Positron emission tomography and the quantitative assessment of regional myocardial blood flow

The continual innovation of commercial PET/CT solutions in nuclear cardiology: Siemens Healthineers

Cardiac PET/CT is an evolving, non-invasive imaging modality that impacts patient management in many clinical scenarios. Beyond offering the capability to assess myocardial perfusion, inflammatory cardiac pathologies, and myocardial viability, cardiac PET/CT also allows for the non-invasive quantitative assessment of myocardial blood flow (MBF) and myocardial flow reserve (MFR). Recognizing the need for an enhanced comprehension of coronary physiology, Siemens Healthineers implemented a sophisticated solution for the calculation of MBF and MFR in 2009. As a result, each aspect of their innovative scanner and image-processing technology seamlessly integrates into an efficient, easy-to-use workflow for everyday clinical use that maximizes the number of patients who potentially benefit from this imaging modality.

Assessment of myocardial blood flow and coronary flow reserve with positron emission tomography in ischemic heart disease: current state and future directions

Positron emission tomography (PET) is a versatile imaging technology that allows assessment of myocardial perfusion, both at a spatially relative scale and also in absolute terms, thereby enabling noninvasive evaluation of myocardial blood flow (MBF) and coronary flow reserve (CFR). Assessment of MBF using FDA-approved PET isotopes, such as ⁸²Rb and ¹³N-ammonia, has been well validated, and several software packages are currently available, thereby allowing for MBF evaluation to be incorporated into routine workflow in contemporary nuclear laboratories. Incremental diagnostic and prognostic information provided with the knowledge of MBF has the potential for widespread applications. Improving the ability to identify the true burden of obstructive epicardial coronary stenoses and allowing for noninvasive assessment of coronary micro circulatory function can be achieved with MBF assessment. On the other hand, attenuated CFR has been shown to predict adverse cardiovascular prognosis in a variety of clinical settings and patient subgroups. With expanding applications of MBF, this tool promises to provide unique insight into the integrity of the entire coronary vascular bed beyond what is currently available with relative perfusion assessment. This review intends to provide an in-depth discussion of technical and clinical aspects of MBF assessment with PET as it relates to patients with ischemic heart disease.

Noninvasive quantification of myocardial blood flow in humans. A direct comparison of the [13N]ammonia and the [15O]water techniques

BACKGROUND

[13N]Ammonia has been validated in dog studies as a myocardial blood flow tracer. Estimates of myocardial blood flow by [13N]ammonia were highly linearly correlated to those by the microsphere and blood sample techniques. However, estimates of myocardial blood flow with [13N]ammonia in humans have not yet been compared with those by an independent technique. This study therefore tested the hypothesis that the [13N]ammonia positron emission tomographic technique in humans gives estimates of myocardial blood flow comparable to those obtained with the [15O]water technique.

METHODS AND RESULTS

A total of 30 pairs of positron emission tomographic flow measurements were performed in 30 healthy volunteers; 15 volunteers were studied at rest and 15 during adenosine-induced hypermia. Estimates of average and of regional myocardial blood flow by the [13N]ammonia and the [15O]water approaches correlated well (y = 0.02 + 1.02x, r = .99, P < .001 SEE = 0.023 for average and y = 0.06 + 1.00x, r = .97, P < .001, SEE = 0.025 for regional values) over a flow range of 0.45 to 4.74 mL.min-1.g-1. At rest, mean myocardial blood flow was 0.64 +/- 0.09 mL.min-1.g-1 for [13N]ammonia and 0.66 +/- 0.12 mL.min-1.g-1 for [15O]water (P = NS). For adenosine-induced hyperemia, mean myocardial blood flow was 2.63 +/- 0.75 mL.min-1.g-1 for [13N]ammonia and 2.73 +/- 0.77 mL.min-1.g-1 for [15O]water (P = NS). The coefficient of variation as an index of the observed heterogeneity of myocardial blood flow averaged, for [13N]ammonia, 9 +/- 4% at rest and 12 +/- 7% during stress and, for [15O]water, 14 +/- 11% at rest and 16 +/- 9% during stress. The coefficients of variation for [15O]water were significantly higher than those for [13N]ammonia (P = .004 at rest and P = .03 during stress).

CONCLUSIONS

The two approaches yield comparable estimates of myocardial blood flow in humans, which supports the validity of the [13N]ammonia method in human myocardium previously shown only in animals. However, the [15O]water approach reveals a greater heterogeneity (presumably method-related), which might limit the accuracy of sectorial myocardial blood flow estimates in humans.