1. Cardio-Respiratory Nuclear Imaging fromCardio-Respiratory Nuclear Imaging from
basics to challenging clinical casesbasics to challenging clinical cases
Dr Ihab Suliman FESCDr Ihab Suliman FESC
Assistant professor of Cardiology and ConsultantAssistant professor of Cardiology and Consultant
Division of advanced Cardiac ImagingDivision of advanced Cardiac Imaging
Member of the European working group on nuclearMember of the European working group on nuclear
cardiology and cardiac CTcardiology and cardiac CT
Member of the Saudi ministry of health expertsMember of the Saudi ministry of health experts
panel committee on guidelinespanel committee on guidelines
3/9/20163/9/2016

2. DisclosureDisclosure
 Nothing to declareNothing to declare

3. NUCLEAR MEDICINE NMNUCLEAR MEDICINE NM
 IMAGING SPECIALITY THAT FOCUSES ONIMAGING SPECIALITY THAT FOCUSES ON
THE USE OF RADIOACTIVE MATERIALSTHE USE OF RADIOACTIVE MATERIALS
CALL “RADIOPHARMACEUTICALS” FORCALL “RADIOPHARMACEUTICALS” FOR
DIAGNOSIS, THERAPY, AND MEDICALDIAGNOSIS, THERAPY, AND MEDICAL
RESEARCH.RESEARCH.

4. NMNM
Physiology & FunctionPhysiology & Function

5. RadiopharmaceuticalsRadiopharmaceuticals
+
Biochemical
Bonding
Pharmaceutical
Traces physiology
/ localises in
organs of interest
Radioactive
nuclide
Emits radiation for
detection or
therapy

6. TRACERSTRACERS
 ARE SELECTED THAT LOCALIZE INARE SELECTED THAT LOCALIZE IN
SPECIFIC ORGANS OR TISSUESSPECIFIC ORGANS OR TISSUES
 Ex: GLUCOSEEx: GLUCOSE
 THE AMOUNT OF RADIOACTIVETHE AMOUNT OF RADIOACTIVE
TRACER MATERIAL IS SELECTEDTRACER MATERIAL IS SELECTED
CAREFULLY TO PROVIDE THECAREFULLY TO PROVIDE THE
LOWEST AMOUNT OF RADIATIONLOWEST AMOUNT OF RADIATION
EXPOSUREEXPOSURE

7. RADIOACTIVE TRACERSRADIOACTIVE TRACERS
 PRODUCE ALPHA,GAMMA or BETAPRODUCE ALPHA,GAMMA or BETA
EMISSION FROM WITHIN THE ORGANEMISSION FROM WITHIN THE ORGAN
BEING STUDIEDBEING STUDIED
 EMISSIONS ARE TRANSFORMED INTOEMISSIONS ARE TRANSFORMED INTO
IMAGE THAT PROVIDE INFORMATIONIMAGE THAT PROVIDE INFORMATION
ABOUT THE FUNCTION OF THEABOUT THE FUNCTION OF THE
ORGAN OR SYSTEM BEING STUDIED.ORGAN OR SYSTEM BEING STUDIED.

9.  ALARAALARA RadiationRadiation
exposure is an occupationalexposure is an occupational
reality in NMT. Goodreality in NMT. Good
radiation safety practicesradiation safety practices
keep exposures “keep exposures “AAss LLowow AAss
RReasonablyeasonably AAchievable”chievable”
(ALARA).(ALARA).
• FILM BADGESFILM BADGES
• RING BADGESRING BADGES
• SPILLED CHEMICALSSPILLED CHEMICALS
MUST BE CLEANEDMUST BE CLEANED
UP IMMEDIATELYUP IMMEDIATELY

10. INSTRUMENTATIONINSTRUMENTATION
• RADIOACTIVE DETECTORSRADIOACTIVE DETECTORS
– GEIGER COUNTERGEIGER COUNTER
– DOSE CALIBRATORDOSE CALIBRATOR

