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Cardiac Imaging Update 2017
GN Mahapatra, PC Manoria, Diwakar Jain
SECTION 1: CARDIAC IMAGING
1:
NONINVASIVE Echocardiographic Evaluation of Infective Endocarditis: The Current Status
INTRODUCTION
EVALUATION OF INFECTIVE ENDOCARDITIS
Indications for Echocardiography in IE
Anatomical and Echocardiographic Features in IE
Vegetation
Abscess and Perivalvular Involvement
New Dehiscence of a Prosthetic Valve
Other Echocardiographic Features in IE
Echocardiography for the Diagnosis of Complications of IE
Echocardiography for the Follow-up of IE
Echocardiography during Surgery
Echocardiography in Specific Situations
Prosthetic Valve IE
Cardiac Device-related IE
Right Heart Infective Endocarditis
Limitations of Echocardiography in IE
CONCLUSION
ACKNOWLEDGEMENT
2:
The Intricacies in Echocardiographic Evaluation of Aortic Stenosis
MAIN ECHOCARDIOGRAPHIC INDICES USED TO ASSESS AS SEVERITY
Flow Velocities and Gradients
Sources of Error for Gradient Calculations
AORTIC VALVE AREA
Sources of Error for Aortic Valve Area Calculations
DIMENSIONLESS VELOCITY INDEX
Real Dilemmas in the Diagnosis of Aortic Stenosis
Low-flow-Low-gradient Aortic Stenosis (LF/LGAS) with LV Systolic Dysfunction
ASSESSING LEFT VENTRICLE CONTRACTILE AND/OR FLOW RESERVE
Dobutamine Stress Echo Study in Low-gradient Aortic Stenosis
DISTINGUISHING BETWEEN TRUE SEVERE AND PSEUDOSEVERE AORTIC STENOSIS
Normal Left Ventricular Contractility and Low-gradient Severe Aortic Stenosis
CONCLUSION
3:
Echocardiography of Heart Failure: How to Use it in Routine Clinical Practice?
INTRODUCTION
HOW TO ASSESS SYSTOLIC FUNCTION OF THE HEART?
Ejection Fraction
Fractional Shortening
Stroke Volume
Myocardial Strain
HF with Reduced EF and HF with Preserved EF
HOW TO ASSESS DIASTOLIC FUNCTION OF THE HEART?
Transmitral Flow Velocity
Mitral Annular Velocity
Pulmonary Venous Flow Velocity
Left Atrial Volume
LEFT VENTRICULAR GEOMETRY AND ABNORMAL ECHOES
RIGHT VENTRICULAR FUNCTION
Tricuspid Annular Plane Systolic Excursion
Right Ventricular Fractional Area Change
Systolic Tricuspid Annular Velocity by Tissue Doppler Echocardiography
Others
INTRACARDIAC PRESSURE ESTIMATION
Assessment of Right Atrial Pressure
Estimation of Systolic Pulmonary Arterial Pressure (RV Systolic Pressure)
Estimation of LV Diastolic Pressure and Mean Pulmonary Wedge Pressure
CONCLUSION
4:
Speckle Tracking Echocardiography: Basics and Clinical Applications
CARDIAC MUSCLE STRUCTURE
METHODS OF SPECKLE TRACKING ECHOCARDIOGRAPHY AND PARAMETERS MEASURED
Image Acquisition
Image Processing
CONCLUSION
ACKNOWLEDGMENTS
5:
A Gold Standard for Evaluation of Cardiomyopathies
INTRODUCTION
IDIOPATHIC-DILATED CARDIOMYOPATHY
Cine MR Imaging
Delayed Enhanced MR Imaging
MYOCARDITIS
Delayed Enhanced MR Imaging
HYPERTROPHIC CARDIOMYOPATHY
Cine and Phase Contrast MR Imaging
Delayed Enhanced MR Imaging
RESTRICTIVE CARDIOMYOPATHY
CARDIAC AMYLOIDOSIS
Cine and Black-blood MR Imaging
Delayed Enhanced MR Imaging
ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY
Cine and Black-blood MR Imaging
Delayed Enhanced MR Imaging
LEFT VENTRICULAR NONCOMPACTION
MR Imaging
MYOCARDIAL SARCOIDOSIS
Cine MR Imaging
Delayed Enhanced MR Imaging
T2-weighted Imaging
IRON OVERLOAD CARDIOMYOPATHY
T2*-weighted Imaging
CONCLUSION
6:
Real World Indications for Cardiac Magnetic Resonance Imaging: When is it invaluable in Clinical Practice?
