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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5946_Библиотеки_им_академика_М_И_Перельмана
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174
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M. L. De Rimini and G. Borrelli
Fig. 9.6 (a) 82Rb PET MPI stressor dipyridamole:
Transient perfusion defect on antero-apical myocardial
segments. (b) Extensive calcied plaque on LDA. (c)
Clinical Case No. 4: Obstructive CAD
Male, 63 years old.
Cardiovascular risk factor: History of hyper-
lipidemia and hypertension.
For about 3 months, the patient complains of
feeling of easy tiredness and chest pain symptoms during sleep.
Basal EKG: Normal. Stress EKG: BEV, also
organized in run at the acme of stress.
Patient underwent:
82
Rb PET/CT basal/dipyridamole, fast protocol:
35min for both phases; basal conditions and
stressor dipyridamole (0.56 mg/kg/4′) in
dynamic list-mode acquisition.
Report: Extensive transient ischemia evocated
during dipyridamole infusion (Fig.
LV perfusion summed scores and contractile
function indexes are reported, respectively, in
Table Clinical Case A and Table Clinical Case B.
9.7a).
CACS = >400, consistent with ischemia with high risk of
future coronary events
Table Clinical Case A semiquantitative analysis
AutoQuant-QPS-(PFQ)
Scores Dipyridamole Rest
Summed scores SSS 16 SDS
14
SS% 18 SD%
15
Perfusion defect extension 15% LV 2%
LV
TPD 12% 3%
Transient ischemic dilation value (abnormal TID >1.13
(0.98 + 2.5 SD) = 1.1
Table Clinical Case B semiquantitative analysis
AutoQuant QGS
LV contractile function Dipyridamole Rest
EF 52% 57%
EDV 138 mL 127
mL
ESV 69 mL 66
mL
Patient underwent ICA, with evidence of RCx occlusion,
treated with stenting (Fig.
n.v. LVEF >46%; EDV <126 mL; ESV <68 mL
9.7b)
9 PET Myocardial Perfusion Imaging: 82Rb
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a
175
b
Fig. 9.7 (a) 82Rb PET/TC MPI: Short axis slices dipyridamole slices and polar map: dipyridamole (up); basal (down).
(b) RCx at ICA, red arrows show, respectively, stenosis (on the left) and post-stenting revascularization (on the right)
Clinical Case No. 5: LV
Pseudoaneurysm
At CT and PET/CT fusion imaging analysis,
clear evidence of pseudoaneurysm at the apex,
with a wide and unknown component of calcic
Male, 54 years old.
Diabetes type 2 for almost 3 years, smoker,
dystrophy in the area of previous necrosis
9.8c).
(Fig.
abdominal obesity, hypertension.
Known history of chronic CAD with transmu-
ral anterior and apex AMI, LDA stenting.
At the time of study, hospital admission for
syncopal episode. Baseline Echo: LV
dysfunction.
82
Rb PET/TC MPI: Dipyridamole/rest was
scheduled in the aim to evaluate LV perfusion for
transient ischemia and/or viability (Fig.9.8a, b),
in order to planning new target revascularization.
Table Clinical Case A semiquantitative analysis
AutoQuant-QPS-(PFQ)—Cedars Sinai LA
Scores Dipyridamole Rest
Summed scores SSS 24 SD 4
SS% 25 SD%
5
Perfusion defect extension 27% LV 24%
LV
TPD 21% 19%
Transient ischemic dilation value was also obtained: 1.28
(abnormal TID >1.13 (0.98 + 2.5 SD)
n.v. LVEF >46%; EDV <126 mL; ESV <68 mL
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M. L. De Rimini and G. Borrelli
a
b
Fig. 9.8
Semiquantitative analysis results are reported in Table
Clinical Case A. (b)
ole/rest. LV surface. (c) LV transaxial images show the
(a) 82Rb PET/TC MPI: dipyridamole/rest.
82
Rb gated PET/TC MPI: dipyridam-
perfect morphologic overlapping of calcic dystrophy
with the transmural perfusion defect. (d) ICA: LDA
obstruction
9 PET Myocardial Perfusion Imaging: 82Rb
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c
177
d
Fig. 9.8 (continued)
Image analysis shows: dysfunctionally LV
with volumetric overload, associated with extensive chronic CAD.
