Cardiovascular Imaging

193 Pages·2009·9.049 MB·English

by  Yi-Hwa Liu, Frans J Th Wackers

CARDIOVASCULAR
IMAGING
Yi-Hwa Liu, PhD
Section of Cardiovascular Medicine
Department of Internal Medicine
Yale University School of Medicine
New Haven, Connecticut, USA
Frans J. Th. Wackers, MD
Section of Cardiovascular Medicine
Department of Internal Medicine
Yale University School of Medicine
New Haven, Connecticut, USA
MANSON
PUBLISHING
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ISBN: 978-1-84076-109-2
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C
ONTENTS
Preface 6 Electron beam tomography 18
Multidetector computed tomography 18
Contributors 7 Cardiac anatomy 19
MDCT imaging artifacts 20
Abbreviations 8 Clinical cardiac computed tomography 23
Pericardial disease 23
Myocardial disease 23
Chapter One Valvular disease 24
An Overview of the Assessment of Coronary artery disease 24
Cardiovascular Disease by Noninvasive Coronary artery calcification 25
Cardiac Imaging Techniques 9 Coronary angiography 26
Frans J. Th. Wackers, Robert L. McNamara, Cardiac venous anatomy 32
and Yi-Hwa Liu Function 34
Introduction 9 Myocardial scar and viability imaging 34
Cardiac imaging parameters 10 Myocardial perfusion imaging 36
Stress testing 10 Incidental findings 38
Physical exercise 10 Conclusions 38
Vasodilator stress 11 Clinical Cases
Adrenergic stress 11 Case 1: Ulcerated atherosclerotic plaque 39
Choice of imaging modality in stress Case 2: Anomalous origin of the RCA 40
testing 11 Case 3: Normal right upper pulmonary
Clinical indications 12 vein and right lower pulmonary vein 41
Pathophysiological vs. Case 4: Focal calcification and
anatomical information 12 thickening of the pericardium 42
Image quantification 12 Case 5: Patent stent in the proximal LAD 43
Reporting 13
Comparative strengths and weaknesses of
various imaging modalities 13 Chapter Three
Nuclear Cardiac Imaging 44
Raymond R. Russell, III, James A. Arrighi,
Chapter Two and Yi-Hwa Liu
Cardiac Computed Tomography Introduction 44
and Angiography 14 Myocardial perfusion imaging 44
Richard T. George, Albert C. Lardo, and An overview of myocardial perfusion
Joao A.C. Lima imaging 44
Introduction 14 Myocardial perfusion radiotracers 46
Technical considerations 14 Image acquisition and processing 48
Temporal resolution 14 SPECT myocardial perfusion imaging:
ECG gating and segmental principles and techniques 50
reconstruction 15 PET perfusion imaging: principles and
Spatial resolution 16 techniques 50
Contrast resolution 17 Diagnostic accuracy of SPECT and PET 50
4
Quantification of SPECT and Chapter Four
PET images 52 Echocardiographic Imaging 80
Attenuation correction for SPECT Robert L. McNamara, Farid Jadbabaie, and
and PET 52 Kathleen Stergiopoulos
Prognostic value of SPECT perfusion Introduction 80
imaging 54 Physics and image generation 81
Prognostic value of PET perfusion Physics 81
imaging 55 Image generation 82
Assessment of myocardial viability 55 Standard transthoracic
Assessment of left ventricular function 56 echocardiographic views 83
FPRNA approach 56 M-mode and two-dimensional
ERNA approach 57 echocardiography in evaluation of
GSPECT approach 58 cardiac diseases 85
GBPS approach 58 Chamber sizes 85
Clinical Cases Left ventricular systolic function 87
Case 1: SPECT with normal stress/rest Right ventricle 89
perfusion 59 Valves 91
Case 2: Normal SPECT with stress Aorta 95
perfusion 60 Pericardium 96
Case 3: SPECT showing ischemia 61 Spectral Doppler 97
Case 4: High-risk SPECT study 62 Flow rates 97
Case 5: SPECT showing scar 63 Pressure gradients 98
Case 6: SPECT showing scar mixed with Diastolic function 100
ischemia 64 Doppler tissue imaging 101
