Multimodality cardiovascular molecular imaging, part I

Molecular imaging of high-risk atherosclerotic plaques: is it clinically translatable?

The explosive epidemics of diabetes and obesity as well as an aging population have led to cardiovascular diseases as the leading cause of world-wide morbidity and mortality beyond cancer. The recent introduction of drug-eluting stents and medications such as statins, dual anti-platelet therapy, and angiotensin converting enzyme inhibitors has dramatically improved clinical outcomes in patients with cardiovascular diseases. However, mortality is still increasing despite state-of-the-art therapeutics, as current diagnostic and therapeutic strategies against cardiovascular disease center on "locking the barn door after the horse has been stolen". Novel diagnostic solutions that identify individuals at risk before the disease is overt are needs. Imaging approaches that visualize molecular targets rather than anatomical structures aim to illuminate vital molecular and cellular aspects of atherosclerosis biology in vivo. Recent technological advances in small animal imaging systems and dedicated targeted/activatable molecular imaging probes have positioned molecular imaging to greatly impact atherosclerosis imaging in the next decade. However, several issues must be addressed before its clinical translation.

Atherosclerosis drug development in jeopardy: the need for predictive biomarkers of treatment response

The limited predictability of phase II biomarkers for atherosclerosis outcomes in phase III studies stands in contrast to the number and varied types of biomarkers--soluble, imaging, and functional--that have been used in a diverse array of trials. Although collectively abundant, these biomarker data exist in a fragmented state. Most biomarkers are studied one at a time, only measure a specific aspect of atherosclerosis, are not integrated in a substantive way, and compete with one another for validation; in the end, progress is slow. The proposed solution from the Atherosclerosis Working Group, a committee of experts from academia, the pharmaceutical industry, government, and the nonprofit sector and managed by the Foundation for the National Institutes of Health Biomarkers Consortium, is to integrate these different measures into an in silico model of atherosclerosis. Through integration of diverse biomarker measurements and outcomes in silico, we may be able to improve trial design as well as the predictive power of short-term markers for longer-term outcomes.

Targeted Nanocarriers for Imaging and Therapy of Vascular Inflammation

Vascular inflammation is a common, complex mechanism involved in pathogenesis of a plethora of disease conditions including ischemia-reperfusion, atherosclerosis, restenosis and stroke. Specific targeting of imaging probes and drugs to endothelial cells in inflammation sites holds promise to improve management of these conditions. Nanocarriers of diverse compositions and geometries, targeted with ligands to endothelial adhesion molecules exposed in inflammation foci are devised for this goal. Imaging modalities that employ these nanoparticle probes include radioisotope imaging, MRI and ultrasound that are translatable from animal to human studies, as well as optical imaging modalities that at the present time are more confined to animal studies. Therapeutic cargoes for these drug delivery systems include diverse anti-inflammatory agents, anti-proliferative drugs for prevention of restenosis, and antioxidants. This article reviews recent advances in the area of image-guided translation of targeted nanocarrier diagnostics and therapeutics in nanomedicine.

Nanomedicine approaches in vascular disease: a review

Nanomedicine approaches have revolutionized the treatment of cancer and vascular diseases, where the limitations of rapid nonspecific clearance, poor biodistribution and harmful side effects associated with direct systemic drug administration can be overcome by packaging the agents within sterically stabilized, long-circulating nanovehicles that can be further surface-modified with ligands to actively target cellular/molecular components of the disease. With significant advancements in genetics, proteomics, cellular and molecular biology and biomaterials engineering, the nanomedicine strategies have become progressively refined regarding the modulation of surface and bulk chemistry of the nanovehicles, control of drug release kinetics, manipulation of nanoconstruct geometry and integration of multiple functionalities on single nanoplatforms. The current review aims to capture the various nanomedicine approaches directed specifically toward vascular diseases during the past two decades. Analysis of the promises and limitations of these approaches will help identify and optimize vascular nanomedicine systems to enhance their efficacy and clinical translation in the future.

FROM THE CLINICAL EDITOR

Nanomedicine-based approaches have had a major impact on the treatment and diagnosis of malignancies and vascular diseases. This review discusses various nanomedicine approaches directed specifically toward vascular diseases during the past two decades, highlighting their advantages, limitations and offering new perspectives on future applications.

Activated platelets in carotid artery thrombosis in mice can be selectively targeted with a radiolabeled single-chain antibody

Background

Activated platelets can be found on the surface of inflamed, rupture-prone and ruptured plaques as well as in intravascular thrombosis. They are key players in thrombosis and atherosclerosis. In this study we describe the construction of a radiolabeled single-chain antibody targeting the LIBS-epitope of activated platelets to selectively depict platelet activation and wall-adherent non-occlusive thrombosis in a mouse model with nuclear imaging using in vitro and ex vivo autoradiography as well as small animal SPECT-CT for in vivo analysis.

