotra4; 1Cook County Health, scans by a Level 111 nuclear reader (KA) of 69 patients who underwent Chicago, IL, 2University at Buffalo, Buffalo, NY, 3Brigham & Tc-99m pyrophosphate (PYP) scan for the diagnosis of TTR-CA for the Women’s Hospital, Boston, MA, 4Cardiology, Cook County Health, past 3 years at single institution. Three groups identified: Low (N = 25, Chicago, IL PYPL, HCL ratio \ 1.2 ? visual grade 1/0), Intermediate (N = 20, Background: Recognition of several clinical features (red flags) has PYPI, HCL ratio 1.2–1.49 ? visual grade 2/3), and high uptake (N =24 been suggested to guide referral for Tc-99m Pyrophosphate scintigraphy PYPH, HCL ratio [ 1.5 ? visual grade 2/3). We reviewed patient (PYP imaging). However, the diagnostic yield of these red flags for demographics and history, echo parameters, laboratory and imaging cardiac TTR amyloidosis (ATTR) is not known. diagnostic testing, biopsy Methods: Clinical data of 87 heart failure patients referred for PYP Results: Data were analyzed with continuous and categorical variable imaging, were reviewed. Cardiac ATTR was diagnosed if Perugini score formats. All variables were compared between PYP groups using was C 2 at one hour on planar PYP imaging, with myocardial uptake on Kruskal–Wallis tests while categorical variables are compared between SPECT, along with the absence of monoclonal proteins on immunologic groups using Chi-square or Fisher’ s exact tests. Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

Results: Mean patients’ age was 73?, male to female ratio 4:1, 55% of patients were African American. Cardiovascular comorbidities, cardiac biomarkers (BNP and Troponin), ejection fraction were similar in all groups. A statistically significant difference in septal and posterior wall thickness were found between the groups (mean IVSd 1.44 PYPL, 1.72 PYPH, p = 0.005, mean posterior wall thickness 1.33 PYPL vs 1.58 PYPH, p = 0.009). No patients in PYPL group were diagnosed with TTR-CA. in the PYPI group 25% (n = 5) of patients were found to have CA with further evaluation. In the PYPH group 22/24 (92%) had TTR- CA. The distribution of overall diagnostic testing for the PYPI groups included SPEP 95%, UPEP 70%, free light chain 85%, CMR 35%, tissue biopsy 25% and bone marrow biopsy in 20% (all p = ns between PYPL and PYPH groups). Overall 25% (n = 5, 4 TTR-CA and 1 AL amyloid) of patients in the PYPI had a final diagnosis of cardiac amyloidosis established with adjunctive testing (p = 0.001 vs other groups). Re-Re- view resulted in identification of wrong region of interest in 2 cases and reclassification to PYPL as no TTR-CA based on blood pool misinter- pretation of planar data. Five cases overall in PYPL and PYPI had visual PYP grade changed. Conclusion: PYP scan is an accurate noninvasive test for cardiac TTR- CA. Importantly 25% of patients with PYPI had a final diagnosis of cardiac amyloidosis reiterating that early TTR-CA or AL needs to be excluded. Internal quality control and continued education for technol- ogists and readers of PYP scan is an important process to avoid 308-05 misdiagnosis. A standardized protocol for evaluation of cardiac amy- loidosis will eliminate variability in testing patterns. TRANSTHYRETIN CARDIAC AMYLOIDOSIS—A CONTEM- PORARY DISEASE PREDICTION MODEL BASED ON MULTIMODALITY IMAGING TECHNIQUES M. Indaram*, A. Elhamdani, K. Kashyap, M. Doyle, I. Poornima; 308-04 Allegheny Health Network, Pittsburgh, PA INTEROBSERVER VARIABILITY OF TECHNETIUM-99M Introduction: Transthyretin amyloid cardiomyopathy (ATTR-CM) is PYROPHOSPHATE UPTAKE QUANTITATION often underdiagnosed due to its varied clinical manifestations, poor FOR TRANSTHYRETIN CARDIAC AMYLOIDOSIS specificity of echocardiography (ECHO) and the need for invasive car- R. Miller*,1 S. Cadet,2 D. Mah,3 P. Pournazari,1 D. Chan,3 N. Fine,1 diac biopsy as a gold standard diagnosis. Technetium pyrophosphate (Tc- D. S. Berman,4 P. J. Slomka4; 1Libin Cardiovascular Institute of PYP) scintigraphy has grown as a standard of care and confirmatory test Alberta, Calgary, AB, Canada, 2Cedars Sinai Medical Center, Los for ATTR-CM due to its high specificity. We aim to build a disease Angeles, CA, 3University of Calgary, Calgary, AB, Canada, 4Cedars- prediction model for Tc-PYP diagnosed ATTR-CM based on clinical Sinai Medical Center, Los Angeles, CA characteristics and multimodality imaging parameters. Introduction: Transthyretin cardiac amyloidosis (ATTR-CM) is an Methods: We performed a single-center retrospective review of demo- increasingly recognized cause of heart failure and 99mTc-pyrophosphate graphics, clinical comorbidities, ECHO and cardiac MRI of patients imaging has emerged as an important noninvasive method to establish undergoing Tc-PYP scans between January 2018 and December 2019. the diagnosis. Quantitation of abnormal myocardial 99mTc-pyrophos- Results: Of 192 Tc-PYP scans performed, 42(22%) were positive for phate activity could be a marker of ATTR-CM disease burden. We ATTR-CM (PYP Grade 2/3, H:CL ratio [ 1.5). 22(52.3%) of the 42 assessed the interobserver variability of new and existing 99mTc-py- scans showed right ventricular (RV) uptake. H:CL [ 1.5 correlated rophosphate measurements. positively with age, congestive heart failure (CHF), ventricular Methods: Patients who underwent 99mTc-pyrophosphate imaging for arrhythmias, carpal tunnel syndrome and ECHO-based left ventricle suspected ATTR-CM were identified and quantitation was performed by (LV) mass, interventricular septal thickness (IVST), increasing grades of two authors. Using SPECT images, radiotracer activity in the myo- diastolic and RV dysfunction (R2 [ 0.01, p \ 0.05). Tc-PYP positive cardium was calculated using cardiac pyrophosphate activity (CPA) and cohort had significant difference in incidence of lumbar stenosis, carpal volume of involvement (VOI). Thresholds for abnormal activity were tunnel syndrome, CHF and ECHO parameters compared to negative derived from LVBP activity as shown in Figure 1. Interobserver vari- cohort (Figure 1). On regression analysis, age (Odds Ratio [OR] 1.1, ability was assessed for CPA, VOI and heart-contralateral (H/CL) ratio. p \ 0.05), IVST (OR 45.4, p \ 0.05), RV dysfunction grade on ECHO Results: In total, 124 patients were included, mean age 73.9 ± 11.4 and (OR 1.8, p \ 0.05) predicted a positive Tc-PYP scan. RV dysfunction 94 (73.4%) male, with ATTR-CM diagnosed in 43 (34.7%) patients. grade (OR 4.8, p = 0.05) was also a sole predictor of RV uptake. Interobserver variability for CPA (mean difference 1.0%, limits of Conclusions: Tc-PYP positivity confirming ATTR-CM was best pre- agreement - 19.4% to 21.4%) and VOI (mean difference 0.6%, limits of dicted by a model comprised increasing age, IVST and severity of RV agreement - 17.2% to 18.4%) were good with excellent agreement on dysfunction on ECHO. The novel finding in this contemporary cohort absence of activity (kappa 1.00). Interobserver variability was similar for was that RV dysfunction in the absence of pulmonary hypertension is a H/CL ratio (mean difference 2.2%, limits of agreement - 20.5% to predictor of Tc-PYP positivity in the LV and RV. The prognostic 24.9%). implication of RV dysfunction in ATTR-CM requires further Conclusions: Quantitative assessment of myocardial radiotracer activity investigation. with CPA or VOI have low interobserver variability and are potentially useful quantitative markers for ATTR-CM.

Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

Figure: Example of heart and rib ROI (left), relationship between H/CL and SPECT-H/R (middle) and distribution of SPECT-H/R for ATTR? and ATTR- patients. Conclusions: SPECT-H/R correlates with planar H/CL measurements and may obviate the need for acquiring planar images. Other SPECT comparators did not correlate as well as SPECT-H/R. SPECT-H/R also 308-06 was significantly different in ATTR? and ATTR- reports. RELATIONSHIP OF SPECT HEART TO RIB (SPECT-H/R) UPTAKE TO HEART TO CONTRALATERAL (H/CL) UPTAKE OF 99MTC PYROPHOSPHATE (PYP) 308-07 J. A. Case*,1 B. W. Sperry,2 E. Moloney,3 S. A. Courter,1 T. M. DISCRIMINATIVE ABILITY OF TECHNETIUM-99 M Bateman4; 1Cardiovascular Imaging Technologies, Kansas City, PYROPHOSPHATE IMAGING FOR ATTR CARDIAC AMY- MO, 2St. Luke’s MidAmerica Heart, Kansas City, MO, 3CVIT, LOIDOSIS AT A NON-AMYLOID REFERRAL CENTER Kansas City, MO, 4St. Luke’s Mid America Heart Institute, Kansas J. A. Quaggin-Smith*, R. Wehbe, P. Kansal, T. A. Holly; North- City, MO western University, Chicago, IL Introduction: Elevated heart to contralateral uptake (H/CL) on planar Introduction: Cardiac scintigraphy with technetium-99 m pyrophos- PYP has been demonstrated to be highly predictive of transthyretin phate (Tc-PYP) has been proposed as a noninvasive gold standard for the cardiac amyloidosis, if confirmed by SPECT. Quantitative measurements diagnosis of transthyretin cardiac amyloidosis (ATTR-CA). Prior studies of PYP uptake in tomographic SPECT images are more challenging due have reported sensitivities and specificities up to 97% and 100%, to inconsistencies in comparator regions of interest (ROI). This study respectively, though the majority were conducted at amyloid referral investigated the SPECT-H/R ratio as an analog to the planar H/CL centers with high disease prevalence not representative of the majority of measurement. patient populations. We sought to further evaluate the diagnostic per- Methods: Fifty patients with a clinically indicated PYP study were formance of Tc-PYP scans in patients at a non-amyloid referral center. examined for this analysis. Each image set had planar and 360° SPECT Methods: Clinical, pathologic, echocardiographic (echo) and cardiac acquisitions acquired on a Siemens Symbia, 16-slice SPECT/CT system. magnetic resonance imaging (cMRI, when available) data were collected Studies were acquired approximately 1 h after injection of 10–20 mCi of for patients referred for Tc-PYP imaging between 2018 and 2019 at PYP. Planar data were acquired for 750,000 counts in an anterior view. Northwestern Memorial Hospital. Patients were grouped by overall SPECT data were reconstructed using a 2D OSEM method and analyzed qualitative assessment of Tc-PYP Results by the interpreting physician: using ImagenSPECT (CVIT, Kansas City). A H/CL ratio was extracted ‘‘not suggestive,’’ ‘‘equivocal,’’ or ‘‘strongly suggestive.’’ This assess- from identically sized circular ROIs from the anterior planar view. Mean ment was based on a combination of quantitative analysis of heart to and maximum counts were extracted from a central transverse slice of contralateral lung ratio and semi-quantitative visual scoring (grade 0–3) the myocardium: Heart, rib and right lung (RL). Rib ROIs did not include at 1 and/or 3 h after tracer injection. Between group comparisons were sternum, spine or focal uptake regions. The SPECT-H/R was defined as performed using Kruskal–Wallis test and Chi-square analysis. the max heart counts divided by the max rib counts in that slice. SPECT- Results: In this cohort (n = 117), there were fewer strongly suggestive H/R was also compared to visual heart to rib grading scores (0–3). Tc-PYP studies (24.7%) and more equivocal studies (29.9%) compared Results: The H/CL planar ratios ranged from 0.79 to 2.27. SPECT H/R to previously published series. Patients with strongly suggestive inter- correlated most closely with heart to contralateral ratios, fig- pretations were older (p \ 0.001), had thicker LV myocardium by echo ure (r = 0.85). Other ratios were less correlated with planar H/CL (p \ 0.001), lower lateral mitral annular tissue velocities (e’) (p = 0.04), (r = 0.79 (mean heart/max rib), r = 0.82 (max heart/mean RL)). SPECT- and were more likely to have typical features on cMRI with elevated H/R was significantly different between patients with a positive overall extracellular volume (p = 0.015) and typical delayed gadolinium finding for ATTR (1.46 (ATTR?) vs 0.77 (ATTR-)). enhancement pattern (p \ 0.001). Among patients who underwent endomyocardial biopsy (EMBx), a strongly suggestive Tc-PYP inter- pretation was 58% sensitive and 78% specific for ATTR-CA. Including

Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

patients with a presumptive diagnosis, but no EMBx, a strongly sug- Methods: Retrospective search of all bone scans undertaken for non- gestive Tc-PYP interpretation was 84% sensitive and 93% specific for cardiac indications Technetium-99m methylene diphosphonate (MDP), ATTR-CA. Overall, the prevalence of ATTR-CA by presumptive diag- read by a single reporter who prospectively reported cardiac uptake from nosis (?EMBx or strongly suggestive Tc-PYP) was 27%. Approximately 2013. Reports were searched for the terms ‘cardiac’, ‘cardiac uptake’, half of those patients with an equivocal interpretation by Tc-PYP ‘myocardial’ and ‘heart’. Cases were reviewed independently. Further underwent subsequent EMBx. cohort reported by others from 2009 onwards were reviewed to deter- Conclusions: This is the first study evaluating utility of Tc-PYP scans at mine cardiac uptake by a blinded reported with second review. Review a non-referral center for cardiac amyloidosis. In our patient population of electronic patient records. with a lower disease prevalence, we saw a lower proportion of studies Results: 14,126 scans performed from 2009; 27 of 8076 had prospec- interpreted as strongly suggestive and a concomitant increase in the tively reported cardiac uptake. These cases were all were Perugini 2/3. proportion of equivocal studies. The higher proportion of equivocal 96% male, 96% Caucasian. Average age 83 years (75–92 years). studies compared to the established literature suggests that the discrim- Prevalence of Perugini 2/3 uptake 0.33%. 13/27 had echocardiography inative ability of Tc-PYP testing may be dependent on pre-test confirming moderate to severe left ventricular hypertrophy in all. 8/27 probability of the referral population, and disease prevalence should be had NT pro BNP measured; average 328 pg/ml (169–15,479). 3/27 Trop considered when interpreting Results. T (HS); average 75 ng/l (56–111). One patient had ATTR diagnosis confirmed by the National Amyloid Centre. 4/27 patient had died. Time from bone scan to death average 3 years (1–5 years). 72 of 6050 had 308-09 retrospectively reported Perugini 1–3 uptake. Prevalence of 1.2%. Average age 78 years (45–99 years). 79% (57/72) male. ESTIMATION OF PREVALENCE OF TRANSTHYRETIN Conclusions: DPD scintigraphy is the preferred noninvasive test to (TTR)-RELATED AMYLOIDOSIS IN A RETROSPECTIVE distinguish TTR-related cardiac amyloidosis from other etiologies of COHORT OF 14,126 BONE SCANS IN A GENERAL UK unexplained left ventricular hypertrophy. Technetium-99 m methylene POPULATION diphosphonate (MDP) may also demonstrate cardiac uptake in ATTR R. S. Schofield*, R. Moshy, T. Sadek, A. Tester, K. Thompson; amyloid or be a surrogate marker for increased extracellular volume or North West Anglia Foundation Trust, Peterborough, United cancer. It therefore may be useful in determining the prevalence of Kingdom ATTR amyloid. Further analysis is planned. Introduction: Myocardial uptake of 99 mTc-3,3-diphosphono-1,2- References: Scully PR, Patel KP, Treibel TA, et al. Prevalence and propanodicarboxylic acid (DPD) is reported using the visual grading outcome of dual aortic stenosis and cardiac amyloid pathology in patients Perugini system. A score of 0 indicating no myocardial uptake, scores 1– referred for transcatheter aortic valve implantation [published online 3 increasing evidence of myocardial and soft tissue uptake. Studies ahead of print, 2020 Apr 8]. Eur Heart J. 2020; ehaa170. https://doi.org/ suggest the prevalence of TTR-related cardiac amyloid is 1 in 7 patients 10.1093/eurheartj/ehaa170. worked up for Transcatheter Aortic Valve Implantation 1, prevalence in the general population is unclear. Treatment options exist for ATTR amyloid, although not currently NICE approved. NHS Heart failure costs [ £625 million per annum. This project aimed to estimate the prevalence of cardiac uptake, as a surrogate marker of possible ATTR amyloid, in a general non-selected patient cohort.

Journal of Nuclear CardiologyÒ ePOSTERS: BEYOND PERFUSION: MOLECULAR IMAGING OF INFILTRATIVE HEART DISEASE, CALCIFICATION, INFLAMMATION, INFECTION 3