It is suggestive of:
• Transmural necrosis involving the apex and
anterior-septal wall.
• Inferior-septal: chronically hypoperfused but
viable myocardium.
• Mild transient ischemia at basal segment of
anterior-septal wall and at basal-septum.
• Mild additional impairment of LVEF related
to stressor test.
• Note: It must be underlined the efcacy of
multimodality technique and the capability of
82Rb PET for assessing LVEF in real time
with stressor test, as a prognostic factor of
main relevance.
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82
Rb PET/TC MPI addressed the patient to
surgery.
• Clinical impact: 82Rb PET/CT MPI modied
the therapeutic strategy of the patient.
Before surgery patients underwent cardiac
MRI and ICA.Images at comparison are shown
in Fig.9.8c.
Clinical Case No. 6: 82Rb PET/CT
inMonitoring theEcacy
ofMedical Therapy versus
Progression Disease
M. L. De Rimini and G. Borrelli
15% of LV, thus doubling the previous extent,
in the same region of the inferior wall, involving more extensively the LDA territory.
Patient underwent stenting revascularization
on LDA and RCA.
Clinical impact: Capability of 82Rb PET/CT in
monitoring the efcacy of therapy and in suggesting a shift of treatment when progression disease occurred.
Clinical Case No. 7: Ischemic,
Dysfunctional CMD Associated
withBalanced Ischemia
Male patient, 62 years old. Multiple risk factor
for CAD.Atypical chest pain.
A. (1 control) Rest/dipyridamole 82Rb PET/CT
(Fig. 9.9a): Transient ischemia involving the
7% of LV, pertinent to the apical-medium segments of inferior wall; limited hypoperfusion
in anterior wall. Severe calcium score on
LDA.Patient underwent medical therapy, but
one year later, he referred angina stress induced.
B. (2 control). A new 82Rb PET/CT showed pro-
gression of CAD (Fig. 9.9b), involving the
Fig. 9.9 (a) 82Rb PET/
CT: The three-standard
level of slices and polar
map at comparison. (b)
At the 2 control, clear
evidence of progression
of disease extension
with the prevalence of
territories of LDA
pertinence. Severe
calcic atheromasia on
LDA is also evident
ab ab
Male, 54 years old. Diabetes type 2 for almost
3 years, smoker, abdominal obesity,
hypertension.
Known history of chronic CAD: Acute coronary syndrome in anterior wall and apex; LDA
stenting (at that time the patient rejected CABG
recommended by the clinicians).
New hospital admission because of stressinduced shortness of breath (Fig.9.10a).
• 3D transthoracic echocardiography: LV ejec-
tion fraction (LVEF 40%). Akinesia at apex,
a
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179
anterior wall; septum. Conclusion: dysfunctional CMD.
– LDA: Obstructive stenosis distal segment;
stenosis 1 diagonal artery 75%.
– RCX: 65% Stenosis.
Patient underwent:
– RCA: 80% Stenosis distal segment.
• 18F-FDG PET/CT: main results are shown in
• 18F-FDG PET/CT (for viability assessment)
and MSCT CE coronary angiography (CTA)
showing MVD with:
the Fig.9.10b.
• 82Rb PET/CT basal/dipyridamole was also
obtained for perfusion analysis (Fig.9.10c) to
b
Fig. 9.10 (a) Basal EKG: disappearance of R wave in
leads V1–V6. (b)
raphy fusion imaging. (c)
slices. (d) At
shows transaxial slices soon after dipyridamole (up) and
82
Rb PET/CT MPI: LV fusion imaging
18
F-FDG PET/MSCT coronary angiog-
82
Rb PET/TC MPI: short axis
c
at basal scan (down). The yellow lines show clearly the
difference between the maximum diameters of LV soon
after stressor test in respect of the basal scan, due to transient ischemic dilation of LV related to dipyridamole
induced ischemia
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Fig. 9.10 (continued)
M. L. De Rimini and G. Borrelli
better quantify risk stratication and schedule
therapeutic strategy.
