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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3723_Библиотеки_им_академика_М_И_Перельмана
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24 Cardiovascular FDG-PET Atlas ofCases
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Case 3
Initial Evaluation
A 66-year-old woman, known for type 2 diabetes
and AF, underwent cardiac transplantation
7 years prior for hypertrophic cardiomyopathy.
She presented with worsening dyspnea over the
course of several months. Transplant rejection
was suspected. CT pulmonary angiography
(CTPA) was remarkable for a right atrial lling
defect measuring 24×18×29mm. Transthoracic
echocardiogram (TTE) showed a normal left ventricle with a systolic ejection fraction of 60%.
However, a mobile, lobulated mass measuring
25×22mm was reported alongside the anterior
wall of the dilated right atrium. The differential
diagnosis included a thrombus, myxoma, or
metastasis (Fig.24.4).
a b
Follow-Up
The patient underwent surgery for mass resection. Histopathologic analysis conrmed the
diagnosis of myxoma. Follow-up TTE showed no
residual mass.
Teaching Point
Right atrial location of cardiac masses increases
the likelihood of malignancy [12]. In this case,
however, the associated low intensity uptake seen
on FDG-PET accurately predicted a benign
lesion. There is a broad differential for cardiac
masses, from pseudotumors (e.g., thrombus, vegetation, abscess, aneurysm) to neoplasms [4, 13].
Most cardiac lesions are benign, while primary
malignant tumors of the heart are mainly sarco-
d
Fig. 24.4 PET Interpretation. Whole-body FDG-PET/
CT (a) was performed following a myocardial suppression protocol consisting of a low-carbohydrate diet, 12h
fasting, and intravenous heparin in order to further characterize the right atrial mass. Myocardial suppression was
excellent. A low intensity (SUV
neous focus of uptake was visualized within the right
atrium (b, transaxial plane) (c, coronal plane). The corre-
c
= 3.5) and homoge-
max
e
sponding right atrium lling defect seen on CTPA and
mass visualized on TTE are shown in images (d) and (e),
respectively. No pericardial or pleural effusions were
seen. Diffuse low grade uptake at the site of the previous
sternotomy was seen, without evidence of infection. A
diagnosis of myxoma was favored. No extracardiac hypermetabolic lesions were seen on whole-body FDG-PET
images
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Y. A. Lucinian et al.
matous [4, 13, 14]. Although echocardiography is
frequently employed, magnetic resonance imaging (MRI) is usually considered the gold standard
for the characterization of cardiac masses [12,
13, 15]. FDG-PET’s role in the diagnostic work
up of cardiac masses continues to develop.
However, many studies suggest its potential usefulness and high diagnostic accuracy for distinguishing malignant from benign lesions [16].
Case 4
Initial Evaluation
An 89-year-old woman, known for type 2 diabetes, hypertension and end stage chronic kidney
disease (CKD), presented with acute pleuritic
chest pain and shortness of breath. Review of
systems revealed hematochezia accompanied by
weight loss and night sweats in the preceding
months. Both white blood cell count (WBC) and
C-reactive protein (CRP) levels were elevated.
High-sensitivity cardiac troponin T (hs-cTnT)
levels were slightly elevated at 39ng/L (normal
<14 ng/L), without signicant change on serial
measurements. -dimer levels were highly elevated at 3952ng/mL (normal <250ng/mL). ECG
showed a sinus rhythm with widespread concave
up ST elevation. Ventilation/perfusion lung scan
with
99m
Tc-technegas and
99m
Tc-MAA performed
to exclude pulmonary embolism was normal.
Transthoracic echocardiogram (TTE) showed a
small (2mm thick) anterior pericardial effusion
that was not present on TTE performed a year
prior. A diagnosis of acute pericarditis was
strongly suspected (Fig.24.5).
Follow-Up
Pericardiocentesis was not performed. A diagnosis of idiopathic/viral pericarditis was retained.