309-01 standardized protocol was followed for acquisition of the images. The following arteries were examined: coronary artery (CA), ascending aorta ATHEROSCLEROTIC CARDIOVASCULAR DISEASE RISK (AS), arch of aorta (AR), descending aorta (DA), abdominal aorta (AA), ESTIMATED BY POOLED COHORT EQUATION PREDICTS common iliac artery (CIA), external iliac artery (EIA), femoral artery GLOBAL CARDIAC MICROCALCIFICATION IN PATIENTS (FA), popliteal artery (PA). Average SUVmean (aSUVmean) was cal- WITH ANGINA culated for each arterial segment in all healthy controls and patients. A K. Gonuguntla*,1 C. Rojulpote,2 S. Patil,1 P. Karambelkar,3 A. paired t-test comparing the aSUVmean between CA vs. AS, AR, DA, Bhattaru,4 K. Vuthaluru,4 T. J. Werner,4 P. Hoilund-Carlsen,5 A. AA, CIA, EIA, FA, and PA was done. Alavi2; 1University of Connecticut, Farmington, CT, 2Radiology, Results: CA aSUVmean in the at-risk group was found to be higher than University of Pennsylvania, Philadelphia, PA, 3The Wright Center the healthy control group (0.75 ± 0.12 vs. 0.68 ± 0.16, p = 0.03), with for Graduate Medical Education, Scranton, PA, 4University of similar findings in the upper limb and lower limb arteries. Furthermore, Pennsylvania, Philadelphia, PA, 5Odense University Hospital, the NaF uptake in the AS, AR, DA, AA, CIA, EIA, FA, and PA were Odense, Denmark found to be higher than CA in both healthy (0.80 ± 0.19, 0.81 ± 0.23, Objective: Relationship of ASCVD risk estimated by pooled cohort 0.91 ± 0.39, 1.30 ± 0.38, 2.37 ± 0.58, 1.76 ± 0.43, 1.45 ± 0.32, equation (PCE) and coronary plaque burden in patients with angina is 1.36 ± 0.32 vs 0.68 ± 0.16, respectively) and high risk group unknown. We hypothesize that ASCVD risk score correlates positively (0.98 ± 0.28, 1.02 ± 0.35, 1.04 ± 0.29, 1.32 ± 0.41, 2.43 ± 0.81, with global cardiac microcalcification as a surrogate marker for coronary 1.79 ± 0.50, 1.73 ± 0.45, 1.56 ± 0.36 vs 0.75 ± 0.12, respectively). In plaque burden as assessed by NaF-PET/CT. healthy controls and at-risk patients, a paired t-test comparing the Methods: We identified 25 individuals at-risk for cardiovascular disease aSUVmean of CA with that of AS, AR, DA, AA, CIA, EIA, FA, and PA age C 40 years (55.8 ± 9.3 years, 13 females, 100% Caucasian) from was found to be significant (p = \ 0.0001). the CAMONA trial who had chest pain suggestive of angina. These Conclusion: We observed a higher NaF uptake in upper limb and individuals underwent PET/CT imaging 90 min after the injection of peripheral arteries when compared to the CA uptake in both healthy NaF (2.2 Mbq/Kg). Analysis was performed on axial images using controls and patients, suggesting that CA affection is a late manifestation OsiriX MD software. The global cardiac uptake was measured by a of atherosclerosis. This differential expression of atherosclerosis is likely trained physician by manually defining regions of interest (ROIs) on each due to interaction of hemodynamic parameters specific to the vascular axial slice while excluding the cardiac valves, aortic wall, and nearby bed and systemic factors related to the development of atherosclerosis. skeletal structures. The global cardiac average SUVmean (aSUVmean) was calculated for each individual. We calculated their 10-year ASCVD risk score for major cardiovascular events using the PCE as per ACC/ 309-03 AHA guidelines. These individuals were categorized into low, border- line, intermediate and high risk groups based on their ASCVD risk score UTILITY OF NAF-PET/CT IN ASSESSING SUBCLINICAL and average global cardiac SUVmean were compared using the one-way ATHEROSCLEROSIS IN PERIPHERAL ARTERIES ANOVA test. Linear regression model was used to assess the relationship OF HEALTHY INDIVIDUALS WITH AN OPTIMAL CAR- between ASCVD score and global cardiac aSUVmean. DIOVASCULAR RISK FACTOR PROFILE Results: The global cardiac aSUVmean was higher in groups estimated K. Gonuguntla,1 C. Rojulpote*,2 S. Patil,1 P. Karambelkar,3 to have elevated 10-year risk for major cardiovascular events with a K. Vuthaluru,4 A. Bhattaru,4 V. Zhang,4 T. J. Werner,4 P. Hoilund- difference of 15.2% in aSUVmean between low and high risk groups carlsen,5 A. Alavi2; 1University of Connecticut, Farmington, CT, (Mean ± SD: 0.68 ± 0.06; 0.73 ± 0.09; 0.76 ± 0.06; 0.78 ± 0.10; 2Radiology, University of Pennsylvania, Philadelphia, pa, 3The Wright p = 0.05). There was a positive linear relationship between ASCVD center for Graduate Medical Education, Scranton, PA, 4University of score and global cardiac aSUVmean (r = 0.48, p = 0.01). Pennsylvania, Philadelphia, PA, 5Odense University Hospital, Odense, Conclusion: ASCVD risk score estimated by PCE can predict with Denmark atherosclerotic burden in coronary vessels in patients with angina. Objective: We aimed to detect, quantify and compare subclinical atherosclerosis in lower extremity peripheral arteries using NaF- PET/CT in healthy individuals with an optimal cardiovascular risk factor profile 309-02 (CVRFP) to healthy controls without a similar profile. We hypothesize that subclinical atherosclerosis will be present in both groups, and PRESENCE OF CORONARY MOLECULAR CALCIFICATION moreover that the latter, despite being healthy, will show a higher AND ITS CORRELATION TO CALCIFICATION PROCESSES atherosclerotic burden as assessed by NaF-PET/CT uptake. IN UPPER LIMB, ABDOMINAL AND LOWER EXTREMITY Methods: We selected 10 healthy individuals (34 ± 12.5 years, 5 males, 5 ARTERIES AS ASSESSED BY NAF-PET/CT females) with an optimal CVRFP from the CAMONA trial. As per current K. Gonuguntla*,1 C. Rojulpote,2 S. Patil,1 P. Karambelkar,3 K. guidelines, these individuals met all of the following criteria: total choles- Vuthaluru,4 A. Bhattaru,4 V. Zhang,4 T. J. Werner,4 P. Hoilund- terol \ 200 mg/dL, LDL \ 100 mg/dL, HDL [ 40 mg/dL, fasting plasma Carlsen,5 A. Alavi2; 1University of Connecticut, Farmington, CT, glucose \ 100 mg/dL, HbA1c \ 5.7%, systolic blood pressure (SBP) \ 2Radiology, University of Pennsylvania, Philadelphia, PA, 3The 130 mmHg, diastolic blood pressure (DBP) \ 80 mmHg, and nonsmoker. Wright Center for Graduate Medical Education, Scranton, PA, These individuals were age matched to 10 healthy controls from the 4University of Pennsylvania, Philadelphia, PA, 5Odense University CAMONA trial (36 ± 11.8 years, 4 females, 6 males) who did not meet all Hospital, Odense, Denmark of the above criteria. These individuals underwent PET/CT imaging 90 min Objective: Atherosclerosis is a systemic process with focal manifesta- after the injection of NaF (2.2Mbq/Kg). Analysis was performed on axial tions affecting multiple vascular beds. We aimed to detect, quantify and images using OsiriX MD software. The NaF uptake was measured by a compare vascular calcification in coronary arteries with that of upper trained physician by manually defining regions of interest (ROIs) on each limb and peripheral arteries to assess the heterogeneity of atherosclerosis. axial slice from the common iliac to popliteal arteries. The average SUV- Methods: In this study, 68 healthy controls (42 ± 13.5 years, 35 mean (aSUVmean) was calculated for each artery. Paired t-test was females, 33 males) and 40 patients at-risk for cardiovascular disease employed for statistical analysis. (55 ± 11.9 years, 22 females, 18 males) underwent PET/CT imaging Results: The total aSUVmean in the lower extremity peripheral arteries 90 min after the injection of NaF (2.2Mbq/Kg). A uniform and in healthy asymptomatic individuals with an optimal cardiovascular risk Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