11. Exposure vs Effective doseExposure vs Effective dose
the mean effective dose:the mean effective dose:
• NM diagnosticNM diagnostic
procedureprocedure
• CXRCXR
• UGI seriesUGI series
• Lower GI seriesLower GI series
• CT HeadCT Head
• CT ChestCT Chest
• CT AbdomenCT Abdomen
• 4.6 mSv4.6 mSv
• 0.008 mSv0.008 mSv
• 4.5 mSv4.5 mSv
• 6 mSv6 mSv
• 1.5 mSv1.5 mSv
• 5.4 mSv5.4 mSv
• 3.9 mSV – 6.1 mSv3.9 mSV – 6.1 mSv

13. Gamma CameraGamma Camera

14. Dual Head Gamma CameraDual Head Gamma Camera

15. Single Head Gamma CameraSingle Head Gamma Camera

16. Triple Head Gamma CameraTriple Head Gamma Camera

17. The Gamma CameraThe Gamma Camera
Position
circuitry
X Y Z
Collimator
NaI
Crystal
Photo Multiplier
Tubes
Analogue to
Digital Converters
Digital
circuitry
Output position
& energy signals

18. Tc-99m preparationTc-99m preparation

19. Tc-99mTc-99m

33. What does the heart do ?What does the heart do ?
• The heart is a powerful muscle
consisting of two pumps side by
side.
• Its steady beating maintains
flow of blood to all parts of the
body throughout life.
ECG/ Treadmill
Radiography
Echocardiography
CT scan
MRI
Angiography
RadionuclideRadionuclide
imagingimaging
Diagnostic modalities in heart disease

34. History of nuclear cardiologyHistory of nuclear cardiology
 Blumgard and Weiss (1927) :Blumgard and Weiss (1927) :
the first use of radioactivity in the study of thethe first use of radioactivity in the study of the
cardiovascular systemcardiovascular system
 Wilson : measurement of the circulation timesWilson : measurement of the circulation times
 Tl-201 (1971)Tl-201 (1971)
 The development and improvement of SPECTThe development and improvement of SPECT
 The development and established Tc-labeled agentsThe development and established Tc-labeled agents
 Alternative stress than physical exerciseAlternative stress than physical exercise
 Gate-spect allows simultaneous assessment both ofGate-spect allows simultaneous assessment both of
myocardial perfusion, function and assessment ofmyocardial perfusion, function and assessment of
myocardial viabilitymyocardial viability
 Gamma camera coincidence imaging systemGamma camera coincidence imaging system
 Myocardial metabolic imagingMyocardial metabolic imaging

35.  Diagnosis & prognosisDiagnosis & prognosis
 Risk stratificationRisk stratification
 Medical vs. surgical treatmentMedical vs. surgical treatment
 Efficiency of managementEfficiency of management
Clinical applicationsClinical applications
• CAD
• Acute and post MI
• Cardiomyopathy
• Valvular disease and Shunts
• Cardiotoxicity
• Aneurysms
• Transplants
Stress-rest Tl-201 and Tc-99m labeled agents has been widely used in the diagnosis and assessment of coronary artery disease
MPI still an important position in clinical practice
only 1/3 of symptom-free men with exercise induced ST segment depression had coronary angiographic lesions > 50% diameter stenosis
MPI has been proposed to improve the accuracy and risk assessment of exercise testing in patients with suspected CAD
Sensitivity 74% - 96%, specificity 65% -97%

36. Cardiac stress testCardiac stress test
Physical exercisesPhysical exercises
Exercise has to be adequate to produced the heterogenityExercise has to be adequate to produced the heterogenity
in blood flow to achieve high detection sensitivityin blood flow to achieve high detection sensitivity
 TreadmilTreadmil
 ErgocycleErgocycle
PharmacologicalPharmacological
 Pharmacological stress test become important, sincePharmacological stress test become important, since
many patients are unable to exercisemany patients are unable to exercise
 Pharmacological stress agents largely remove the needPharmacological stress agents largely remove the need
for patient cooperation and motivation, and enable afor patient cooperation and motivation, and enable a
confident assessment of cardiac function in virtually allconfident assessment of cardiac function in virtually all
casescases
 DipyridamoleDipyridamole
 DobutamineDobutamine
 AdenosineAdenosine

37. Image interpretationImage interpretation
I. DefectsI. Defects
 LocationLocation
 ExtentExtent
 SeveritySeverity
 Reversible or fixedReversible or fixed
 Quantitative or semi quantitative analysisQuantitative or semi quantitative analysis
II. Other informationII. Other information
 Transient ischemic dilationTransient ischemic dilation
 Lung uptakeLung uptake

