Nuclear Cardiology: Role in The World of Multimodality Cardiac Imaging

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Rev Esp Cardiol. 2015;68(6):460–464

Editorial

Nuclear Cardiology: Role in the World of Multimodality Cardiac


Imaging
Cardiologı́a nuclear: papel en el mundo de la imagen cardiaca multimodal
José F. Rodrı́guez-Palomaresa,* and Santiago Aguadé-Bruixb
a
Servei de Cardiologia, Hospital Vall d’Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
b
Servei de Medicina Nuclear, Hospital Vall d’Hebron, Barcelona, Spain

Article history:
Available online 2 May 2015

The concept of multimodality imaging has been developing patients with ischemic heart disease. These myocardial perfusion
rapidly in recent years due to the need to integrate information on images represent the integration of the regional myocardial blood
anatomy (which defines coronary artery disease) with functional flow and the metabolic activity of the cardiac muscle cells
data (which reflects the effects of this disease on tissues) to enable (molecular image). The use of a tomographic technique in
the proper evaluation of patients with ischemic heart disease. the acquisition of these images facilitates the 3-dimensional
From the clinical point of view, it has been well established that presentation of both the stress and rest images, simplifying
a complete evaluation of a coronary lesion requires not only their comparison. A number of studies have demonstrated their
morphological information on the location of the stenosis, but also relevance in the assessment of patients with ischemic heart
functional information on its impact. Van Werkhoven et al1 have disease, due to both their diagnostic value and their prognostic
demonstrated that the combination of anatomical and functional value during follow-up. In this respect, the event rate recorded
information can improve patient risk stratification. Thus, patients during follow-up in patients with good functional capacity and
with  50% coronary occlusion associated with perfusion defects absence of myocardial perfusion defects is low.2
experienced a higher annual event rate during follow-up (9%) than Noninvasive computed tomography (CT) coronary angiography
patients with no significant coronary lesions or perfusion defects has been introduced more recently. However, as a result of the
(1%). progressive technical advances made in scanners in recent years,
While the severity of ischemia is related to the degree of this modality has gained widespread clinical acceptance.3 The
stenosis, this relationship is not always linear. A number of factors latest generation of scanners have improved spatial and temporal
apart from the degree of occlusion (assessed by coronary resolution and have reduced the radiation dose. Thus, through a
luminography) establish whether or not a given stenosis induces noninvasive approach, these scanners allow accurate and neces-
a myocardial perfusion defect. Among these factors, we stress sary anatomical information to be obtained and combined with the
the importance of the existence of collateral circulation and the findings of other imaging modalities (multimodality imaging).
phenomenon of arterial vasospasm, a functional mechanism that However, the presence of coronary calcification still constitutes a
can overlap a mild fixed lesion, leading to significant occlusion. In limitation to the luminographic assessment of CT studies, as the
addition, a nonsignificant arteriosclerotic plaque can become partial volume artifact produced by coronary calcification can
destabilized and produce serious or even total arterial occlusion. result in an overestimation of the severity of the lesion. In these
Moreover, the phenomenon of ‘‘ischemic preconditioning’’ could equivocal cases, the availability of functional information increases
play a role in the discrepancy between anatomical and functional diagnostic accuracy and improves the sensitivity and specificity of
changes. Given all these circumstances, evaluation of the the examination.
functional relevance of the coronary stenosis is recommended to In 2002, Cerqueira et al4 standardized the division of the left
guide revascularization strategies. If, in addition, this dual ventricular myocardium into 17 segments and, moreover,
information can be obtained using noninvasive methods and established a correlation with coronary anatomy. However,
can be presented jointly (by means of image fusion), the result more recent studies have demonstrated that these designations
facilitates optimal clinical decision-making, while also reducing vary, depending on the dominance of the arteries in a given
the risk inherent in invasive diagnostic techniques. patient.5 For example, segments 3, 9, and 15 can be assigned to
Since the 1990s, stress and rest myocardial perfusion scintig- the right coronary artery or to the anterior descending coronary
raphy has been developed as an excellent noninvasive method to artery; segments 4, 5, 10, and 11 to the right coronary artery or
obtain the functional information required for the assessment of to the circumflex artery; and segment 12 to the anterior
descending coronary artery or to the circumflex artery. This
view of the segmentation of myocardial perfusion creates
* Corresponding author: Servei de Cardiologı́a, Hospital Universitari Vall
uncertainty about the identity of the culprit vessel in the
d’Hebron, Pg. Vall d’Hebron 119–129, 08035 Barcelona, Spain.
E-mail addresses: jfrodriguezpalomares@gmail.com; absence of individualized anatomical information provided by
jfrodrig@vhebron.net (J.F. Rodrı́guez-Palomares). CT or coronary angiography.