factor profile was found to be 9.9% lower than individuals without a Methods: In all 602 studies were performed in 322 patients. Of the 602, similar profile (7.1 ± 1.1 vs. 7.8 ± 0.6, p = 0.02). only 573 studies in 315 patients could be reprocessed using Jetstream, Conclusion: As detected by NaF-PET/CT, subclinical atherosclerosis in Inc. (JS) and MIM Software, Inc. (MIMS) packages for estimating LV lower extremity peripheral arteries occurred in young healthy individu- EF. LV EF was determined by localizing a region of interest around the als, albeit with a lower burden in individuals with optimal control of LV in a left anterior oblique projection. multiple cardiovascular risk factors. Results: Median age was 53 ± 12.88 years and 226 patients (70.2%) were female. Baseline data and cancer type are listed in the table. The most common comorbidities were hypertension (45%) followed by dia- 309-04 betes mellitus (19.2%). In the 573 studies analyzed, the mean EF and standard deviation for MIMS and JS were 55.62% ± 10.12% and DISCORDANT TC-99M PYROPHOSPHATE PLANAR GRADE 65.51% ± 10%, respectively (p value \ 0.00001, Student’s paired t-test AND H/CL RATIO: COMPARISON WITH DIFFUSE TRACER and Z-test). Despite a correlation of 0.84 (see figure 1), JS tended to UPTAKE ON SPECT measure a higher EF. The mean difference in EF between the paired 1 2 1 1 1 S. Bukhari*, A. Masri, S. Ahmad, Y. S. Eisele, A. Brownell, J. studies was 10.4%, and 312 (55%) of the studies had a difference in EF Ibrahim,1 P. Soman1; 1University of Pittsburgh Medical Center, greater than 10%. Interobserver variability in EF for JS and MIMS was 2 Pittsburgh, PA, Oregon Health and Science University, Portland, measured as 1 and 0.994, respectively. OR Conclusion: Our study highlights that software packages are not inter- Introduction: We sought to determine the prevalence and interpretive changeable in measuring EF. Additionally, 55% (312 patients out of 573) implication of a discordance between the Perugini grade (C 2 considered demonstrates a difference in EF of [ 10% depending on the software positive) and the heart to contralateral ratio (H/CL, C 1.5 considered used. This variability may lead to inappropriate delaying or discontinuing positive) on Tc-99m pyrophosphate (PYP) scintigraphy. Diffuse chemotherapy or radiation. MUGA reports should note the software myocardial tracer uptake on SPECT is increasingly being used as the version used, and future serial imaging of patients should be processed defining parameter of a positive PYP scan. on the same software. Methods: We analyzed the 1-hour images of the PYP scans performed between 06/2015 and 02/2020. Diffuse PYP uptake on SPECT was considered the final arbitrator of PYP positive or negative status. Results: Of the 440 PYP scans, 40 (9%) had a discordance between the Perugini grade and H/CL. In 31 (78%) of the discordant cases, the planar grade corresponded with the SPECT finding (p = 0.001, Table 1). All 9 cases of discordance between the Perugini grade and SPECT occurred in grades 1 and 2. Conclusions: In PYP scans with discordant Perugini grade and H/CL, the grade corresponded more often with SPECT. Discordance between Perugini grade and SPECT occurred only when the grade was marginally negative or positive (1 or 2) and may reflect subjectivity of interpretation. Discordant Perugini grade and H/CL ratio SPECT Positive SPECT Negative Perugini Grade C 2 and H/CL \ 1.5 11 7 (all Grade 2) Perugini Grade \ 2 and H/CL C 1.5 2 (all Grade 1) 20

309-05

VARIABLE LEFT VENTRICULAR EJECTION FRACTION IN MULTIGATED RADIONUCLIDE IMAGING ANALYZED BY DIFFERENT SOFTWARE PACKAGES IN PATIENTS WITH CANCER A. Raza*, G. Suero-Abreu, P. Lim, K. Mehta, H. Salcedo, K. Joshua, J. Gardin, Y. Liu, M. Klapholz, A. H. Waller; Rutgers New Jersey Medical School, Newark, NJ Background: Baseline and serial multigated acquisition (MUGA) scans are an established method for assessing left ventricular (LV) ejection fraction (EF) in oncology patients. The purpose of the study was to explore the interchangeability of 2 commercially available software on evaluation of LV EF. Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