• Protocol: Fast protocol 35min for basal con-
• 82Rb PET/TC suggested the need of revascularization. Patient underwent CABG 5 days
after PET-MPI
ditions and stressor dipyridamole (0.56 mg/
kg/4′). Dynamic list-mode acquisition.
Perfusion
defect
SSS SDS
27 2 37% 35% 39% 45%
Transient ischemic dilation TID = 1.35 r.v. >1.13 (0.98
+ 2.5 SD)
Severe perfusion defect of wide extension involving:
Apex, septum, anterior and inferior wall at
medio-ventricular level
extension
dipyridamole
– Transmural necrosis involving the apex,
apical-medium segment of septum,
anterior- septal and inferior wall.
– Mild transient ischemia and viable myo-
cardium at medium-basal segment of
anterior- septal wall; septum; inferior wall.
– Mild impairment of LVEF related to
Perfusion
defect
extension
basal
LVEF
dipyridamole
LVEF
basal
Clinical Case No. 8: 82Rb PET/CT
MPI—Impaired Regional LV MBF
Female, 65 years old.
Cardiovascular risk factor: Diabetes type 2 for
almost 12 years, hypertension.
Shortness of breath and chest pain stress
induced (Fig.9.11a, b).
• 3D transthoracic echocardiography: LV ejection fraction (LVEF 55%). No abnormalities
of regional wall motion.
• ECK stress test: inconclusive.
• 82Rb PET/CT dipyridamole/basal (dynamic,
list mode, fast protocol: 35 min for both
phases) (Fig.9.11c).
stressor test.
– Transient ischemic dilation (Fig.9.10d).
Stressor dipyridamole (0.56 mg/kg/4′): ECK: N.
9 PET Myocardial Perfusion Imaging: 82Rb
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a
181
b
Fig. 9.11
abnormalities. (b)
sient ischemia in response to the vasodilation due to
dipyridamole. (c) MBF at stressor dipyridamole. Analysis
obtained by QPET (G. Germano-Cedars-Sinai Medical
(a) Basal ECK: LV hypertrophy, unspecic
82
Rb PET MPI: No evidence of tran-
Center, LA, CA). Impairment of regional MBF at apex,
septal-inferior wall, according with microcirculation
impairment. (d) No epicardial coronaries stenosis, FFR
impairment on the selected areas
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M. L. De Rimini and G. Borrelli
c
d
Fig. 9.11 (continued)
a
b
a
b
9 PET Myocardial Perfusion Imaging: 82Rb
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Fig. 9.12 82Rb PET/CT: transient ischemia at vasodilator
test, more severe in infero-lateral, inferior wall. ICA:
MVD.Severe stenosis at RCA was treated with stent tar-
82
get on the basis of
induced ischemia results
Rb PET evidence of dipyridamole-
183
Patient underwent ICA that conrmed: No
epicardial coronaries stenosis (Fig.9.11d).
MBF at 82Rb PET/CT dipyridamole/basal was
suggestive of microcirculation impairment.
life clinical practice for helping the workup of
patients affected with MVD, where MPI with fast
protocol can identify the functional signicance
of stenosis and suggest which one to revascularize, given priority.
Clinical impact: 82Rb PET/CT can address
Clinical Case No. 9: 82Rb PET/CT
intheEmergency ofCath-lab
target revascularization of culprit lesion, early
out of the beginning of acute coronary syndrome
(ACS).
Female patient, 77 years old. Two different hospital admission for acute coronary syndrome
(ACS), at ICA (48 h post ACS): MVD.LVEF:40%.
References
At the end of ICA in Cath-lab she underwent
rest/dipyridamole
82
Rb PET/CT fast protocol,
showing:
Perfusion defect corresponding to LDA and RCA
territories, but more severe at RCA level that
was identied as culprit lesion (Fig.9.12).
Within 35min of PET scanning, patient was
re-addressed in Cath-lab for RCA stenting
revascularization.
At 24 h post-revascularization, EKG: ST resolution; Echo: improvement of LV compliance.
This condition is especially meaningful of real
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Berman DS, et al. Phase II safety and clinical com-
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Hsiao E, et al. Detection of obstructive coronary
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2013;54:1748–54.
Manabe O, etal. Which PET ow tracer is the best for
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82
Rb
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