henry bom, md, phd, fanmb prof., cnu med sch, s. korea ... · henry bom, md, phd, fanmb . prof.,...
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Henry Bom, MD, PhD, FANMB
Prof., CNU Med Sch, S. Korea President, AOFNMB
IPET 2015.10.09.
Disclosure
No conflict of interest
Issues for Cardiac Multimodality Imaging
• PETCT: Plaque imaging
• PETMRI: Cardiac sarcoidosis
• Flow reserve
Higher the FDG uptake Earlier the CVD event
Arterial FDG uptake on cancer surveillance
improves incident prediction of cardiovascular disease
FDG PET imaging of atherosclerosis is a reliable and reproducible measure of
vascular inflammation, which can be used as a
surrogate end point in clinical drug trials.
Tarkin JM et al. Nat Rev Cardiol 2014
Features of high-risk atherosclerotic plaques
High macrophage density Neovascularization PET
Features of high-risk atherosclerotic plaques
Thin fibrous cap Low collagen content Few smooth muscle cells Large, lipid-rich necrotic core Expansive (outward) remodeling ‘Spotty’ (micro)calcification Intra-plaque hemorrhage
IVUS OCT
Features of high-risk atherosclerotic plaques
Thin fibrous cap Low collagen content Few smooth muscle cells Large, lipid-rich necrotic core Expansive (outward) remodeling Intra-plaque hemorrhage ‘Spotty’ (micro)calcification
IVUS OCT
CT
In pts without confirmed CAD next step according to the likelihood of stable CAD • 61~90% invasive CAG • 30~60% MPI • 10~29% CT calcium
No calcium No further test
Can we use AC-CT for coronary calcium?
Comparison of ACS by AC-CT according to SPECT results
n=225, p = 0.049
121.2 ± 319.3
319.3 ± 681.5
Pts: MI 40, stable angina 40 F-18 NaF & F-18 FDG PET
Invasive CAG
Acute STEMI
18F-NaF 18F-FDG tissue-to-background ratios: culprit 2·27 versus reference segment 1·09
culprit 1.63 versus reference segment 1·91
Invasive CAG Acute STEMI
Culprit & Non-culprit
lesions
tissue-to-background ratios: culprit 2·03 versus reference segment 1·08
culprit 1.62 versus reference segment 1·49
18F-NaF 18F-FDG
CAG Non-obstructive
RCA lesion
18F-NaF IVUS tissue-to-background ratio
3.13
18F-NaF Carotid endarterectomy
Summary 1
• FDG & NaF PET/CT are useful plaque imaging tools. • We can add valuable information of plaques to oncology reports
Ga-67 scan
Immunosuppressive Therapy Response
Responder Nonresponder
Clinically ~5% of patients with sarcoidosis show cardiac symptoms. Baughman et al. Am J Respir Crit Care Med 2001 Autopsy 13~25% involve heart in the United States Silverman et al. Circulation 1978 Autopsy 58~85% involved heart in Japan Iwai et al. Sarcoidosis 1994
Asymptomatic Fatal Conduction Abnormality
Presentation of Cardiac Sarcoidosis
HRS expert consensus: Diagnosis and Management Arrhythmia associated with Cardiac Sarcoidosis
Biopsy proven extra-cardiac sarcoidosis
Cardiac history, ECG, Echocardiography
1. Symptom positive (palpitation, syncope) 2. Abnormal ECG 3. Abnormal Echocardiogram
One or more of 1~3
Advanced cardiac imaging: MRI or PET
None of 1~3
Low probability of CS
Heart Rhythm 2014; 11:1305-23
Fasting 6 hr Fasting + Heparin 12 hr 50 IU/kg
IV unfractionated heparin activates lipoprotein and hepatic lipases, thereby increasing plasma free fatty acid levels, and ultimately causing a reduction in glucose consumption of normal myocytes. (iv 15 min before FDG)
PET/MRI in Cardiac Sarcoidosis
Eur Heart J 2014
Ammonia FDG
FDG
PET/MRI in Cardiac Sarcoidosis
Eur Heart J 2014
Treatment was started using corticosteroids and a medical heart failure regime. However, MRI after 4 months revealed still impaired LV-function of 27% (Panel G). This finding and the
presence of a complete left bundle branch block provided the indication for cardiac
resynchronization therapy (CRT-D) (Panel I).
Serial assessment of edema and LGE by MRI as well the inflammatory status using FDG PET may be helpful for therapy-monitoring and guidance of primary preventive device therapy.
Summary 2
1. FDG PET/CT is accurate for diagnosis of sarcoidosis especially for the diagnosis of extra-pulmonary involvement.
2. Cardiac involvement of sarcoidosis is sometimes life-threatening. It can be diagnosed by heparin loading protocol of FDG PET/CT or MRI. Target for biopsy or for ICD application can be decided by it.
3. Immunosuppressive therapy effect can be monitored.
Fractional Flow Reserve (FFR)
Definition: the pressure behind (distal to) a stenosis relative to the pressure before the stenosis
Pijls, NH et al, Measurement of Fractional Flow Reserve to Assess
the Functional Severity of Coronary-artery Stenosis.
New Engl J Med 1996;334:1703
Optimal medical therapy PCI / revascularization
1.0 0.80 0.75 0
Fractional Flow Reserve (FFR)
CFR
FFR
N=69 r = 0.566
Correlation analysis
CFR
FFR
No plaques Non-obstructive plaques Obstructive plaques
FFRPET
CFR
Discordant lesions
P = 0.023
FFR
CFR
Focal lesions show lower FFR Diffuse lesions show lower CFR
diffuse
focal
Summary 3
1. CFR is an indicator for diffuse (microvascular) disease.
2. FFR is an indicator for focal disease, therefore better indicator for coronary intervention.
Issues for Cardiac Multimodality Imaging
• PETCT: Plaque imaging
• PETMRI: Cardiac sarcoidosis
• Flow reserve