assessment of myocardial viability - csaim.com€¦ · assessment of myocardial viability professor...

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@02-126_Coronary_calcification.ppt

Jamshid Maddahi, M.D., FACC, FASNCJamshid Maddahi, M.D., FACC, FASNC

Assessment of Myocardial ViabilityAssessment of Myocardial Viability

Professor Molecular and Medical Pharmacology

(Nuclear Medicine) and Medicine (Cardiology)

David Geffen School of Medicine at UCLA

Professor Molecular and Medical Pharmacology

(Nuclear Medicine) and Medicine (Cardiology)

David Geffen School of Medicine at UCLA

Director, Biomedical Imaging InstituteDirector, Biomedical Imaging Institute

Definition of Myocardial ViabilityDefinition of Myocardial Viability

Potential for improvement ofPotential for improvement of

myocardial dysfunctionmyocardial dysfunction

after revascularizationafter revascularization

Potential for improvement ofPotential for improvement of

myocardial dysfunctionmyocardial dysfunction

after revascularizationafter revascularization

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Causes of Abnormal Regional Wall Motion andPotential for Recovery after RevascularizationCauses of Abnormal Regional Wall Motion andPotential for Recovery after Revascularization

Recovery afterRecovery afterCauses of AbnormalCauses of Abnormal

Transmural MITransmural MI

Nontransmural MINontransmural MI

HibernatingHibernating

Transmural MITransmural MI

Nontransmural MINontransmural MI


Recovery after Revascularization

Recovery after Revascularization

NoNo

NoNo

NoNo

NoNo

Causes of Abnormal Regional Wall motionCauses of Abnormal

Regional Wall motion


StunnedStunned

Repetitively StunnedRepetitively Stunned

MyopathicMyopathic


StunnedStunned

Repetitively StunnedRepetitively Stunned

MyopathicMyopathic

YesYes

SpontaneousSpontaneous

YesYes

NoNo

YesYes

SpontaneousSpontaneous

YesYes

NoNo

Myocardial Perfusion, Reperfusion, and FunctionMyocardial Perfusion, Reperfusion, and Function

Hibernation100

PerfusionFunctionPerfusionFunction

(%)

Nor

mal

80

60

40

20

010

Elapsed Time

0 2 6 8 104Days Weeks

RevascularizationRevascularization

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Myocardial Perfusion, Reperfusion, and FunctionMyocardial Perfusion, Reperfusion, and Function

100

Repetitive Stunning


(%)

Nor

mal

80

60

40


PerfusionFunctionPerfusionFunction

20

00 2 6 8 104

Days Weeks

Elapsed Time

rest

redist

Short Axis

rest

redist

Vertical Long Axis

rest

redist

Horizontal Long Axis

UCLA

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Rest

Redist

Rest

Redist

Rest

Redist

Rest

Redist

Question

What is the likelihood of improvement of functionf ll i l i ti ?following revascularization?

A) High (>80%)

B) High-intermediate (60%-70%)

C) Intermediate (50% 60%)C) Intermediate (50%-60%)

D) Low-intermediate (30%-40%)

E) Low (<20%)

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D.S. 1

Question

Resting LVEF is 24%. What is the most likely LVEFf ll i l i ti ?following revascularization?

A) <30%

B) 30%-34%

C) 35% 39%C) 35%-39%

D) 40%-44%

E) 45%-50%

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D.S. 1

• SPECT tracers are inherently good markers of

PET vs. SPECT for Viability AssessmentWhen to Use What

PET vs. SPECT for Viability AssessmentWhen to Use What

myocardial viability, but their myocardial uptake is flow dependent.

• About 35% of nonreversible SPECT defects are hibernating myocardium with severe reduction of blood flow.

• SPECT underestimates the extent of myocardial viability.

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Clinical History

M.L.

76 year-old male with history of MI and S/P CABG

Presenting with angina and symptoms of heart failure

SPECT study showed nonreversible inferior, apical,and inferolateral defects

PET was performed to assess viability

VerticalLong Axis

M.L. p51896

ShortAxis Axial

Rest NH3

Rest FDG

UCLA

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Rest NH3 Rest FDG

M.L. p51896

UCLA

PET Viability Patterns

Perfusion-R FDG-PP FDG-Fast

Normal Normal Normal

Tx MI Absent Absent

Non-Tx MI 1-2+ Reduced 1-2 + Reduced

Hibernating 1-3 + Reduced Normalg

Repetitively stunned

Myopathic

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Restperfusion

RestFDG

Horizontallong axis

Verticallong axis

Short axis

UT Health Science Center

What is the patient’s metabolic state?

Question

A) Fasting

B) Post-prandial

C) Diabetic

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What is the pattern of viability in the inferior wall?

Question

A) Hibernating

B) Non-transmural infarction

C) Transmural infarction

D) Non-ischemic myopathy

E) Repetitively stunned

Restperfusion

RestFDG

Pt#20

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Normal Normal Normal Absent

Tx MI Absent Absent Absent

Non-Tx MI 1-2+ Reduced 1-2 + Reduced Absent

Hibernating 1-3 + Reduced Normal Normalg


Myopathic

Clinical History

C.S.• 47 year-old male with no prior cardiac history,

experienced sudden death at a job interview. VFib p jconverted to NSR and was transferred to UCLA.

• Emergency coronary angiogram:– LAD: 90% proximal, 80% mid, 90% Dx– LCX: 100% OM– RCA: 100% proximal

E h di EF 20 25% LVEDD 69 l b l• Echocardiogram: EF 20-25%, LVEDD 69 mm, global hypokinesis. Normal RV size with reduced function. Mild pulmonary HTN, RVSP 35-40 mmHg. Moderate MR

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EKG on admissionEKG on admission

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Restperfusion

Stressperfusion

Horizontallong axis

Verticallong axis

Short axis

UT Health Science Center

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Normal Normal Normal Absent


Non-Tx MI 1-2+ Reduced 1-2 + Reduced Absent

Hibernating 1-3 + Reduced Normal Normalg


Normal/

1+ reduced

Normal Variable

Myopathic Normal Normal Absent

Added Benefits of Stress Perfusion Imaging

1 Better Identification of candidates for revascularization1. Better Identification of candidates for revascularization

by detecting jeopardized myocardium

2. Differentiation of repetitively stunned from myopathic

myocardium

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Perfusion-R FDG-PP Perfusion-S

Normal Normal Normal Normal/

decrease


Non-Tx MI 1-2+ Reduced 1-2+ Reduced No change/

More decrease

Hibernating 1-3 + Reduced Normal No change/Hibernating 1 3 + Reduced Normal No change/

More decrease


Normal/

1+ reduced

Normal Decrease

Myopathic Normal Normal Normal

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