Case 7: SPECT complicated by attenuation 65 Color Doppler 102
Case 8: SPECT complicated by motion 67 Transesophageal echocardiography 105
Case 9: SPECT complicated by Procedure protocol and risks 106
subdiaphragmatic radioactivity 68 Tomographic views 106
Case 10: SPECT with extracardiac findings 70 Clinical applications 109
Case 11: PET showing ischemia 71 Intracardiac echocardiography 111
Case 12: PET with normal perfusion 72 Stress echocardiography 112
Case 13: PET showing a scar 74 Contrast echocardiography 113
Case 14: PET showing viable myocardium 75 Overview 113
Case 15: ERNA with normal left ventricular Detection of shunts 113
function 76 Cavity opacification and improved
Case 16: ERNA with depressed left border detection 113
ventricular function 77 Myocardial perfusion contrast
Case 17: Gated SPECT with normal echocardiography 115
perfusion and normal left ventricular Three-dimensional echocardiography 115
function 78 Clinical Cases
Case 18: Gated SPECT with scar, Case 1: Aortic valve endocarditis 117
depressed left ventricular function 79 Case 2: Pericardial effusion 118
Case 3: Aortic stenosis 119
5
Chapter Five Chapter Six
Cardiovascular Magnetic Resonance Future Prospects of Cardiovascular
Imaging 120 Imaging 157
André Schmidt and Joao A.C. Lima Albert J. Sinusas
Introduction 120 Introduction 157
MRI principles 120 Molecular imaging 157
MRI scanner 121 Historical perspective 158
MRI safety 121 Newer applications 158
Clinical applications 121 Imaging technology 159
Anatomical evaluation 122 Image quantification 161
Assessment of global ventricular Specific cardiovascular applications of
function 122 molecular imaging 161
Assessment of ventricular mass 123 Imaging of angiogenesis 161
Assessment of regional ventricular Imaging of atherosclerosis and
function 124 vascular injury 166
Evaluation of ischemic heart disease 125 Imaging of postinfarction remodeling 168
Assessment of myocardial viability 129 Imaging of apoptosis 170
Evaluation of valvular heart disease 131 Multidisciplinary cardiovascular imaging
Evaluation of cardiomyopathies 133 programs 170
Evaluation of pericardial disease 139 Summary 171
Evaluation of aortic disease 141
Evaluation of thrombi and masses 143 References 172
Evaluation of congenital heart disease 146
Emerging applications of cardiovascular Index 189
MRI 149
Atherosclerosis imaging 149
Interventional cardiovascular MRI 150
Evaluation of coronary arteries 151
Clinical Cases
Case 1: Mass in the apex of the left
ventricle 152
Case 2: Large anterior myocardial
infarction 153
Case 3: Microvascular obstruction 154
Case 4: Dilated cardiomyopathy 155
Case 5: Hypertrophic obstructive
cardiomyopathy 156
6 P
REFACE
The purpose of this book is to provide up-to-date technical and practical information about
various cardiac imaging techniques for the assessment of cardiac function and perfusion, as well as
their potential relative roles in clinical imaging. This book also aims to stimulate use of the new
developments of integrated cardiovascular imaging and molecular targeted imaging. It will be the
charge of future investigators and clinicians to define the appropriate role(s) for each of the
imaging modalities discussed in this book. As distinct from other textbooks, this book provides
numerous illustrations of clinical cases for each imaging modality to guide the reader in the
diagnosis of cardiovascular diseases and the management of patients based on the imaging
modality used. We hope that this book will help the reader to understand the values and
limitations of the imaging techniques and to determine which test, in which patient population,
and for which purpose would be the most appropriate to use.