INTRODUCTION
MYOCARDITIS
NONISCHEMIC DILATED CARDIOMYOPATHIES
HYPERTROPHIC CARDIOMYOPATHY
CORONARY ARTERY DISEASE
VIABILITY/HIBERNATION
OTHER INDICATIONS
CONTRAINDICATIONS AND LIMITATIONS
7:
Cardiac MRI and Cardiac CT: Indispensable Tools for the Diagnosis of Coronary Artery Disease
INTRODUCTION
CARDIAC COMPUTED TOMOGRAPHY
Calcium Scoring
Coronary Angiography
To Rule Out Coronary Artery Disease
Stents
Plaque Evaluation
Perfusion11
Following Bypass Surgery
CARDIAC MAGNETIC RESONANCE IMAGING
Coronary Arteries
Perfusion
Viability Imaging
CONCLUSION
8:
Cardiac Imaging: Current Scenario and Future Directions
INTRODUCTION
COMPUTED TOMOGRAPHY CORONARY ANGIOGRAPHY
PERFUSION IMAGING
VIRTUAL COMPUTED TOMOGRAPHY—FRACTIONAL FLOW RESERVE
SPECTRAL COMPUTED TOMOGRAPHY
PLAQUE CHARACTERIZATION
HYBRID IMAGING
CARDIAC MAGNETIC RESONANCE IMAGING
Delayed Enhancement MRI (DE-MRI)
Dobutamine Stress MRI
Myocardial Viability
T1 AND T2 MAPPING
Coronary MR Angiography
CMR-guided Coronary Interventional Procedures
MR Spectroscopy
CONCLUSION
9:
Clinical Decision-making with Myocardial Perfusion Imaging in Patients with Known or Suspected Coronary Artery Disease
INTRODUCTION
DIABETES MELLITUS
WOMEN AND ELDERLY
CHRONIC KIDNEY DISEASE
10:
Current Status of Rubidium-82 PET-CT Myocardial Perfusion Imaging
HISTORICAL PERSPECTIVE
CHARACTERISTICS OF SR-82/RB-82 GENERATOR AND PHYSIOLOGY OF RB-82
COMPARISON WITH SPECT AGENTS
COMPARISON BETWEEN RB-82 AND N-13 AMMONIA
DOSIMETRY
CONCLUSION
11:
Innovation of New Tracers in the Era of Multimodality Cardiac Imaging
INTRODUCTION
MYOCARDIAL FUNCTION
MYOCARDIAL PERFUSION
FLUORINE-18 LABELED AGENTS FOR MYOCARDIAL PERFUSION STUDIES
ENERGY METABOLISM
IMAGING ATHEROSCLEROTIC PLAQUES
SUMMARY
12:
Myocardial Imaging Products’ Evolution: Change for the Better
INTRODUCTION
THALLIUM-201 AS MYOCARDIAL PERFUSION MARKER
TECHNETIUM-99M COMPOUNDS AS MYOCARDIAL PERFUSION MARKERS
LABELED FATTY ACID AS MARKER FOR METABOLISM: IODINE-123 PRODUCTS
PET TRACERS AS MYOCARDIAL PERFUSION MARKERS
Advantage of Quantitation while Using PET Tracers
PET TRACERS AS MARKER OF MYOCARDIAL VIABILITY
Scope for Additional PET Tracers for Myocardial Imaging
CONCLUSION
13:
Efficacy of Combining FDG-PET Metabolic and Tc-99m–MIBI Myocardial Perfusion Study in Assessment of Myocardial Viability
WHAT IS MYOCARDIAL VIABILITY?
