CT or PET/CT for coronary artery disease · Dual gated 1188F--FDG PET/CT of coronary arteries in ACS patientsDG PET/CT of coronary arteries in ACS patientsF • 20 ACS (non-STEMI

Juhani Knuuti, MD, PhD, FESC

Turku PET Centre

CT or PET/CT for coronary artery disease

Rotterdam 2012

University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre

Turku PET Centre

University of Turku

Turku, Finland

[email protected]

Disclosure: Juhani Knuuti, M.D.

Juhani Knuuti, M.D. has financial interests to disclose. Potential conflicts of interest have been resolved.

Research Support / Grants None

University of Turku • Åbo Akademi University • Turku University HospitalTurku PET Centre 2

Research Support / Grants NoneStock/Equity (any amount) NoneConsulting LantheusEmployment NoneSpeakers Bureau / Honoraria Philips

Research contracts (institutional): Orion Pharma, Turku Imanet Ltd, GE Healthcare, GSK, Merck, Bayer-Schering, Novartis, Lundbeck, Roche; Lantheus

Imaging and CADCurrent main trends

� From ischemic cascade to CAD cascade� From diagnosis of CAD to guidance of


� From diagnosis of CAD to guidance of therapy

� Novel imaging applications• Quantification• Imaging of vulnerable plaque

hypoperfusion

diastolic dysfunction

Myo

card

ial p

erfu

sion

Myo

card

ial p

erfu

sion metabolic alterations

Paradigm shift 1: From ischemic to CAD cascade

Preclinical atherosclerosis

Non-obstructive CAD


diastolic dysfunction

systolic dysfunction

ECG-Changes

angina

Signs of ischaemiaSigns of ischaemia

Myo

card

ial p

erfu

sion

Myo

card

ial p

erfu

sion

Multislice CT vs. Myocardial Perfusion Multislice CT vs. Myocardial Perfusion Regional comparison in 140 patients

Data from Schuijf et al. 2006, Di Carli et al. 2006, Hacker et al. 2005, and Rispler et al. 2006

MDCT findings in patients with normal SPECT perfusion imaging result


Werkhoven JM, et al Am J Cardiol. 2008 Jan 1;101(1):40-5.

CT angiography

LAD LCXRCA

Curved MPR reconstructions of the major coronary vessels

Case LP

>50%

>50%

30-40%

CT Acquisition:

• Premedication: Metoprolol 10 mg i.v. HR 46/min

• Acquisition: Prospective step-and-shoot protocol, mA 650, 120 kV

• Contrast: Iomeron 400mg/ml 68 ml

• Radiation dose 7.4 mSV

Case:LP

PET perfusion imaging during stress Displayed as fused volume rendered images scaled to absolute scale 0-3.5 ml/g/minNormal perfusion: above 2.5 ml/g/min: yellow or red

3.5 ml/g/min

Case:LP

PET Acquisition:

• Injected Dose: 1100 MBq O-15-water

• Stress: Adenosine 140 µg/min/kg for 6.5 min

• Acquisition time: dynamic 4.5 min


0.0 ml/g/min

Invasive angiography + FFR

FFR: 0.86 (normal)

FFR: 0.92 (normal)

Right Left

Case LP

48%

46%

60%

FFR: ?

FFR = Fractional flow reserve – invasive measurement of the stenosis functional gradient

during adenosine infusion

Case:LP

Prognostic Value of Myocardial Perfusion SPECT

7,4

6

8

10

P < 0.001

n = 12 000 pts

0,6

0

2

4

6

Iskander S et al. JACC 1998;32:57

normal abnormal

Additional prognostic value of CT and perfusion imaging

Van Verkhoven et al J Am Coll Cardiol 2009;53: 623–32

N=541






Paradigm shift 2: From diagnosis to guidance of therapy

Anatomy

(Obstructive CAD)

Flow-Limiting

(Perfusion, FFR)