http://dx.doi.org/10.1016/j.rec.2015.03.001
1885-5857/ß 2015 Sociedad Española de Cardiologı́a. Published by Elsevier España, S.L.U. All rights reserved.
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J.F. Rodrı´guez-Palomares, S. Aguadé-Bruix / Rev Esp Cardiol. 2015;68(6):460–464 461

Thus, there is interindividual variability in the sites of practice, as the processing required with the initial systems was
myocardial ischemia and of coronary stenosis. In this respect, extremely time-consuming.6
fusion of 3D images based on software able to merge perfusion The first clinical reports involving multimodality fusion with
information from single-photon emission computed tomography nuclear cardiology images date back to the beginning of the year
(SPECT) with anatomical information provided by CT offers 2000,7,8 with the integration of scintigraphic images of myocardial
diagnostic information that improves on simple identification of perfusion and conventional invasive biplane coronary angiographic
the culprit lesion. This information increases confidence in the images, acquired at Emory University (Atlanta, Georgia, United
diagnosis and contributes to a better classification of intermediate States). This multimodality approximation prior to the use of CT
lesions and equivocal perfusion defects (Figure 1). was not further developed because of the complexity of the
The current technological progress also joins forces with efforts digitization of biplane coronary angiographic studies.
to aid the direct performance of multimodality imaging through In Europe, the group at University Hospital Zurich, in
the design of hybrid scanners that integrate 2 technologies in a Switzerland,6 pioneered the use of studies involving the fusion
single unit. In nuclear cardiology, the new hybrid systems for of myocardial perfusion SPECT and coronary CT, producing a large
SPECT/CT, positron emission tomography (PET)/CT, and PET/ number of publications and review articles. According to
magnetic resonance (MR) have sufficient imaging quality and Gaemperli et al,9 in addition to being intuitively convincing,
sufficiently powerful software to enable the integration of this SPECT/CT fusion images provide added value in the form of
information in multimodality hybrid images obtained with the diagnostic information on the functional relevance of coronary
same scanner. However, because of the high cost of these systems artery stenoses. For this reason, those authors recommend
(both their purchase and maintenance), their use is restricted to a multimodal image fusion in clinical practice.
small number of centers. Moreover, the still limited experience in The use of fusion images improves sensitivity (17% increase)
the interpretation and clinical value of these hybrid images and, particularly, the specificity of the diagnosis of significant10
relegates their use mainly to research, and consequently that this coronary artery disease compared with analysis of myocardial
information is not a determining factor in clinical decision-making. perfusion alone, or even with evaluation of perfusion and coronary
Another important technological advance is the commercial CT separately, leading to a change in the initial interpretation in
availability of different programs for the fusion of images from 28% of cases. Moreover, in patients with multivessel disease and a
different complementary studies. The speed and automation with heavy coronary calcium burden (in which analysis of the
which they function have facilitated their application in daily anatomical lesion is complicated), image fusion improves

Stress perfusion, %
73

89
61 75
89
84 95

80 77 84

70 79
66
50 61
50

38

Figure 1. Polar map from stress myocardial perfusion scintigraphy (left), 3D reconstruction of the coronary computed tomography scan with high calcium burden
in the 3 vessels (right), and anterior and posterior single-photon emission computed tomography/computed tomography fusion images that permit the correct
evaluation of the culprit vessel (right coronary artery, center).
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462 J.F. Rodrı´guez-Palomares, S. Aguadé-Bruix / Rev Esp Cardiol. 2015;68(6):460–464