METHODS OF ASSESSMENT OF VIABILITY
COMBINATION OF MPS WITH MIBI AND FDG-PET
SUMMARY
14:
Myocardial Viability Assessment: Is it Alive?
15:
Hybrid Myocardial Imaging Techniques: Role in Functionally Relevant Coronary Disease
MORPHOLOGY VERSUS ANATOMY
TECHNICAL DEVELOPMENTS
Protocols of Hybrid Cardiac Imaging Software
SPECT-CT and PET-CT Hybrid Imaging—Added Advantages
CALCIUM SCORING AND MYOCARDIAL PERFUSION IMAGING
Coronary CT Angiography and Myocardial Perfusion Imaging
HYBRID PET-MR
Functions
Challenges and Pitfalls including Radiation Dosimetry
Radiation Dosimetry
CONCLUSION
16:
Role of Coronary Flow Reserve in Coronary Artery Disease
INTRODUCTION
DIAGNOSIS OF CORONARY ARTERY DISEASE
Imaging Modalities
Nuclear Medicine Techniques
SPECT Myocardial Perfusion Imaging
Limitations of SPECT, Invasive Coronary Angiography and CT Angiography
Coronary Flow Reserve
Methods to Measure CFR4,13,18-22
CFR Using PET4,5,13,20,24
Technical Aspects20,24
Clinical Significance of CFR5,9,10,13,14,16-21,25
Difficulties in Performing and Limitations of CFR5,20,21,24
Future Prospects in CFR Measurement26,27
Conclusion
17:
Nuclear Medicine in Assessment of Cardiac Dyssynchrony
INTRODUCTION TO CARDIAC DYSSYNCHRONY
NUCLEAR MEDICINE TECHNIQUES IN ASSESSMENT OF CARDIAC DYSSYNCHRONY
Equilibrium Radionuclide Angiography
Gated Myocardial Perfusion SPECT
Cardiac Positron Emission Tomography
CLINICAL UTILITY OF ASSESSMENT OF CARDIAC MECHANICAL DYSSYNCHRONY
Prediction of Response to Cardiac Resynchronization Therapy
Coronary Artery Disease
Other Clinical Applications
CONCLUSION
18:
INVASIVE Is Optical Coherence Tomography Ready to Replace Intravascular Ultrasound in Percutaneous Coronary Intervention?
INTRODUCTION
ROLE OF OPTICAL COHERENCE TOMOGRAPHY BEFORE PERCUTANEOUS CORONARY INTERVENTION
Plaque Composition and Lesion Severity
Ambiguous Angiographic Lesions
Lesion Progression and Vulnerability
Acute Coronary Syndrome and Primary Percutaneous Coronary Intervention
Bifurcation Lesions
Left Main Disease
Implantation of Bioabsorbable Vascular Scaffold
OPTICAL COHERENCE TOMOGRAPHY IN ASSESSMENT OF STENTING
POSTINTERVENTION ASSESSMENT
ARTIFACTS
WILL OPTICAL COHERENCE TOMOGRAPHY REPLACE INTRAVASCULAR ULTRASOUND?
CONCLUSION
19:
Association of Coronary Stenosis and Plaque Morphology with Fractional Flow Reserve and Outcomes
SEVERITY OF LUMINAL STENOSIS AND FRACTIONAL FLOW RESERVE
PLAQUE MORPHOLOGY AND FRACTIONAL FLOW RESERVE
FRACTIONAL FLOW RESERVE AND SUBSEQUENT CLINICAL EVENTS
PLAQUE MORPHOLOGY: A LINK BETWEEN FRACTIONAL FLOW RESERVE AND CLINICAL OUTCOMES
CONCLUSION
ARTICLE INFORMATION
SECTION 2: CLINICAL CARDIOLOGY
20:
EMERGING THERAPIES PCSK9 Inhibitors: Will they be the Next Wonder Drug after Statins?