Optimal Medical Treatment


Optimal Medical Treatment

Complete Functional Revascularization and optimal medical treatment

DEFER JACC 2007;49:2105FAME NEJM 2009;360:213FAME JACC 2010;56:177

Hachamovitch Circulation 2003;107:2900 COURAGE NEJM 2007;356:1503COURAGE Circulation 2008;117:1283

Noninvasive function: Perfusion, WMA Invasive function: FFR

Functional consequences of stenoses

LAD

D1

Turku PET Centre, Finland

D1

LAD

D1

Invasive Anatomy vs. Functional Consequences

deri

ved

FF

R

0.6

0.8

1.0

Angiographic Diameter Stenosis (%)

Pre

ssu

re-d

eri

ved

FF

R

0 20 40 60 80 100

0.0

0.2

0.4

N = 2334

Wijns, de Bruyne, Vanhoenacker, JNC 2007;93:856-61

Tonino et al. FAME

CT angiography

LAD LCXRCA

Curved MPR reconstructions of the major coronary vessels

Case LP

>50%

>50%

30-40%

CT Acquisition:

• Premedication: Metoprolol 10 mg i.v. HR 46/min

• Acquisition: Prospective step-and-shoot protocol, mA 650, 120 kV

• Contrast: Iomeron 400mg/ml 68 ml


Case:LP

PET perfusion imaging during stress Displayed as fused volume rendered images scaled to absolute scale 0-3.5 ml/g/minNormal perfusion: above 2.5 ml/g/min: yellow or red

3.5 ml/g/min

Case:LP

PET Acquisition:

• Injected Dose: 1100 MBq O-15-water

• Stress: Adenosine 140 µg/min/kg for 6.5 min

• Acquisition time: dynamic 4.5 min


0.0 ml/g/min

LAD RCA C E

Multivessel disease: What is the culprit lesion?

FFR=0.54

FFR=0.94


D1

3.5

ml/g/min0

D F

FFR=0.63

Multivessel disease: What is the culprit lesion?

RCA LCX LAD

Case: stenoses in all major vessels; RCA is culprit


Microvascular diseaseAbsolute perfusion decreased but no epicardial disease

Relative perfusion Absolute perfusion


Hybrid noninvasive (PET/CT) vs. Hybrid invasive (ICA + FFR)

Sensitivity (%)Specificity (%)PPV (%) NPV (%) Accuracy (%)MDCT 75 95 76 94 91PET 94 93 77 98 93MDCT-PET hybrid 95 99 96 99 98

Figure 3: Vessel Analysis against ICA +FFR

50

60

70

80

90

100

pe

rce

nta

ge

MDCT

PET

Vessel analysis in patients with intermediate likelihood of CAD, N=107


Kajander et al Circulation 2010

0

10

20

30

40

50

pe

rce

nta

ge

PET

MDCT-PET hybrid

MDCT 76 94 91

PET 77 98 93

MDCT-PET hybrid 96 99 98

PPV (%) NPV (%) Accuracy (%)

Challenges and solutions of perfusion imaging

Challenge Solution� LM disease ?� Balanced 3 vessel disease ?


� Multivessel disease ?� Anatomical location ?� Non-ischemic CAD ?� Microvascular disease ?

Challenges and solutions of ischemia imaging

Challenge Solution� LM disease Hybrid

� Balanced 3 vessel disease


� Multivessel disease� Anatomical location Hybrid

� Non-ischemic CAD Hybrid

� Microvascular disease /Hybrid

Impact of hybrid imaging on downstream resource utilizationImpact of hybrid imaging on downstream resource utilization

Revascu

lari

sati

on

s

86%100%

80%

60%

p<0.001

45%

96%


Revascu

lari

sati

on

s

CAD yieldPer CATH

CATHrate

40%

20%

0%

REVASCPer CATH

45%

NEJM 2010

USA

N=400‘000

39%

GER

N=840‘000

36%

Eur Heart J 2011 Jul 30.