The patient underwent a 3 months treatment
course with oral prednisone. Her symptoms
quickly resolved, with follow-up TTE showing
a b
c
Fig. 24.5 PET Interpretation. Whole-body FDG-PET/
CT (a) was performed in order to help determine an etiology for pericardial effusion. The pericardial effusion associated with circumferential, low intensity uptake
(SUV
=2.5), compatible with the diagnosis of pericar-
max
ditis (b, c). No signs suggestive of pericardial malignancy
d
e
were seen. A hypermetabolic lesion (SUV
suring approximately 30×20×20mm at the level of the
rectosigmoid colon was visualized (d, e). No hypermetabolic lymph nodes or lesions suggestive of a metastatic
process were seen
=14.2) mea-
max
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no residual pericardial effusion. Colonoscopy
discovered 2 polyps, a 5mm sessile polyp and a
30mm subpedunculated polyp, both localized in
the rectum.
Teaching Point
Although most pericarditis cases are considered
benign and attributed to viral infection, a nonnegligible proportion have an underlying neoplastic
process (5–23%), especially in the presence of
pericardial effusion [17]. As primary malignant
tumors of the heart are rare, most cases of cancerrelated pericarditis are caused by metastatic or
locally inltrating tumors [17–20]. However,
other mechanisms have been described, including
radiotherapy, chemotherapy, and paraneoplastic
syndrome [17–20]. In this context, FDG-PET/
CT may be clinically helpful in the diagnostic
workup of pericarditis, especially when malignancy is suspected and pericardiocentesis is nondiagnostic or technically difcult to perform [21].
Other potential roles of FDG- PET/CT include
determining the extent of tuberculous pericarditis
and predicting treatment response in constrictive
pericarditis [21, 22].
Case 5
Initial Evaluation
A 55-year-old male, known for type 2 diabetes
mellitus, hypertension, AF, ischemic cardiomyopathy with a LVEF of 25% and a dual chamber
implantable cardioverter- debrillator (ICD), presented with fatigue and fever. Blood cultures
were positive for methicillin- susceptible
Staphylococcus aureus (MSSA). Multiple pulmonary opacities were seen on chest radiograph.
TEE demonstrated thickening of the right atrium
ICD lead with partial mobility, suspicious for
vegetation. An indeterminate lament- like structure attached to the aortic valve was also visualized (Fig.24.6).
a b
c
Fig. 24.6 PET 1 interpretation.Whole-body FDG-PET/
CT (a) was performed following a myocardial suppression
protocol (low-carbohydrate diet, 12h fasting, and intravenous heparin) in order to further characterize TEE ndings.
Of note, the patient had undergone 4 days of antibiotic
treatment. Myocardial suppression was adequate. Focal
increased uptake (SUV
=3.7) was visualized on the ICD
max
d
e
lead (b, c, white arrows) at the cavoatrial junction. Uptake
was also present on non–attenuation-correction images (not
shown). Increased uptake within bilateral lung consolidations was seen (b, c, d, yellow arrows). No abnormal uptake
was seen within the generator pocket (d, gray arrow) and
valvular areas. An incidental focus of uptake (SUV
was noted within the prostate (e, red arrow)
max
=6.0)
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Y. A. Lucinian et al.
Follow-Up
A diagnosis of ICD lead infection with septic
pulmonary emboli (PE) was made on the basis of
the PET ndings. The aortic valve ndings on
initial TEE were considered possibly degenerative due to the lack of FDG uptake, although
absence of uptake does not exclude endocarditis
of native valve. The ICD was removed.
Microbiological analysis of the lead samples was
positive for MSSA (Fig.24.7).
Teaching Point
On the initial PET, FDG-PET/CT accurately
identied ICD lead infection with septic PE.The
a b
absence of abnormal uptake within the tricuspid
valve area is reassuring, but FDG-PET has suboptimal sensitivity for the detection of ICD-IE
[23]. Cardiac implantable electronic device
(CIED) infection can arise at any level, from the
generator pocket to the intracardiac leads.
Echocardiographic evaluation of CIED lead
infection (LI) can be challenging due to considerable artifacts. The accuracy of the Modied
Duke’s Criteria has also been shown to be reduced
in this context [24, 25]. FDG-PET/CT can be
especially useful when CIED-LI is clinically suspected in the presence of indeterminate diagnostic ndings [26, 27]. Moreover, extracardiac
ndings such as septic emboli can provide crucial
information for diagnosis and optimal management [28, 29].
d
c
Fig. 24.7 PET 2 interpretation. A second whole-body
FDG- PET/CT (a) was performed 14 days following the
initial evaluation. The quality of myocardial suppression
was slightly suboptimal as there was low-intensity diffuse
uptake within the left ventricular walls (b, white arrows).