the interpretation of coronary CT and also allows identification myocardium at risk (Figure 2), also leads us to be critical of the
of the causative lesion11 (Figure 1). In a recent study, Schaap et al12 indiscriminate use of the different cardiac imaging techniques. In
evaluated the value of hybrid SPECT/CT images, comparing them this respect, in patients with stable ischemic heart disease
with analysis based on SPECT or CT alone, in 205 patients with who have undergone myocardial perfusion SPECT as a first
significant coronary artery disease (diagnosed on the basis of the noninvasive study and with a clear indication for the performance
presence of  50% coronary occlusion according to invasive of invasive coronary angiography based on the results of SPECT,
coronary angiography or because the fractional flow reserve was the performance of a CT scan and the acquisition of SPECT/CT
less than 0.80). These authors concluded that the yield of SPECT/CT fusion images do not appear to be indicated, as the results would
fusion images was superior to analysis using SPECT or CT alone in not change the approach adopted for therapeutic management.
the diagnostic study of patients with suspected significant There is still little experience in the multimodality fusion
coronary artery disease. imaging of myocardial perfusion and cardiac MR, especially
Fusion images have been shown to be valuable not only in the because of the limited availability of hybrid PET/MR scanners
diagnosis of coronary artery disease, but also to have prognostic and the nonexistence of SPECT/MR systems. From the cardio-
implications. In 324 patients followed-up for a median of 2.8 years, vascular point of view, PET/MR could be an excellent tool for the
Pazhenkottil et al13 demonstrated that a matched defect on a assessment of myocardial viability (glucose metabolism with
hybrid image is a strong predictor of major adverse cardiovascular fluorodeoxyglucose [18F-FDG PET] and late gadolinium enhance-
events (MACE) during follow-up. ment in MR) and for the combined study of areas of fibrosis and
Given the scientific evidence accumulated in recent years, the inflammatory activity, as in the case of myocarditis or
use of multimodality fusion images of myocardial perfusion and sarcoidosis. In the latter, the differentiation between the acute
coronary CT is now defined in the guidelines of the European phase and chronic phase of sarcoidosis is highly useful in
Association of Nuclear Medicine14 (EANM) and the guidelines of guiding patient treatment and in influencing the prognosis of
the Society of Nuclear Medicine and Molecular Imaging/American the disease (as cardiac involvement is the major marker
Society of Nuclear Cardiology/Society of Cardiovascular Computed of adverse events during patient follow-up). Another applica-
Tomography15 (SNMMI/ASNC/SCCT) in the United States. Both tion of PET/MR image fusion would be the study of cardiac
guidelines recommend the use of hybrid images in patients at masses. Cardiac MR imaging, together with CT, is currently
intermediate risk for coronary artery disease, since the diagnostic one of the gold standards for the noninvasive differential
and prognostic information they provide is superior to that offered diagnosis and local staging of cardiac tumors. An additional
by myocardial perfusion SPECT or coronary CT alone. perspective on tumor metabolism could probably aid in the
However, the cumulative experience in our center, where we evaluation of the grade of malignancy and in the detection of
use image fusion to evaluate the culprit artery and the extent of occult tumor sites.

Stress Rest

Figure 2. Fusion of single-photon emission computed tomography/coronary computed tomography images in the evaluation of myocardium at risk, extent of the
perfusion defect, and myocardial viability (courtesy of E.V. Garcı́a, Emory University). Upper images: left anterior oblique views. Lower images: left posterior
oblique views. Left: stress study. Right: rest study. Black area overlying the image, blackout region that exceeds the normal reference ranges for myocardial
perfusion in these segments.
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J.F. Rodrı´guez-Palomares, S. Aguadé-Bruix / Rev Esp Cardiol. 2015;68(6):460–464 463

Figure 3. Positron emission tomography with fluorodeoxyglucose (18F-FDG PET) and cardiac computed tomography in the evaluation of prosthetic endocarditis.
A: 18F-FDG PET slices, PET/CT fusion, and cardiac CT at the level of the aortic valve prosthesis, showing intense focal glucose hypermetabolism in the periannular
region. B: 18F-FDG PET slices, PET/CT fusion, and cardiac CT at the supravalvular level, where the existing vegetations and the larger periannular area of 18F-FDG
uptake can be observed.

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