INTRODUCTION
RESIDUAL ATHEROGENIC RISK POSTSTATIN THERAPY
Low HDL-C as a Determinant of Residual Atherogenic Risk
HIGH TRIGLYCERIDES AS A DETERMINANT OF RESIDUAL ATHEROGENIC RISK
PCSK9
Loss-of-function Mutation (Table 2)
Gain-of-function Mutation
PCSK9 Inhibition
Evolocumab
Alirocumab
Bococizumab
Side Effects
Are there any off-target Effects?
CLINICAL APPROVAL IN EUROPE AND USA
Europe
USA
Where will this Class of Agents Fit in ?
OSLER and ODYSSEY LONG-TERM Trials
CONCLUSION
21:
Fighting the Devil of Stroke in Atrial Fibrillation: The New Weapons in the Armory
INTRODUCTION
WHEN TO USE NEW ORAL ANTICOAGULANTS?
LIMITATIONS OF NEW ORAL ANTICOAGULANTS
Renal Dysfunction
Monitoring Anticoagulant Effect
Antidote
Treatment of Bleeding with Newer Agents
Gastrointestinal Bleed
Increased Myocardial Infarction
Which Patient should Continue with Warfarin?
NICE Guidelines 2014
COMPARISON OF TSOACS
CONCLUSION
22:
CORONARY ARTERY DISEASE Management of Prehospital Phase of Acute Myocardial Infarction
INTRODUCTION
PATHOPHYSIOLOGY AND IMPACT OF TIME
DELAYS IN PROVIDING TREATMENT FOR CARDIAC EMERGENCIES
Patient Decision Time
Doctor Decision Time
Dispatching
Ambulance Response Interval
PREHOSPITAL ECGS IN PATIENTS WITH STEMI: WHAT ARE THE BENEFITS? (BOX 1)
CURRENT GUIDELINES FOR PREHOSPITAL ECGS AMONG PATIENTS WITH ST-SEGMENT–ELEVATION MYOCARDIAL INFARCTION
The Chain of Survival for Cardiac Arrest
Early Access
Early Cardiopulmonary Resuscitation (CPR)
Early Defibrillation
Automated External Defibrillation
Early Advanced Care
TREATMENT OF ACUTE CORONARY SYNDROMES IN THE PREHOSPITAL PHASE
General Measures for Patients without Overt Complications
REPERFUSION THERAPY: PREHOSPITAL THROMBOLYSIS
Current Guidelines
PREREQUISITES FOR PREHOSPITAL THROMBOLYSIS
CHOICE OF THROMBOLYTIC AGENTS FOR PREHOSPITAL THROMBOLYSIS
PREHOSPITAL VERSUS IN-HOSPITAL THROMBOLYSIS
COMPARISON OF THROMBOLYSIS WITH PERCUTANEOUS CORONARY INTERVENTION IN RANDOMIZED CONTROLLED TRIALS5
Registry Data
French Registries
Vienna Registry (Fig. 3)
Swedish Registry
International GRACE Registry
Indian Perspective
CONCLUSION
23:
STEMI Care in India and the Real World: Pharmacoinvasive Approach
INTRODUCTION
DEVELOPMENT OF THROMBOLYTIC THERAPY
The Discovery of Streptokinase
Mechanism of Action of Streptokinase
Source for Streptokinase
Human Studies on Streptokinase
Urokinase
Tissue-type Plasminogen Activator
Alteplase (tPA and rtPA)
Reteplase (rPA)
Tenecteplase (TNK-tPA)
Prehospital Thrombolysis
Advantages of Newer Agents Over the Older Agents
TRENDS IN THROMBOLYSIS FOR STEMI
Prehospital Thrombolysis
Pharmacoinvasive Approach for STEMI
Facilitated PCI
Pharmacoinvasive Approach
Reasons for Superiority of Pharmacoinvasive Approach
STEMI CARE IN INDIA: PROBLEMS AND SOLUTIONS