Again, no abnormal uptake was seen at the levels of the
e
valves (c). A PICC line had been placed in the interval (d,
gray arrow). The previously visualized lung consolidations had partly resolved. The hypermetabolic focus of
uptake within the prostate had resolved in the interval (e,
red arrow)
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Case 6
Initial Evaluation
A 73-year-old man was known for obstructive
sleep apnea and hypertension. On a routine chest
radiograph, a right apical opacity was noted.
Review of systems was unremarkable other than
nonspecic fatigue. Noncontrast chest CT scan
revealed a possible right apical centimetric nodule within brotic changes (Fig.24.8).
Follow-Up (1)
Large-vessel vasculitis (LVV) was strongly suspected, presumed to be giant-cell arteritis (GCA)
given the patient’s age. Rest ECG was unremarkable. Computed tomography angiography (CTA)
performed from the carotids down to the lower
a b
extremities showed arterial wall thickening at the
levels of the distal ascending aorta, the brachiocephalic trunk, the circumex artery, the abdominal
aorta, and both common iliac arteries, but no stenosis or dilation. In the absence of symptoms, a multidisciplinary team opted for a wait-and-see approach
rather than initiating pharmacologic treatment.
Temporal artery biopsy was not pursued (Fig.24.9).
Follow-Up (2)
As the patient remained asymptomatic, treatment
was not initiated. Five months later, the patient
started experiencing increased fatigue and dyspnea on exertion. During exercise ECG stress
testing, the patient’s dyspnea was elicited alongside inferolateral horizontal ST depressions.
Flare-up of LVV was suspected (Fig.24.10).
d
Fig. 24.8 PET 1 interpretation. Whole-body FDG-PET/
CT (a) was performed for further assessment. Slight
hypermetabolism was seen within the lung nodule and
brotic changes in the right lung apex (b, white arrow,
SUV
=3.5). Multiple vascular abnormalities were visu-
max
alized. Intense uptake was seen at the origin of the bra-
c
chiocephalic trunk and the distal ascending aorta (c,
yellow arrow, SUV
artery (d, gray arrow, SUV
aorta (e, red arrow, SUV
right common iliac artery (e, orange arrow, SUV
e
= 9.2), the circumex coronary
max
= 6.3) and the abdominal
max
=12.9) with extension to the
max
max
=6.8)
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a b
c
Fig. 24.9 PET 2 interpretation.Whole-body FDG-PET/
CT (a) following a myocardial suppression protocol was
performed 10months later. Myocardial suppression was
excellent. No signicant change was seen within the right
lung apex. Uptake within the origin of the brachiocephalic
trunk and the distal ascending aorta (b, white arrow,
SUV
= 4.9), the circumex coronary artery (c, gray
max
d
e
arrow, SUV
arrow, SUV
Uptake within the right common iliac artery was stable (d,
orange arrow, SUV
the level of the abdominal aorta is seen (e, red arrow,
6.7 mm) without signicant progression compared to
CTA performed 4months prior (6.4mm)
= 2.5) and the abdominal aorta (d, gray
max
=7.2) showed partial interval regression.
max
=6.4). Arterial wall thickening at
max
a b
c
Fig. 24.10 PET 3 interpretation. Whole-body FDGPET/CT (a) following a myocardial suppression protocol
was performed. Myocardial suppression was excellent.
Uptake within the origin of the brachiocephalic trunk (b,
white arrow) and the distal ascending aorta (c, yellow
arrows) was slightly decreased from prior (SUV
=3.9).
max
d
e
Uptake at the level of the circumex coronary artery was
stable (d, gray arrow, SUV
the abdominal aorta (e, red arrow, SUV
right common iliac artery (e, orange arrow, SUV
was also partially regressed. Uptake in the iliac arteries
corresponded to residual blood pool activity
=2.4). Uptake at the level of
max
=6.2) and the
max
max
=4.8)
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Follow-Up (3)
Coronary CT angiography (CCTA) was remarkable for proximal circumex artery mural thickening alongside atherosclerotic plaque luminal
narrowing of 70%. Coronary angiogram showed
luminal narrowing of 70% at the level of the second left marginal artery which was successfully
stented. Minimal/nonobstructive coronary artery
disease (CAD) was seen within the right coronary artery (RCA) and the left anterior descending coronary artery (LAD).
