Nuclear Cardiology: Myocardial Perfusion Studies and Ventriculography

Croft Stone Nuclear Medicine

Basics of MPI
Radionuclide injected at rest and/or stress Radionuclide taken up by myocardium and gamma rays emitted Rest images compared with stress images Decreased perfusion stress and rest MI Decreased perfusion at stress, normal with rest ischemia
Area indicates the coronary artery, size correlates with severity of CAD

Basics
Two conditions necessary for blood flow deficit measurement:
1) coronary flow must be elevated to near maximal levels 2) radiotracer whose myocardial extraction is proportional to coronary artery blood flow must be used

Stress
Exercise and pharmacologic agents are used to achieve maximal coronary dilation and flow. Exercise stress gives additional information:
Degree of exercise tolerance Time to maximal heart rate Blood pressure response

Pharmacologic stress
Agents:
Dipyridamole (persantine) Dobutamine Adenosine

Indications for Pharmacologic Stress Imaging

Inability to perform adequate exercise Left bundle branch block Ventricular pacemaker CCBs or Beta blockers Evaluation of patients very early after acute MI (<3 days) or very early after stenting (<2 weeks)

Physics
Radioactive decay
Alpha particles (ionized helium nuclei) Beta particles (high energy electrons or positrons) Gamma rays (photons) Electron capture (x-rays)

Gamma Camera

Camera
Multiple images taken at different rotation angles to obtain 3-D information Lead collimator excludes photons not traveling in direction of holes in the collimator 3-D picture can be reconstructed using a mathematical model Projection system modeled as system of simultaneous linear equations; matrix is then inverted to reveal the source distribution.

Protocols

Radionuclide Properties
Property Chemistry Shelf life Photon energy Uptake Thallous Chloride +1 cation, hydrophilic 6 days 68-80 keV Active: Na-K ATPase pump 85% 4% Redistributes Tc-Sestamibi +1 cation, lipophilic 6 hours 140 keV Passive diffusion (if intact membrane potentials) 66% 1.2% Fixed

Extraction fraction Heart uptake Redistribution

Comparison of 201Tl and 99mTc for Myocardial Perfusion Imaging

Property
Photon energy
201Tl 99mTc

140 keV 69-80 keV Scatter and absorption Less scatter and absorption Low resolution High resolution 73 hours High dosage (20-30 Low dosage (2-3 mCi) mCi) High count densities Low count densities 1.3 rad 1.1 rad

Half life

Effective dose

Availability

Cyclotron-commercial mfr

Generator - local

Tc-99m
Technetium chelated to to a molecule that will be absorbed by the myocardium
Tc-99m-methoxyisobutyl (setamibi) Tc-99m 1,2bis[bis (2ethoxyethyl)phosphinoethane (tetrofosmin)

During stress, metabolism changes polarization of cell membrane, driving agent into cell Also readily absorbed by liver and bowel

Tc-99m preparation

Tc-99m

Quality control
1. Motion -- There is no evidence of patient motion. 2. Alignment --The alignment is very good. 3. Count Increase --The myocardial max counts increases in the stress study as expected. 4. Normalization --Both studies are normalized to the portion within the myocardium with the highest uptake. 5. Extra-Cardiac Activity --There is no significant extra cardiac activity. 6. Soft tissue attenuation minimized 7. Protocol consistency

ECG Gated SPECT imaging (MUGA: multi gated acquisition)

Simultaneous assessment of perfusion and function in a single injection, single acquisition sequence. Tc-99m permits evaluation of regional myocardial wall motion and wall thickening throughout the cardiac cycle Quantitates LV volume and EF

Technique
Stannous pyrophosphate injected Tc-sodium pertechnetate injected Pertechnetate enters RBCs, becomes reduced by the intracellular stannous ion, and is bound to hemoglobin RBCs now tagged with radioisotope: hence blood pool image

Technique
Images of heart are triggered (gated) on the R wave of the ECG 32 or more frames taken per cardiac cycle Many cardiac cycles imaged and stored for statistical significance Total amount of activity stored in frames at each gated time point plotted vs. total time cycle

Technique
Heart rate variations can result in temporal blurring (mixing of counts in adjacent frames). Beat rejection window usually set at 20%

Sources
Cerqueira, Manuel D. Nuclear Cardiology, 1994, pp 93 100, 103-109. Crean, Andrew and Coulden, Richard. Cardiac Imaging using nuclear medicine and positron emission tomography. Radiologic Clinics of North America, 42 (2004) 619-634 Heller,Gary V. and Hendel, Robert C. Nuclear Cardiology: Practical Applications, 2004. pp 1312. Kowalsky, Richard J. and Falen, Steven W. Radiopharmaceuticals in Nuclear Medicine and Nuclear Pharmacy, 2004: pp 515 555.