FUTURE DIRECTIONS FOR STEMI PROGRAM IN INDIA
CSI Forum
24:
Bioresorbable Vascular Scaffold
INTRODUCTION
POLYMER BASED
METAL BASED
COHORT A
E-BVS IMPLANTATION: TIPS AND TRAPS
Bifurcation Lesions
Long Lesions
ROLE OF INTRAVASCULAR IMAGING IN BVS IMPLANTATION AND FOLLOW-UP
E-BVS FROM CLINICAL TRIALS TO CLINICAL PRACTICE
NONINVASIVE ASSESSMENT OF BVS
RESTORATION OF VASOMOTION
Other BRS in Trials (Tables 4A and B)
Current Limitations
CONCLUSION
25:
Statin Intolerance
STATIN-MYOPATHY
Introduction
COMMON CONCERNS ASSOCIATED WITH LONG-TERM USE OF STATINS
Clinical Manifestations of Statin Intolerance
Incidence of Statin Myopathy
Mechanism of Statin Myopathy
Predisposing Factors
Diagnosis
LDL-C Reduction in Statin Intolerant Subjects
Prevention
Persistence of Myopathy After Statin Withdrawal
A Note on PCSK9 Inhibition and Statin Intolerance (Table 2)
26:
Sudden Cardiac Death: How to Predict and Prevent it?
INTRODUCTION
MAGNITUDE OF THE PROBLEM
CAUSES OF SUDDEN CARDIAC DEATH
MECHANISM OF SUDDEN CARDIAC DEATH
RISK FACTORS FOR SUDDEN CARDIAC DEATH
Risk Stratification of Sudden Cardiac Death
High-risk Factors for Sudden Cardiac Death
TREATMENT
Role of ICD
Out-of-hospital Resuscitation
27:
New Gadgets Knocking at the Door: Leadless Pacemakers, Subcutaneous Implantable Cardioverter Defibrillators, Wearable Defibrillators
INTRODUCTION
LEADLESS PACEMAKER
WIRELESS CARDIAC STIMULATION SYSTEM
SUBCUTANEOUS IMPLANTABLE CARDIOVERTER DEFIBRILLATOR
WEARABLE CARDIOVERTER-DEFIBRILLATOR
CONCLUSION
28:
Echocardiographic Evaluation of Left Atrial Clot and its Utility in Clinical Practice
29:
Clinical Applications of Nuclear Cardiology Procedures and its Future Directions
SCOPE OF RADIONUCLIDE IMAGING PROCEDURES
MYOCARDIAL PERFUSION
Stress/Redistribution Stress Thallium Myocardial Perfusion Study (Fig. 1)
STRESS-GATED SPECT TC-99M MYOCARDIAL PERFUSION IMAGING AGENTS
Sestamibi
Tetrofosmin
Teboroxime
CLINICAL APPLICATIONS OF MYOCARDIAL PERFUSION IMAGING
PHARMACOLOGICAL STRESS PERFUSION IMAGING
DIPYRIDAMOLE MYOCARDIAL PERFUSION IMAGING
Protocol
MECHANISM OF ACTION OF DIPYRIDAMOLE
Side Effects
ADENOSINE MYOCARDIAL PERFUSION IMAGING
Imaging Protocol
Mechanism of Action
Side Effect
Serious Adverse Effects
DOBUTAMINE MYOCARDIAL PERFUSION IMAGING
Protocol
Mechanism of Action
Side Effects
Sensitivity and Specificity in Detecting Coronary Artery Disease
PHARMACOLOGICAL STRESS PERFUSION IMAGING WITH LOW LEVEL TREADMILL/BICYCLE EXERCISE
NEW OPTIONS IN PHARMACOLOGICAL STRESS (Fig. 10)
Mode of Action
REGADENOSON MYOCARDIAL PERFUSION SCINTIGRAPHY (Fig. 11)
Positron Emission Tomography Imaging
Tracers of Myocardial Perfusion
Rubidium-82 PET Myocardial Perfusion Imaging (Fig. 12)