Methodology/Principal Findings

LIBS as well as an unspecific control single-chain antibody were labeled with ¹¹¹Indium (¹¹¹In) via bifunctional DTPA ( = ¹¹¹In-LIBS/¹¹¹In-control). Autoradiography after incubation with ¹¹¹In-LIBS on activated platelets in vitro (mean 3866±28 DLU/mm², 4010±630 DLU/mm² and 4520±293 DLU/mm²) produced a significantly higher ligand uptake compared to ¹¹¹In-control (2101±76 DLU/mm², 1181±96 DLU/mm² and 1866±246 DLU/mm²) indicating a specific binding to activated platelets; P<0.05. Applying these findings to an ex vivo mouse model of carotid artery thrombosis revealed a significant increase in ligand uptake after injection of ¹¹¹In-LIBS in the presence of small thrombi compared to the non-injured side, as confirmed by histology (49630±10650 DLU/mm² vs. 17390±7470 DLU/mm²; P<0.05). These findings could also be reproduced in vivo. SPECT-CT analysis of the injured carotid artery with ¹¹¹In-LIBS resulted in a significant increase of the target-to-background ratio compared to ¹¹¹In-control (1.99±0.36 vs. 1.1±0.24; P<0.01).

Conclusions/Significance

Nuclear imaging with ¹¹¹In-LIBS allows the detection of platelet activation in vitro and ex vivo with high sensitivity. Using SPECT-CT, wall-adherent activated platelets in carotid arteries could be depicted in vivo. These results encourage further studies elucidating the role of activated platelets in plaque pathology and atherosclerosis and might be of interest for further developments towards clinical application.

Principles and basic concepts of molecular imaging

Advanced knowledge in molecular biology and new technological developments in imaging modalities and contrast agents calls for molecular imaging (MI) to play a major role in the near future in many human diseases (Weissleder and Mahmood Radiology 219:316-333, 2001). Imaging systems are providing higher signal-to-noise ratio and higher spatial and/or temporal resolution. New specific contrast agents offer the opportunity to drive new challenges for obtaining functional and biological information on tissue characteristics and tissue processes. All this information could be relevant for diagnosis, prognosis and treatment follow-up and to drive local therapies, enhancing local drug/gene delivery. The recent explosion of all these developments is a radical change of perspective in our imaging community because they could have a tremendous impact on our clinical practice and on teaching programs and they call for a more prominent multidisciplinary approach in this field of research.

Novel iodinated tracers, MIBG and BMIPP, for nuclear cardiology

With the rapid growth of molecular biology, in vivo imaging of such molecular process (i.e., molecular imaging) has been well developed. The molecular imaging has been focused on justifying advanced treatments and for assessing the treatment effects. Most of molecular imaging has been developed using PET camera and suitable PET radiopharmaceuticals. However, this technique cannot be widely available and we need alternative approach. ¹²³I-labeled compounds have been also suitable for molecular imaging using single-photon computed tomography (SPECT) ¹²³I-labeled meta-iodobenzylguanidine (MIBG) has been used for assessing severity of heart failure and prognosis. In addition, it has a potential role to predict fatal arrhythmia, particularly for those who had and are planned to receive implantable cardioverter-defibrillator treatment. ¹²³I-beta-methyl-iodophenylpentadecanoic acid (BMIPP) plays an important role for identifying ischemia at rest, based on the unique capability to represent persistent metabolic alteration after recovery of ischemia, so called ischemic memory. Since BMIPP abnormalities may represent severe ischemia or jeopardized myocardium, it may permit risk analysis in CAD patients, particularly for those with chronic kidney disease and/or hemodialysis patients. This review will discuss about recent development of these important iodinated compounds.

Molecular imaging of macrophage protease activity in cardiovascular inflammation in vivo

Macrophages contribute pivotally to cardiovascular diseases (CVD), notably to atherosclerosis. Imaging of macrophages in vivo could furnish new tools to advance evaluation of disease and therapies. Proteolytic enzymes serve as key effectors of many macrophage contributions to CVD. Therefore, intravital imaging of protease activity could aid evaluation of the progress and outcome of atherosclerosis, aortic aneurysm formation, or rejection of cardiac allografts. Among the large families of proteases, matrix metalloproteinases (MMPs) and cysteinyl cathepsins have garnered the most interest because of their participation in extracellular matrix remodelling. These considerations have spurred the development of dedicated imaging agents for protease activity detection. Activatable fluorescent probes, radiolabelled inhibitors, and nanoparticles are currently under exploration for this purpose. While some agents and technologies may soon see clinical use, others will require further refinement. Imaging of macrophages and protease activity should provide an important adjunct to understanding pathophysiology in vivo, evaluating the effects of interventions, and ultimately aiding clinical care.