Yi-Hwa Liu
Frans J. Th. Wackers
C 7
ONTRIBUTORS
James A. Arrighi, MD Robert L. McNamara, MD, MHS
Division of Cardiology Section of Cardiovascular Medicine
Department of Medicine Department of Internal Medicine
Brown Medical School Yale University School of Medicine
Providence, Rhode Island, USA New Haven, Connecticut, USA
Richard T. George, MD Raymond R. Russell, III, MD, PhD
Division of Cardiology Section of Cardiovascular Medicine
Department of Medicine Department of Internal Medicine
The Johns Hopkins University School of Yale University School of Medicine
Medicine New Haven, Connecticut, USA
Baltimore, Maryland, USA
André Schmidt, MD
Farid Jadbabaie, MD Division of Cardiology
Section of Cardiovascular Medicine Department of Internal Medicine
Department of Internal Medicine Medical School of Ribeirão Preto
Yale University School of Medicine University of São Paulo
New Haven, Connecticut, USA Ribeirão Preto,
São Paulo, Brazil
Albert C. Lardo, PhD
Department of Medicine, Division of Cardiology Albert J. Sinusas, MD
and Department of Biomedical Engineering Section of Cardiovascular Medicine
The Johns Hopkins University School of Department of Internal Medicine
Medicine Yale University School of Medicine
Baltimore, Maryland, USA New Haven, Connecticut, USA
Joao A.C. Lima, MD Kathleen Stergiopoulos, MD, PhD
Departments of Medicine and Radiology Division of Cardiovascular Medicine
The Johns Hopkins University School of State University of New York at Stony Brook
Medicine Stony Brook, New York, USA
Baltimore, Maryland, USA
Frans J. Th. Wackers, MD
Yi-Hwa Liu, PhD Section of Cardiovascular Medicine
Section of Cardiovascular Medicine Department of Internal Medicine
Department of Internal Medicine Yale University School of Medicine
Yale University School of Medicine New Haven, Connecticut, USA
New Haven, Connecticut, USA
8 A
BBREVIATIONS
A late diastolic velocity IVCT isovolemic contraction time
a
ACC American College of Cardiology IVRT isovolemic relaxation time
AHA American Heart Association IVUS intravenous ultrasound
ARVD arrhythmogenic right ventricular dysplasia LAD left anterior descending artery
ASD atrial septal defect LCX left circumflex artery
ASNC American Society of Nuclear Cardiology LDL low-density lipoprotein
ATP adenosine triphosphate LVEF left ventricular ejection fraction
ATPase adenosine triphosphatase LVOT left ventricular outflow tract
AVA aortic valve area MDCT multidetector computed tomography
A-wave late wave METs metabolic equivalents
bFGF basic fibroblast growth factor MMP matrix metalloproteinase
BMI body mass index MO microvascular obstruction
BP blood pressure MPI myocardial performance index
bpm beats per minute MR magnetic resonance
CAC coronary artery calcium MRI magnetic resonance imaging
CAD coronary artery disease MV mitral valve
ceMRI contrast-enhanced MRI PDA patent ductus arteriosus
CEU contrast-enhanced ultrasound PET positron emission tomography
CMRI cardiac magnetic resonance imaging PFR peak filling rate
CoAo coarctation of the aorta PISA proximal isovelocity surface area
CT computed tomography PMT photomultiplier tube
CW continuous wave PRF pulse repetition frequency
DCM dilated cardiomyopathy PS phosphatidyl serine
DT deceleration time PW pulse wave
DTPA diethylene triamine pentaacetic acid QCA quantitative coronary angiography
D-wave diastolic wave Qp/Qs ratio of pulmonary flow to systemic flow
E early diastolic velocity RCA right coronary artery
a
EBT electron beam tomography RF radiofrequency
ECG electrocardiogram RV right ventricle
ECM extracellular matrix RVe regurgitant volume
EDV end-diastolic volume SPECT single photon emission computed
EF ejection fraction tomography
ERNA equilibrium radionuclide angiography SV stroke volume
ERO effective regurgitant orifice S-wave systolic wave
ESV end-systolic volume T Tesla
ET ejection time TDI tissue Doppler imaging
E-wave early wave TEE transesophageal echocardiography
FDA Food and Drug Administration (US) TEMRI transesophageal MRI
FDG [18F]-2-fluoro-2-deoxyglucose TGA transposition of the great arteries
FGF-2 fibroblast growth factor-2 TGF transforming growth factor
FPRNA first-pass radionuclide angiography TID transient ischemic dilation