309-06 309-07 A NEW SEMI-AUTOMATED QUANTITATIVE TOOL FEASIBILITY OF TC99M-PYP IMAGING USING CADMIUM- FOR ASSESSING AMYLOID HEART: CONTRALATERAL ZINC-TELLURIDE CAMERA LUNG RATIO FROM TC-99M PYP SCANS M. C. Hyun*,1 Y. Otaki,1 B. K. Tamarappoo,2 S. W. Hayes,1 J. D. J. Dhingra*, D. Cooke, S. Muzahir, L. Hall, M. Brown, K. Bhatt, R. Friedman,1 L. Thomson,3 D. S. Berman1; 1Cedars-Sinai Medical Halkar, V. Moncayo; Emory University, Atlanta, GA Center, Los Angeles, CA, 2Imaging, Cedars Sinia Medical Center, Introduction: Cardiac Amyloidosis presents as restrictive cardiomy- Los Angeles, CA, 3Cedars Sinai Medical Center, Los Angeles, CA opathy, heart failure, and arrhythmias caused by localized or systemic Background: Quantitative analysis of the heart to contralateral ratio (H/ deposition of insoluble extracellular fibrillary proteins in organs and CL) derived from images obtained with Cadmium-Zinc-Telluride (CZT) tissues. In a recent study from Columbia Univ, it was found that the ratio SPECT-only cameras presents a challenge since true planar images are of Tc-99m PYP mean counts in the heart to contralateral lung not available. We sought to evaluate the degree to which H/CL derived (HCL), [ 1.5, had a sensitivity of 97% and specificity of 100% for from a pseudo planar image (‘‘projection cine image’’) using a CZT detecting ATTR type of amyloid. The purpose of our study is to intro- system correlates with H/CL using a conventional Anger SPECT (A- duce a semi-automated quantitative tool for assessing HCL in Tc-99m SPECT) camera. PYP scans and to evaluate the interobserver variability among 4 expe- Methods: We studied 71 patients who underwent 99mTc-PYP imaging rienced NM readers. on both A-SPECT large field of view scanner (Siemens Symbia Intevo Methods: 34 patients (20 M, age 34–92) from 6/15/2018 to 9/6/2019, Bold) and D-SPECT camera (Spectrum Dynamics) on the same day. A suspected to have cardiac amyloidosis, underwent planar imaging at 1 dual-isotope approach was used allowing optimal positioning of the heart and 3 h after the IV administration of * 10 mCi Tc-99m PYP. A new within the small field of view. Patients were injected with 20 mCi of semi-automated tool was used to calculate the HCL ratio at 1 and 3 h. 99mTc-PYP and 1 mCi of Tl-201. 3-hour post injection, simultaneous This new tool automatically mirrors the size and location of a user-placed dual isotope imaging on was acquired on A-SPECT followed by D- circular Heart ROI across a user-defined location of the sternum, to the SPECT imaging. An anterior planar view was obtained using LEHR contralateral lung (CL). This ensures that the CL ROI is the same size as collimators on A-SPECT and a projection cine image was obtained on D- the heart ROI, the same distance from the sternum and at the same level. SPECT. Manual ROIs were drawn on A-SPECT anterior planar and on Four experienced NM physicians blinded to clinical history reviewed 1 D-SPECT anterior projection images to calculate H/CL (Figure 1). and 3 h planar and SPECT/CT images, graded the images per the ASNC Results: Among 71 patients (M = 82%, median = 77 [IQR 34–93] scoring Guidelines and calculated the HCL ratio. years), 25 patients were interpreted as strongly suggestive of ATTR. Results: All scores and ratios were converted into 3 categories (Normal, There was strong correlation (r2 = 0.82) in H/CL derived from the Equivocal and Abnormal) using ASNC guidelines (Normal: score = 0 or anterior planar A-SPECT images and projection image on D-SPECT ratio \ 1; Equiv: score = 1 or ratio C 1&B 1.5; Abnormal: score C 2 (Figure 2). or ratio [ 1.5). Agreement between readers was defined as all readers Conclusion: Compared to conventional angers camera, H/CL derived having the same category; Results are shown in Table 1. Agreement was from 99mTc-PYP imaging using a CZT camera is feasible.. greater for both the 1 and 3 h HCL ratio compared to visual, implying that interobserver variability was less. Conclusion: We have created a new semi-automated tool for assessing amyloid HCL Ratio from Tc-99m PYP Scans that aids in reducing interobserver variability.

Agreement among 4 readers for 1 and 3 h planar visual interpretation vs. quantitative HCL ratio

1 h visual 3 h visual score 1 h HCL ratio score 3 h HCL ratio Agreement agreement agreement agreement