Molecular imaging: current status and emerging strategies

In vivo molecular imaging has a great potential to impact medicine by detecting diseases in early stages (screening), identifying extent of disease, selecting disease- and patient-specific treatment (personalized medicine), applying a directed or targeted therapy, and measuring molecular-specific effects of treatment. Current clinical molecular imaging approaches primarily use positron-emission tomography (PET) or single photon-emission computed tomography (SPECT)-based techniques. In ongoing preclinical research, novel molecular targets of different diseases are identified and, sophisticated and multifunctional contrast agents for imaging these molecular targets are developed along with new technologies and instrumentation for multi-modality molecular imaging. Contrast-enhanced molecular ultrasound (US) with molecularly-targeted contrast microbubbles is explored as a clinically translatable molecular imaging strategy for screening, diagnosing, and monitoring diseases at the molecular level. Optical imaging with fluorescent molecular probes and US imaging with molecularly-targeted microbubbles are attractive strategies as they provide real-time imaging, are relatively inexpensive, produce images with high spatial resolution, and do not involve exposure to ionizing irradiation. Raman spectroscopy/microscopy has emerged as a molecular optical imaging strategy for ultrasensitive detection of multiple biomolecules/biochemicals with both in vivo and ex vivo versatility. Photoacoustic imaging is a hybrid of optical and US techniques involving optically-excitable molecularly-targeted contrast agents and quantitative detection of resulting oscillatory contrast agent movement with US. Current preclinical findings and advances in instrumentation, such as endoscopes and microcatheters, suggest that these molecular imaging methods have numerous potential clinical applications and will be translated into clinical use in the near future.

Nanoparticles as magnetic resonance imaging contrast agents for vascular and cardiac diseases

Advances in nanoparticle contrast agents for molecular imaging have made magnetic resonance imaging a promising modality for noninvasive visualization and assessment of vascular and cardiac disease processes. This review provides a description of the various nanoparticles exploited for imaging cardiovascular targets. Nanoparticle probes detecting inflammation, apoptosis, extracellular matrix, and angiogenesis may provide tools for assessing the risk of progressive vascular dysfunction and heart failure. The utility of nanoparticles as multimodal probes and/or theranostic agents has also been investigated. Although clinical application of these nanoparticles is largely unexplored, the potential for enhancing disease diagnosis and treatment is considerable.

Molecular imaging with contrast enhanced ultrasound

Noninvasive cardiovascular imaging techniques are well-established for studying cardiovascular anatomy and physiology. Over the past decade contrast enhanced imaging techniques have been developed that are also able to characterize the molecular constituents of cardiovascular disease. In this regard, microbubble- and ultrasound-based techniques have the ability to assess a broad range of molecular components of cardiovascular pathology such as inflammation, recent ischemia, atherosclerosis, acute transplant rejection, angiogenesis, and thrombosis. The advantages of ultrasound- and microbubble-based approach include the ability to assess multiple molecular disease markers without exposure to ionizing radiation or prolonged imaging protocols. This review highlights the development of microbubble-based molecular imaging, describes successful experimental conditions in which they have been studied, and postulates the importance of translating this technique into the clinical practice.

Current status of cardiovascular magnetic resonance imaging in the assessment of coronary vasculature

The present review describes the contributions of cardiovascular magnetic resonance (CMR) imaging to the assessment of coronary vasculature. It briefly describes various approaches and highlights the value of comprehensive CMR protocols. The limitations of coronary angiography for clinical decision-making and the additional value of plaque imaging and tissues characterization, as well as future directions of CMR and hybrid techniques for assessing microvascular function and myocardial oxygenation, are discussed.

Approaches to Multimodality Imaging of Angiogenesis

Angiogenesis, defined as the formation of new capillaries by cellular outgrowth from existing microvessels, can be assessed by the evaluation of perfusion, function, and metabolism. However, more recently, novel, noninvasive imaging strategies for the evaluation of molecular events associated with the angiogenic process have been developed.

Nanomedicine and Cardiovascular Disease

Nanomedicine has become an important tool in the imaging and therapy of numerous diseases. This is due, in large part, to the ability to generate multifunctional nanoagents bearing combinations of targeting, diagnostic, and therapeutic moieties, allowing for the tailoring of the properties of the synthesized nanomaterials. With respect to cardiovascular disease and its sequelae, nanomedicine has the potential to detect and treat some of the leading causes of death and disability in the developed world, including atherosclerosis, thrombosis, and myocardial infarction. As such, this review focuses on some of the most poignant examples of the utility of nanomedicine in the detection and treatment of cardiovascular disease that have been recently reported.