GBPS gated blood pool SPECT TIMP tissue inhibitor of matrix
GSPECT gated myocardial perfusion SPECT metalloproteinases
HARP harmonic phase MRI tPA tissue plasminogen activator
HCM hypertrophic cardiomyopathy TRV transient visualization of the right ventricle
HDL high-density lipoprotein TTC triphenyltetrazolium chloride
HIV human immunodeficiency virus TTE transthoracic echocardiography
HU Hounsfield units TVI time velocity integral
Hz Hertz VEGF vascular endothelial growth factor
ICD implantable cardiac defibrillator VSD ventricular septal defect
ICE intracardiac echocardiography VTI velocity time integral
9
1. A O A
N VERVIEW OF THE SSESSMENT
C D
OF ARDIOVASCULAR ISEASE BY
N C I
ONINVASIVE ARDIAC MAGING
T
ECHNIQUES
Frans J. Th. Wackers Robert L. McNamara Yi-Hwa Liu
INTRODUCTION The development of each imaging technique in
Noninvasive cardiac imaging has become an integral isolation resulted in different clinical subcultures, each
part of the current practice of clinical cardiology. with its separate clinical and scientific meetings and
Chamber size, ventricular function, valvular function, medical literature. Such a narrow focus and
coronary anatomy, and myocardial perfusion are concentration on one technology may be beneficial
among a wide array of cardiac characteristics that can during the development stage of a technique.
all be assessed noninvasively. Noninvasive imaging can However, once basic practical principles have been
evaluate many signs and symptoms of cardiovascular worked out and clinical applications are established,
disease as well as follow patients with known such isolation contains the danger of duplication of
cardiovascular conditions over time. pursuits and of scientific staleness when limits of
During the past three decades several distinctly technology are reached.
different noninvasive imaging techniques of the heart, Each of the aforementioned techniques provides
such as radionuclide cardiac imaging, echo - different pathophysiologic and/or anatomic
cardiography, magnetic resonance imaging (MRI), information. Coming out of the individual modality
and X-ray computed tomography (CT), have been isolation by cross-fertilization is the next logical step
developed. Remarkable progress has been made by to evolve to a higher and more sophisticated level of
each of these technologies in terms of technical cardiac imaging. Patients would benefit tremendously
advances, clinical procedures, and clinical applications if each technique were to be used judiciously and
and indications. Each technique was propelled by a discriminately. Clinicians should be provided with
devoted group of talented and dedicated investigators those imaging data that are most helpful to manage
who explored the potential value of each technique specific clinical scenarios.
for making clinical diagnoses and for defining clinical It can be anticipated that in the future a new type
characteristics of heart disease that might be most of cardiac imaging specialist will emerge. Rather than
useful in the management of patients. Thus far, most one-dimensional subspecialists, such as nuclear
of these clinical investigations using various cardiologists or echocardiographers, multimodality
noninvasive cardiac imaging techniques were imaging specialists, who have in-depth knowledge and
conducted largely in isolation from each other, often experience of all available noninvasive cardiac imaging
pursuing similar clinical goals. There is now an techniques, will be trained. These cardiac imaging
embarrassment of richness of available imaging specialists will fully understand the value and
techniques and of the real potential of redundant limitations of each technique and will be able to apply
imaging data. However, as each noninvasive cardiac each of them discriminately and optimally to the
imaging technique has matured, it has become clear benefit of cardiac patients. Recently a detailed
that they are not necessarily competitive but rather proposal for such an Advanced Cardiovascular
complementary, each offering unique information Training Track was proposed (Beller 2006).
under unique clinical conditions.