16/34 27/34 16/34 23/34 47% 79% 47% 68%

Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

Author Index

A Courter, SA; 303-07, 304-07, 308-06 Hayden, C; 301-02 Abdel Bary, A; 303-06 Cuocolo, A; 305-02, 306-05 Hayes, SW; 309-07 Abdulla, KH; 303-04, 303-05 Helfrich, C; 302-02 Acampa, W; 305-02, 306-05 D Hickey, G; 306-02 Adriana, D; 306-05 D’Antonio, A; 305-02 Higuchi, S; 305-01 Aggarwal, NT; 306-03 Das, S; 307-04 Hoilund-Carlsen, P; 307-01, 309-01, 309-02, Ahmad, S; 309-04 Davies, L; 307-04 309-03 Ahmed, WMK; 303-06 Del Corro, B; 302-03 Holly, TA; 308-07 Akar, FG; 104-06 Dhingra, J; 309-06 Horinouchi, H; 305-01 Alavi, A; 307-01, 309-01, 309-02, 309-03 Dietz, J; 306-02 HORUS Research Team; 304-02 Alessia, G; 306-05 Diliberto, A; 303-03 Huang, Y; 104-06 Allam, AH; 304-02 Donald, J; 303-03 Hwa, J; 104-06 Alves, FBP; 302-08 Doppalapudi, H; 304-01 Hwang, D; 303-01 Ambekar, S; 307-04 Doran, JA; 303-04, 303-05 Hyanl, K; 306-02 Ananthasubramaniam, K; 308-03 Doukky, R; 304-08, 306-03 Hyun, MC; 309-07 Angoulvant, D; 302-04, 303-02, 305-03 Doyle, M; 308-05 Arif, A; 304-08 Dubroff, J; 104-05 I Armstrong, IS; 301-02 Du-Fay-De-Lavallaz, JM; 306-03 Ibrahim, J; 309-04 Arumugam, P; 301-02, 305-02, 306-05 Duvall, WL; 303-04, 303-05 Imhaneni, S; 304-06 Asif, T; 308-02 Imoto, A; 305-01 Assante, R; 305-02, 306-05 E Indaram, M; 308-05 Avendano, R; 306-06 Eisele, YS; 104-04, 308-01, 309-04 Iskander, FH; 304-08 Elhamdani, A; 308-05 Iskander, MH; 304-08 B Elison, B; 304-05 Iskandrian, AE; 304-01, 306-04 Badlani, J; 305-05 El Yaagoubi, Y; 305-04, 305-06 Ives, CW; 304-01 Bailly, M; 302-04, 303-02, 305-03, 305-04 Erriest, J; 302-03 Barakat, A; 308-01 Escobedo Mercado, D; 302-07 J Bashir, Z; 104-04 Jain, S; 308-01 Bateman, TM; 303-07, 304-07, 308-06 F Jayadeva, P; 304-05 Beller, GA; 304-04 Farag, A; 306-04 Jones, KA; 301-01 Berman, DS; 301-04, 301-05, 308-04, 309-07 Feldkamp, MJ; 303-03 Joshua, K; 309-05 Better, N; 304-05 Fine, N; 308-04 Julien, H; 302-05 Beyth, RJ; 302-02 Folks, R; 303-01 Bhambhvani, P; 306-04 Follansbee, W; 104-04, 308-01 K Bhatt, K; 309-06 Fowles, K; 104-06 Kannan, R; 307-06 Bhattacharyya, S; 307-04 Friedman, J D; 309-07 Kansal, P; 308-07 Bhattaru, A; 309-01, 309-02, 309-03 Froede, S; 302-08 Kapinos, M; 104-06 Biederman, R; 307-05 Fugar, S; 302-06 Karambelkar, P; 309-01, 309-02, 309-03 Boccia, D; 302-08 Fukuda, T; 305-01 Kashyap, K; 308-05 Bom, HH; 303-01 Fushiki, H; 307-03 Kassar, K; 307-05 Borja, AJ; 307-01 Kavanagh, P; 301-04, 301-05 Bote, J; 303-04, 303-05 G Keebler, M; 306-02 Bourque, JM; 301-03, 304-04 Gallegos, C; 104-07 Kennedy, KF; 304-07 Brana, Q; 303-02 Garcia, EV; 303-01, 306-01 Khalif, A; 305-05 Bravo, P E; 104-05, 302-05 Gardin, J; 309-05 Khan, M; 304-08 Bremner, DJ; 306-01 Gaudieri, V; 305-02, 306-05 Kiso, K; 305-01 Brown, M; 309-06 Ghumman, SS; 304-04 Klapholz, M; 309-05 Brownell, A; 308-01, 309-04 Goldberg, L; 104-05 Koo, B-K; 303-01 Bruni, W; 306-06 Gomez, JM; 302-06, 306-03 Kothekar, E; 307-01 Bukhari, S; 104-04, 306-02, 308-01, 309-04 Gomez Leiva, V; 302-07 Kukreja, G; 104-06 Buongiorno, P; 305-02 Gona, K; 104-06 Kumar, V; 304-01 Gonuguntla, K; 309-01, 309-02, 309-03 C Goodfield, NER; 301-01 L Cadet, S; 308-04 Guerraty, M; 302-05 Lassen, M; 301-04 Camilletti, J; 302-03 Gupta, A; 308-02 Lee, J; 303-01 Carson, RE; 104-06 Gutierrez, L; 302-03 Lee, L; 304-03 Case, JA; 303-07, 304-07, 308-06 Ligon, C; 104-05 Cerci, R; 304-05 H Lim, P; 309-05 Chan, D; 308-04 Haber, M; 303-01 Liu, C; 104-02, 104-03, 306-06 Chen, X; 104-03 Hage, FG; 304-01, 306-04 Liu, H; 104-02 Cho, S-G; 303-01 Hakimi, M; 304-02 Liu, Y-H; 104-07 Clay, T; 307-04 Halkar, R; 309-06 Liu, Y; 309-05 Cooke, CD; 303-01 Hall, L; 309-06 Lopes, RW; 302-08, 306-07 Cooke, D; 309-06 Hamilton, DJ; 301-01 Lotti, J; 302-03 Courtehoux, M; 302-04, 303-02, 305-03 Hanson, CA; 304-04 Lu, E; 304-04

