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VIABILITY
ASSESSMENT IN
NUCLEAR AND MRI
I Made Indra
Prasetya
VIABILITY IN
NUCLEAR
NUCLEAR IN MEDICINE
The use of radioisotope or radionuclide for
medical assessment
The radionuclide is injected, uptaken by human
tissue, and scanned with a gamma camera
NUCLEAR CARDIOLOGY
non-invasive nuclear imaging
technique that uses radioactive
imaging agents to image the heart
Among the techniques of nuclear
cardiology, myocardial perfusion
imaging is the most widely used
NUCLEAR CARDIOLOGY
Myocardial perfusion imaging :
1. Identify inadequate blood supply as well as the
areas of scarred myocard
2. In addition to the localization of the coronary
artery with atherosclerosis quantify the
extent of the myocard with a limited blood fl ow
3. provide information about the pumping function
of the heart
MYOCARDIAL STUNNING
Prolonged and fully reversible contractile dysfunction
of the ischemic heart that persists after reperfusion
Responsive to inotropes
Spontaneously resolve within a week
Duration of stunning depends on the duration and
severity of ischemia and the adequacy of arterial fl ow
Mechanism:
(1) a oxygen-free radical hypothesis and
(2) a calciumoverload hypothesis
MYOCARDIAL HIBERNATION
Episodic and/or chronically reduced blood fl ow,
which is directly responsible for the decrease in
the myocardial contractile function
Tissue ischemia and resultant remodeling without
necrosis, which causes prioritization of metabolic
process in the myocardial cell relative to
contractile function
Recovery of contractile function after successful
revascularization
Time to restoration:
Months to one year
Depend on duration and severity of fl ow reduction &
ultrastructural changes
Mechanism:
Myocardial function &metabolism reduced to match a
reduction in blood fl ow (Smart heart hypothesis)
Repetitive stunning hypothesis
SPECT
Single Photon Emission
Computed Tomography
TRACERS
Thallium 201
Technetium 99m
Introduced 1990s
Lipid soluble cationic
comp.
Emits 140 keV
T 6h
First pass 60%
Passive distribution
Minimal redistribution
REST-THALLIUM IMAGING
HIBERNATING MYOCARDIUM
Principal and technique
Rest-redistribution exam presence or absence
myocardial viability
3-4 mCi injection of thallium image acquired at the
time and 3-4hours later
tracer activity
Rest perfusion defect that do not demonstrate
improved on delayed images represent scar
Defects w/ < 50% of peak activity low
likelihood improved LV after revascularization
Note: for fixed defects w/ activity < 50% of
maximal uptake, up to 25% have been shown
to be viable by FDG imaging
TECHNETIUM OF HIBERNATING
MYOCARDIUM AND MYOCARD VIABILITIY
Thallium imaging with reinjection is superior to
Tc-sestamibi imaging in identfying viable
myocardium in patients with chronic CAD
Approximately 35% - 60% of reversible
myocardial regions on thallium reinjection
imaging will appear as fi xed defect on exerciserest images with Tc-sestamibi
Thallium is superior to technetium agents for
the assessments of myocardial viability
TRACER
PRODUCED
Perfusion
Oxygen-15 Cyclotron
Nitrogen-13 Cyclotron
Rubidium-82 Generator
Metabolism
Carbon-11
Cyclotron
Fluorine-18
Cyclotron
HALF-LIFE
COMPOUND
Acetate,
palmitate
Deoxyglucos
110 minutes
e
VIABILITY IN MRI
MRI
MR determination of viability:
Based on visible changes in myocardial wall
thickness
Through the use of delayed contrast enhanced
imaging
Assessing inotropic reserve by low-dose Dob-MRI
MR advantages:
Excellent anatomic resolution that can be achieved
with rapid cardiac imaging sequence
Much higher spatial resolution
allow the detection of even a small areas of
subendocardial infarction that will be missed on
SPECT imaging
Delayed contrast (DE MR) can detect acute MIparticularly inferior infarcts and subendocardial scar
with greater sensitivity than SPECT
MR limitation:
DE MR imaging spesifi c for acute MI and scar (not for
hibernating myocardium or repetitively stunned
myocardium) cannot distinguish hibernating myocardium
from normally perfused myocardium in regions of
nontransmural hyperenhancement
FUNCTIONAL MYOCARDIAL
EVALUATION
For functional MR Imaging: 6-8 short axis
Hypokinetic or akinetic segments demonstrate <
1mm of wall thickening
Segments EDWT < 5,5 mm recovery after
revascularization
Wall thinning can predict functional recovery
following revascularization:
Sensitivity: 55 95%
Specifi city: 41%
WALL THICKNESS
End-Diastolic Wall
Thickness
Systolic Wall
Thickening
Normal Myocardial
> 5,5 mm
> 1,5 mm
Hibernating
Myocardial
> 5,5 mm
< 1,5 mm
Infarcted Myocardial
< 5,5 mm
< 1,5 mm
DE MR
Delayed Enhacement MR (DE MR)
Kim et al. in 1999
use of an inversion-recovery prepared T1-weighted
gradient-echo sequence after the intravenous
administration of a Gadolinium-chelate (Gd)
Delayed hyperenhancement:
regions of increased signal intensity on T-1 weighted
images acquired more than 5 minutes after IV
Gadolinium administration
refl ects irreversibly injured myocardium or
replacement fi brosis
AMI is illustrated in 4-chamber projection (end diastole on the left and end
systole in the middle). There is akinesis of the distal LAD distribution
arrowhead) closely corresponding with the transmural hyperenhacement of
the apex (arrow) and subendocardial hyperenhacement of the
distal interventricular septum.
PROGNOSIS MRI
Transmural extent of hyperenhancement within 1st
week after MI predict late improvement in
contractile function
Lack of delayed enhancement is highly predictive for
functional improvement after surgical
revascularization
Regions with greater transmural enhancement are
less likely to demonstrate improved wall motion
Prognosis MRI:
Segments >75% transmural of delayed hyperenhancement
unlikely to recover function
Segments 51-75% hyperenhancement
only 10% will demonstrate functional recovery
with revascularization
Segments <25%
recover function following revascularization
Direct comparison low dose Dob-echo & low dose Dob-MRI study to assess
viability in septal & lateral wall after MI in the same patient. Both techniques
are capable of visualizing an improvement of wall motion after dobutamine
infusion (see arrows) as a sign of residual viability in the areas of interest.
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