Challenges and solutions of CAD/ishchemia imaging

Challenge Solution� LM disease Hybrid� Balanced 3 vessel disease Quantification


� Multivessel disease Quantification

� Anatomical location Hybrid� Non-ischemic CAD Hybrid� Microvascular disease Quantification/

Hybrid

Quantification of myocardial perfusion

Which patients will benefit?� Balanced 3 vessel or multivessel

disease


disease� Culprit lesion vs. non-culprit lesion in

multi vessel disease� Early changes in coronary dysfunction

Absolute flow vs Relative flow


Kajander et al Circ Cardiovasc Imaging. 2011

Absolute flow is as good as flow reserve!

University of Turku • Åbo Akademi University • Turku University Hospital

Joutsiniemi et al (Circ Imaging)






�

Motoyama J Am Coll Cardiol 2009

MDCT Characterization of Coronary Plaques

Motoyama J Am Coll Cardiol 2009

LAD

Left main

LAD

LCX

Plaque characterization using CT vs. Myocardial Perfusion SPECT

Van Verkhoven et al J Am Coll Cardiol 2009;53: 623–32 N=541

MDCT Characterization of Coronary Plaques -

Prognosis

Large low attenuation plaque areaPositive remodelingSpotty calcification

Motoyama J Am Coll Cardiol 200915 ACS in 1059 patients

Dual gated 18F-FDG PET/CT of coronary arteries in

ACS patients

CTA CTA-PET Fusion

Acute LAD plaque rupture

Myocardial FDG uptake supressed by low carbohydrate, high fat diet

Turku PET Centre, FinlandLankinen at al ICNC 2011

Dual gated Dual gated 1818FF--FDG PET/CT of coronary arteries in ACS patientsFDG PET/CT of coronary arteries in ACS patients

• 39 year old man

• Risk factors of CAD:

• Smoking

• Family history +

• 5 days of UAP

• ECG: lateral T-inversion• ECG: lateral T-inversion

• TNT +

• LCX subtotal occlusion stented

TBR ratio 4.2

Turku PET Centre, FinlandLankinen EHJ 2011 (abstract)


Dual gated Dual gated 1818FF--FDG PET/CT of coronary arteries in ACS patientsFDG PET/CT of coronary arteries in ACS patients

• 20 ACS (non-STEMI or UAP) patients

• Dual-gated 18F FDG PET/CT (3d after onset of symptoms)

• High-fat diet intervention to suppress myocardial uptake (Williams AJR 2008)

• Visual coronary FDG uptake in 80% of patients (3 prior to intervention)

• TBR 3.2±1.3 (range 1.8-5.4)


Lankinen EHJ 2011 (abstract)


• Complicated for patients (sequential)• Logistic challenges (hybrid)• Higher work load

Concerns on sequential / hybrid Concerns on sequential / hybrid imaging for CAD imaging for CAD

• Higher work load• Non-standardized image analysis• Radiation burden• Lacking evidence and indications• Costs and cost-effectivenes

Comparison of risks for fatal event

1000

140119200

400

600

800

1000T

he r

isk p

er

10 0

00

140119

16 9 2 0,5 15 1 1 12 5 6 1 230

200

Risk o

f fata

l car

diac e

vent

(10-

year

s)

Aspirin

, life

time

risk o

f fat

al ble

eding

Mot

or ve

hicle

accid

ent

Pedes

trian

acc

ident

Drownin

gBicy

cling

Calcium

scor

e

CT an

giogr

aphy

Dobut

amine

stre

ss e

choc

ardio

grap

hy (C

E)

Dobut

amine

stre

ss C

MR

Adeno

sine

cont

rast

enha

nced

CM

R

Exerc

ise S

PECT perfu

sion

imag

ing

Dipyrid

amole

SPECT pe

rfusio

n im

aging

Adeno

sine

PET per

fusio

n im

aging

Inva

sive

angio

grap

hySince upper limit of lifetime risk of any imaging test was 23 per 10 000only 2.3% of the events need to be prevented to completely cancel the risk of imaging.

Documents

CT or PET/CT for coronary artery disease · Dual gated 1188F--FDG PET/CT of coronary arteries in ACS patientsDG PET/CT of coronary arteries in ACS patientsF • 20 ACS (non-STEMI