N-13 Ammonia/O-15 Labeled Water PET Perfusion Imaging (Fig. 14)
Myocardial Metabolism
Metabolic Tracers
Fluorine-18 FDG Metabolic Imaging (Fig. 14)
Myocardial Stunning and Hibernation
Myocardial Infarct Imaging
Tc-99m Pyrophosphate
Tc-99m Labeled Glucarate
Indium-111 Labeled Antimyosin Antibodies
Technetium-99m Labeled Annexin V (Fig. 17)
DUAL ISOTOPE IMAGING USING TL-201 AND F-18 FDG IMAGING
Glucose Metabolism
Patient Preparation
Data Interpretation
Cardiac PET Scan Protocol
Where do we Ask for FDG PET Imaging in the Assessment of Myocardial Viability
FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY VERSUS FLUORODEOXYGLUCOSE SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY
EMERGING CONCEPTS IN NUCLEAR CARDIOLOGY (FIGS 21 AND 22)
Cardiac Software Program
Quantitation of Myocardial Blood Flow
Protocol
COMPUTATION OF MYOCARDIAL BLOOD FLOW WITH RUBIDIUM-82 AND COMPARISON TO N13 AMMONIA (Fig. 21)
Myocardial Blood Flow Global Reduction in Flow, Coronary Steal (Fig. 24)
Dedicated Cardiac SPECT Gamma Camera
Dynamic SPECT Cardiac Gamma Camera (Figs 25A and B)
System Description
Solid State Dedicated Cardiac Camera (D-Spect) (Figs 27 and 28)
DYNAMIC SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT) (FIGS 29 TO 35)
Drawback of MPI
Suggestion
Acquisition Protocol
F-18 FLURPIRIDAZ POSITRON EMISSION TOMOGRAPHY MYOCARDIAL PERFUSION IMAGING TRACER
Protocol
F-18 BMS MYOCARDIAL PET TRACER
C-11 HYDROXYEPHEDRINE/C-11 EPINEPHRINE/I-123 MIBG AND TC99M TETROFOSMIN/SESTAMIBI SPECT MPI
TRACERS FOR DETECTING CHRONIC INFLAMMATORY DISORDERS SUCH AS CARDIAC SARCOIDOSIS/AMYLOIDOSIS
TRACERS FOR DETECTING ATHEROMATOUS PLAQUE PARTICULARLY VULNERABLE PLAQUE IMAGING
TRACERS FOR STEM CELLS TRACKING
TRACERS FOR PATIENTS WITH INFECTIOUS ENDOCARDITIS AND AORTIC GRAFT PROSTHETIC INFECTION
18-F FDG PET-CT
USEFUL COMBINED NUCLEAR CARDIOLOGY TECHNIQUES (FIGS 41 AND 42)
Dual Isotope Imaging using Tl-201 and F-18 FDG Imaging
Glucose Metabolism
Patient Preparation
Data Interpretation
Cardiac PET Scan Protocol
Combined or Dual Tracer Use of I-123-BMIPP and Perfusion Tracer (Tc-99m Tetrofosmin/Sestamibi)
Example (Fig. 43)
CONCLUSION
30:
Cardiac Positron Emission Tomography Perfusion Tracers: Current Status and Future Directions
INTRODUCTION
CURRENT MYOCARDIAL PERFUSION POSITRON EMISSION TOMOGRAPHY TRACERS
15O Water
13N Ammonia
82Rb
FUTURE DIRECTIONS
18F Flurpiridaz
Unit Dose Availability
High Image Resolution
High Extraction Fraction and Perfusion Defect Resolution
Low Radiation Exposure
Feasibility of Rest Treadmill Exercise Imaging
Peak Stress Function Imaging
Diagnostic Accuracy for Detection of CAD
Absolute Quantitation of Myocardial Blood Flow
CONCLUSION
FUNDING
DISCLOSURE
INDEX
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