Teaching Point
The two major categories of LVV are GCA and
Takayasu arteritis (TAK) [30]. Although large
vessel involvement is grossly similar in both entities, coronary arteries are more frequently
affected in TAK [31]. Serious complications of
coronary arteritis include stenosis, aneurysm and
thrombosis, but may also manifest as accelerated
atherosclerosis [31–34]. When interpreting LVV
on FDG-PET/CT, a standardized approach using
a 4 point-scale system (comparing vascular
uptake to liver uptake) is recommended [35].
FDG-PET/CT is also useful for treatment monitoring, as uptake is typically decreased within
4–12 weeks following effective treatment
initiation [35]. Of note, faint uptake can persist
for several months despite successful therapy
[35–37]. This case illustrates the unique ability of
FDG-PET/CT to detect LVV in the early phase of
the disease before signicant morphological
changes have occurred. The regression of FDG
uptake between initial and subsequent PETs possibly represents a transition from an acute inammatory phase to a chronic phase in which
morphological changes predominate [35].
Case 7
Initial Evaluation
A 45-year-old male, known for type 2 diabetes
mellitus and active smoking, presented to the
emergency department with new-onset epigastric
pain. ECG demonstrated ST-elevation myocardial infarction (STEMI) in the anterolateral territories. Cardiac catheterization showed a
proximally occluded LAD and a severely diseased RCA while the circumex artery had minimal/nonobstructive CAD. Two drug-eluting
stents (DES) were successfully deployed within
the LAD.Shortly after the procedure, the patient
progressed to cardiogenic shock and required
extracorporeal membrane oxygenation (ECMO)
for the subsequent 4days. TTE showed a severely
reduced LVEF (25%) with apical akinesia
(Fig.24.11).
Follow-Up
Standard heart failure treatment was initiated.
Medical treatment was chosen for the RCA
instead of revascularization. Follow-up TTE performed 6 months later showed slight improvement in LVEF (35%), but severe hypokinesis
within the LAD myocardial territories persisted.
Teaching Point
FDG-PET combined with MPI has been considered the gold standard for determining myocardial viability. Myocardial viability as determined
by FDG-PET predicts improvement in regional
function after revascularization with a pooled
sensitivity of 88–93% and specicity of 58–73%
[38–41]. In this case, the presence of hibernating
myocardium in the RCA territory may suggest a
benet for revascularization of this territory,
especially in the presence of reduced LVEF.On
the other hand, the presence of a resting perfusion defect with preserved FDG uptake in the
LAD territory, despite successful revascularization, could be due to inammation in the recent
post infarct period. It has been reported that PET
performed up to 1week in the post infarct period
can overestimate the potential for recovery [41–
44]. As well, in the days following successful
revascularization, xed perfusion defects may
persist despite preserved viability.
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b
Y. A. Lucinian et al.
Fig. 24.11 PET Interpretation. Dipyridamole stress
rubidium-82 positron emission tomography myocardial
perfusion imaging (82Rb PET-MPI) (a) was performed
alongside an FDG-PET myocardial viability study (b).
Imaging was performed 5days post-infarct. A large and
severe xed perfusion defect was seen in the anterior wall
with extension to anterolateral and septal territories. A
moderate xed perfusion defect was seen in the inferior
wall. The lateral wall was free of perfusion defects. On
Case 8
Initial Evaluation
An 85-year-old man, known for AF, ischemic
cardiomyopathy and ICD implantation for secondary prevention, presented with fever and generalized malaise 5 weeks after undergoing
generator replacement. No obvious signs of generator pocket infection were present. Blood cul-
FDG-PET, signicant FDG uptake was seen within the
majority of the anterior, septal, anterolateral, and inferior
territories. The mismatched perfusion defect with preserved metabolism in the LAD territory could be related
to inammation or stunned myocardium in the setting of
recent STEMI and revascularization. Viability within the
myocardial territory supplied by the chronically diseased
RCA was compatible with hibernating myocardium
tures were positive for MSSA. TEE did not
evidence any signs of lead infection (Fig.24.12).