38. Case 1Case 1
 55 years old male with atypical Chest pain and55 years old male with atypical Chest pain and
No risk factors.No risk factors.
 ECG, Echo, Cardiac Enzymes are NormalECG, Echo, Cardiac Enzymes are Normal
 What Next?What Next?
 PET MPI using Rubidium 82PET MPI using Rubidium 82

40. Case 2Case 2
 70 years old lady with AF, DM, HTN, IHD70 years old lady with AF, DM, HTN, IHD
Previous PCI to RCA.Previous PCI to RCA.
 Came with Exertional Chest pain, ECG andCame with Exertional Chest pain, ECG and
Echo are NormalEcho are Normal
 PET MPI using Rubidium 82PET MPI using Rubidium 82

43.  This is a 61 yr old male who is k/c of type IIThis is a 61 yr old male who is k/c of type II
DM. He has sustained acute Anterior wallDM. He has sustained acute Anterior wall
myocardial infarction 2 days ago and wasmyocardial infarction 2 days ago and was
admitted in Affif hospital, where givenadmitted in Affif hospital, where given
thrombolytic therapy. Then he signed DAMAthrombolytic therapy. Then he signed DAMA
and came here for further manangement.and came here for further manangement.

47.  Echo EF 35-40%, Akinetic LAD area, NoEcho EF 35-40%, Akinetic LAD area, No
significant Valvular pathologysignificant Valvular pathology

50. Second CaseSecond Case
 56 years old male with DM, HTN, CVA56 years old male with DM, HTN, CVA
Recovered .Recovered .
 Had occasional Exertional CP, ACS Ruled OutHad occasional Exertional CP, ACS Ruled Out
in ER, Given appointment for PET /CT Stressin ER, Given appointment for PET /CT Stress
as OPas OP

56.  67 years old male with Recent anterior MI from67 years old male with Recent anterior MI from
another hospital.another hospital.

59.  In MCICU he had Multiple and RecurrentIn MCICU he had Multiple and Recurrent
VF/VT.VF/VT.
 EP labelled him as ischemic VF/VTEP labelled him as ischemic VF/VT
 Cardiac surgery insisted on Viability BeforeCardiac surgery insisted on Viability Before
CABGCABG

61. Case (1) 42 Male with DM, Prior LiverCase (1) 42 Male with DM, Prior Liver
transplant, CKD Referred for Pre OPtransplant, CKD Referred for Pre OP
Clearance(Normal studyClearance(Normal study))

62. Case 2 63 F with DM, DLP andCase 2 63 F with DM, DLP and
CKD for Pre Op WorkupCKD for Pre Op Workup (Normal(Normal
study)study)

66.  79 male with S/P CABG ,79 male with S/P CABG ,

69.  Moderate Inferolateral defect with ModerateModerate Inferolateral defect with Moderate
partial peri-infract ischemiapartial peri-infract ischemia

70. 66 years old female 4 Preop Clearance66 years old female 4 Preop Clearance

71.  LBBB in SinusLBBB in Sinus
 Booked for calcium score + Persantin PET/CTBooked for calcium score + Persantin PET/CT

73.  Calcium Score showed Mid LAD mildCalcium Score showed Mid LAD mild
calcificationcalcification

75.  No obvious reversible ischemic defect .No obvious reversible ischemic defect .
 Mild fixed defect at the apex represent apicalMild fixed defect at the apex represent apical
thiningthining

76. MPI(Myocardial perfusion imaging) has been widely used and anMPI(Myocardial perfusion imaging) has been widely used and an
important position in the diagnosis and assessment of CAD Sensitivityimportant position in the diagnosis and assessment of CAD Sensitivity
74% - 96%, specificity 65% -97%74% - 96%, specificity 65% -97%
SummarySummary
• Nuclear cardiology separates high risk patient who need invasive
and expensive procedures from low risk patient who do not.
• Acts as a ”Gate - Keeper” for referral to angiography.
Cost of management strategies using MPI are cheaper and equally
effective when compared with strategies without MPI with same
outcome.
Nuclear cardiology separates persistent defect with LV dysfunction
but viable myocardium from scar tissue