Journal of Nuclear CardiologyÒ Journal of Nuclear CardiologyÒ Abstracts

M R Terakawa, Y; 305-01 Mah, D; 308-04 Raggi, P; 306-01 Tester, A; 308-08 Mahmood, UA; 303-03 Raina, A; 307-05 Thangamuthu, BY; 304-06 Malecki, M; 302-06 Rana, N; 302-06 Thangavel, S; 305-05 Malhotra, S; 104-04, 308-02 Ray, S; 301-01 Thibault, F; 302-04, 303-02, 305-03 Mandour Ali, MA; 304-02 Raynor, W; 307-01 Thomas, GS; 304-02 Mannarino, T; 305-02, 306-05 Raza, A; 309-05 Thompson, K; 308-08 Martin, W; 301-01 Reda, A; 304-02 Thompson, RC; 304-02 Martinez, CM; 302-07 Redolatti, M; 302-03 Thomson, L; 309-07 Masri, A; 309-04 Revheim, M-E; 307-01 Thorn, S; 306-06 Mastrocola, LE; 302-08, 306-07 Ribeiro, M; 302-04, 303-02, 305-03 Thosani, A; 307-05 McGhie, A; 304-07 Rizk, DV; 304-01 Toczek, J; 104-06 Mehta, K; 309-05 Robinson, J; 301-01 Trejo-Paredes, C; 104-07 Mele, A; 302-03 Rojulpote, C; 104-05, 302-05, 309-01, 309-02, Tsatkin, V; 306-06 Memmott, MJ; 301-02 309-03 Menezes, L; 307-04 Romero Acun˜a, A; 302-03 U Metrard, G; 302-04, 303-02, 305-03 Rosamond, T; 303-03 Uppal, R; 307-04 Miller, EJ; 104-02, 104-03, 104-07, 306-06 Rossman, M; 104-05 Miller, R; 301-04, 301-05, 308-04 Rowan, CJ; 304-02 V Moloney, E; 303-07, 308-06 Vaccarino, V; 306-01 Moncayo, V; 309-06 S Van Harn, M; 308-03 Moshy, R; 308-08 Saba, S; 308-01 Vidula, M; 104-05, 302-05 Murakami, Y; 307-03 Sadat, B; 308-03 Vita, N A; 302-03 Muthukrishnan, I; 304-06 Sadeghi, M; 104-02, 104-06 Vitola, J; 304-05 Muzahir, S; 309-06 Sadek, A; 304-02 Volgman, AS; 306-03 Sadek, T; 308-08 Vuthaluru, K; 309-01, 309-02, 309-03 N Saito, Y; 104-07 Nair, G; 306-03 Salam, U; 104-05, 302-05 W Nappi, C; 305-02, 306-05 Salcedo, H; 309-05 Waller, AH; 309-05 Nellayappan, M; 307-05 Saleem, M; 308-03 Wang, R; 104-03 Nieves, R; 104-04, 306-02, 308-01 Sanghani, RM; 302-06, 306-03 Ward, R; 304-03 Nishii, T; 305-01 Santana, JC; 304-01 Wehbe, R; 308-07 Nye, JA; 303-01 Sarma, M; 307-06 Werner, J; 307-01, 309-01, 309-02, 309-03 Schofield, RS; 308-08 White, W; 302-06 O Schorr, R; 307-05 Wiener, P; 302-05 Ota, Y; 305-01 Schwartz, C; 302-01 Williams, KA; 302-06, 306-03 Otaki, Y; 301-04, 301-05, 309-07 Schwartz, R; 303-04, 303-05 Winchester, DE; 302-01, 302-02 Selvaraj, S; 104-05, 302-05 Woldman, S; 307-04 P Shah, AJ; 306-01 Wong, K; 307-04 Pacella, S; 307-02 Shanmugasundaram, P; 307-06 Wong, ND; 304-02 Patel, AR; 304-03 Shaw, LJ; 302-02 Wu, J; 104-02 Patel, FS; 304-07 Shi, L; 104-03, 306-06 Patel, KK; 304-07 Shpilsky, D; 104-04 Y Patel, TR; 301-03 Simon, S; 304-06 Yahia, AE; 304-02 Paterson, CA; 301-01 Singh, A; 301-05 Yao, J; 304-05 Patil, S; 309-01, 309-02, 309-03 Singh, V; 308-02 Yap, W; 303-03 Patterson, K; 104-05 Sinusas, A; 104-03, 306-06 Ye, Y; 104-06 Pavithran, P; 307-06 Slomka, P; 301-04, 301-05, 308-04 Young, B D; 104-02 Philippe, L; 305-04, 305-06 Small, SAD; 301-01 Yousefi, H; 306-06 Piccinelli, M; 303-01, 306-01 Smith, PA; 306-04 Pinto, IMF; 306-07 Soman, P; 104-04, 306-02, 308-01, 309-04 Z Ponce, S; 302-03 Somasundaram, V; 307-06 Zampella, E; 305-02, 306-05 Poornima, I; 307-05, 308-05 Soufer, A; 306-06 Zhang, J; 104-06 Popeck, M; 307-05 Spatz, E; 104-07 Zhang, V; 307-01, 309-02, 309-03 Posada, E; 104-07 Sperry, BW; 308-06 Zheng, M-Q; 104-06 Pournazari, P; 308-04 Spertus, J A; 304-07 Zhou, B; 104-03 Press, B; 303-03 Srinivasan, V; 305-05 Primus, C P; 307-04 Sriwattanakomen, R; 306-02 Prunier-Aesch, C; 305-04, 305-06 Stowers, S; 304-05 Puente, A; 302-07 Suero-Abreu, G; 309-05

Q T Quaggin-Smith, JA; 308-07 Tamarappoo, BK; 309-07 Quyyumi, A; 306-01 Tateishi, E; 305-01

Journal of Nuclear CardiologyÒ Abstracts Journal of Nuclear CardiologyÒ

Keyword Index

Adenosine receptor agonists; 303-02 Fatty acid; 307-03 Outcomes; 104-05, 304-02, 304-03, 304-04, 306-04, 306-05, 307-04 Angina; 302-03, 305-05 Fluorodeoxyglucose; 104-02, 304-06 PET; 104-05, 104-06, 301-02, 302-05, 302-06, Appropriateness criteria; 302-01, 302-02 Hybrid imaging; 306-05, 307-02 303-01, 305-01, 306-01, 307-01, 307-02, 307- 04, 307-05, 307-06, 309-01, 309-02, 309-03 Arrhythmias; 308-01 Image processing; 301-01, 301-04, 303-07, 306-06 PET perfusion agents; 303-07 Atherosclerosis; 307-01, 309-01, 309-02, 309- 03 Ischemia; 301-03, 304-02, 304-07 Pharmacokinetics; 303-01

Calcium scoring; 304-05, 305-03, 306-07 Left ventricle; 309-05 Quality; 302-06, 302-08, 303-05, 308-03

Cardiac MRI; 307-05, 307-06 LV hypertrophy; 104-04, 308-08 Quantification; 104-02, 308-04, 308-06, 309- 06, 309-07 Cardiomyopathy; 104-04, 104-06, 308-01, Metabolism; 307-03 308-03, 308-04, 308-05, 308-07, 308-08, 309- Radionuclide angiography; 301-01 04, 309-06 Myocardial infarction; 303-06, 304-01 Right ventricle; 308-05 Computer processing; 308-06 Myocardial perfusion; 104-03, 104-07, 301- 02, 301-04, 301-05, 302-01, 302-03, 302-04, Risk assessment; 301-05, 302-07, 304-04, 304- Congestive heart failure; 308-02 302-05, 302-07, 302-08, 303-03, 304-03, 304- 08, 305-02 05, 304-07, 304-08, 305-06, 306-02, 306-03, Coronary flow reserve; 104-07, 303-03, 305- 306-07 SPECT techniques; 104-03, 302-04, 303-02, 01, 305-02, 305-04, 305-05, 305-06, 306-01, 303-05, 303-06, 305-03, 305-04, 306-04, 306- 306-02, 306-03 Myocardial viability; 304-06 06, 308-07

Vasodilators; 303-04 Exercise/exercise testing; 301-03 Other; 302-02, 303-04, 304-01, 308-02, 309- 04, 309-05, 309-07

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Journal of Nuclear CardiologyÒ