Follow-Up
On the basis of these ndings, a diagnosis of
CIED generator pocket infection (CIED-GPI)
was made. A procedure to completely remove the
ICD was performed. Microbiological analysis of
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a b
c
Fig. 24.12 PET Interpretation. Whole-body FDG-PET/
CT (a) was performed following a myocardial suppression protocol for further assessment of ICD infection. The
patient had undergone 2days of antibiotic treatment prior
to imaging. Myocardial suppression was adequate. Intense
and heterogeneous uptake was visualized posterior to the
generator pocket (b, yellow arrow, SUV
ing along the lead up to the origin of the superior vena
cava (b, c, white arrows, SUV
=5.1). There was no evi-
max
=7.9), extend-
max
d
e
dence of infection at the level of the intracardiac lead (d,
red arrow). A hypermetabolic pulmonary nodule near the
left hilar region was incidentally found (e, gray arrow,
SUV
=4.5). These ndings are compatible with deep
max
generator pocket infection and lead infection. Lung uptake
could represent a septic embolus in this context but should
be followed on imaging as malignancy cannot be entirely
excluded
generator pocket and lead sample were both positive for MSSA.
Teaching Point
In this case, FDG-PET/CT accurately identied
CIED-GPI with extension into the intravascular
portion of the lead. FDG-PET/CT has the ability
of being able to evaluate the presence of CIED
infection, from the generator pocket up to the
intracardiac leads [45]. The diagnostic accuracy
of FDG-PET/CT in evaluating CIED-GPI is very
high with a sensitivity of 96% and a specicity of
97% [26, 27, 45–47]. It can also detect GPI
before obvious clinical signs such as purulent
discharge are present [45].
Case 9
Initial Evaluation
A 55-year-old woman, known for type 2 diabetes
mellitus and hypertension, presented with dyspnea
and peripheral edema a month after experiencing an
episode of profuse diaphoresis and weakness.
Typical features of recent anterolateral STEMI were
seen on ECG. TTE showed severe left ventricular
dysfunction with a LVEF of 23%. Cardiac catheterization demonstrated chronic total occlusion of the
proximal LAD.Both the RCA and circumex artery
had minimal/nonobstructive epicardial lesions.
Revascularization was not performed and aggressive
medical treatment was initiated instead (Fig.24.13).
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b
Y. A. Lucinian et al.
Fig. 24.13 PET Interpretation. Dipyridamole stress 82Rb
PET-MPI was performed alongside FDG-PET myocardial
viability study (a, b) approximately 2months post-infarct.
An extensive and severe xed perfusion defect was seen in
the anterior, anteroseptal, septal and apical territories (a).
Follow-Up
Despite optimization of medical therapy, the
patient remained severely symptomatic. Six
months later, the patient underwent successful
revascularization following the placement of 3
DES within the LAD.
Teaching Point
In this case, signicant improvement in left ventricular function should be expected during follow- up. Multiple studies have shown that the
extent of perfusion–metabolic mismatch correlates linearly with the improvement of both
LVEF and functional status following revascularization [48–50]. For instance, Di Carli etal.
reported that patients with mismatches totaling
≥18% of myocardium achieved signicantly
On FDG-PET, FDG uptake was preserved within those
territories (mismatched), compatible with the presence of
hibernating myocardium (b). As such, the myocardial territory supplied by the LAD was deemed viable
higher functional status compared to those with
minimal mismatch [48].
Case 10
Initial Evaluation
A 56year-old man, known for hypertension and
chronic obstructive pulmonary disease (COPD),
presented with shortness of breath, chest pain and
syncope. ECG was remarkable for sinus tachycardia, right axis deviation and T-wave inversions
in leads V1, V2 and V3. TTE showed a dilated
right ventricle with signs of pressure overload.
CTPA showed multiple bilateral segmental and
subsegmental pulmonary embolisms (PE)
accompanied by a focal opacity of 11mm within
the right upper lobe (RUL) attributed to probable
alveolar hemorrhage (Fig.24.14).
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