Applications of cardiac multidetector CT beyond coronary angiography

Noninvasive imaging of the coronary arteries using multidetector CT (MDCT) represents one of the most promising diagnostic imaging advances in contemporary cardiology. This challenging application has driven a rapid and impressive advancement in CT technology over the past 10 years; leading to increased spatial and temporal resolution, decreased scan times and substantial reductions in radiation dose. Recent technological improvements have not only improved the status of CT coronary angiography but have also enabled new functional myocardial applications that are gaining a foothold in clinical practice as adjuncts or replacements for conventional coronary angiographic studies. Wide-detector CT designs along with prospective ECG-triggered protocols have opened the possibility of performing multiple complementary myocardial measurements during a coronary CT exam with acceptable radiation and contrast exposure. In this Review, we discuss recent technical developments in cardiac MDCT and outline newly enabled noncoronary cardiac applications including viability assessment, myocardial perfusion and molecular imaging.

Advances in radionuclide molecular imaging in myocardial biology

Molecular imaging is a new and evolving field that employs a targeted approach to noninvasively assess biologic processes in vivo. By assessing key elements in specific cellular processes prior to irreversible end-organ damage, molecular tools will allow for earlier detection and intervention, improving management and outcomes associated with cardiovascular diseases. The goal of those working to expand this field is not just to provide diagnostic and prognostic information, but rather to guide an individual's pharmacological, cell-based, or genetic therapeutic regimen. This article will review molecular imaging tools in the context of our current understanding of biological processes of the myocardium, including angiogenesis, ventricular remodeling, inflammation, and apoptosis. The focus will be on radiotracer-based molecular imaging modalities with an emphasis on clinical application. Though this field is still in its infancy and may not be fully ready for widespread use, molecular imaging of myocardial biology has begun to show promise of clinical utility in acute and chronic ischemia, acute myocardial infarction, congestive heart failure, as well as in more global inflammatory and immune-mediated responses in the heart-like myocarditis and allogeneic cardiac transplant rejection. With continued research and development, molecular imaging promises to be an important tool for the optimization of cardiovascular care.

PET and SPECT in cardiovascular molecular imaging

The current focus of cardiovascular medicine is on early detection and prevention of disease, to control the escalating costs of health care. To achieve this goal, novel imaging approaches that allow for early detection of disease and risk stratification are needed. Traditionally, the diagnosis, monitoring, and prognostication of cardiovascular disease were based on techniques that measured changes in metabolism, blood flow, and biological function. Molecular imaging is emerging as a new tool for the noninvasive detection of biological processes that can differentiate and characterize tissues before manifestation of gross anatomical features or physiological consequences. Leading the way are techniques involving high-sensitivity radiotracers that could revolutionize current diagnostic paradigms. This Review provides an overview of selected molecular-based single photon emission CT (SPECT) and PET imaging strategies for the evaluation of cardiovascular disease-including the evaluation of myocardial metabolism and neurohumoral activity of the heart-and potential future targeted methods of evaluating critical molecular processes, such as atherosclerosis, ventricular remodeling after myocardial infarction, and ischemia-associated angiogenesis.

Hybrid in vivo FMT-CT imaging of protease activity in atherosclerosis with customized nanosensors

OBJECTIVE

Proteases are emerging biomarkers of inflammatory diseases. In atherosclerosis, these enzymes are often secreted by inflammatory macrophages, digest the extracellular matrix of the fibrous cap, and destabilize atheromata. Protease function can be monitored with protease activatable imaging probes and quantitated in vivo by fluorescence molecular tomography (FMT). To address 2 major constraints currently associated with imaging of murine atherosclerosis (lack of highly sensitive probes and absence of anatomic information), we compared protease sensors (PS) of variable size and pharmacokinetics and coregistered FMT datasets with computed tomography (FMT-CT).

METHODS AND RESULTS

Coregistration of FMT and CT was achieved with a multimodal imaging cartridge containing fiducial markers detectable by both modalities. A high-resolution CT angiography protocol accurately localized fluorescence to the aortic root of atherosclerotic apoE(-/-) mice. To identify suitable sensors, we first modeled signal kinetics in-silico and then compared 3 probes with oligo-L-lysine cleavage sequences: PS-5, 5 nm in diameter containing 2 fluorochromes, PS-25, a 25-nm version with an elongated lysine chain and PS-40, a polymeric nanoparticle. Serial FMT-CT showed fastest kinetics for PS-5 but, surprisingly, highest fluorescence in lesions of the aortic root for PS-40. PS-40 robustly reported therapeutic effects of atorvastatin, corroborated by ex vivo imaging and qPCR for the model protease cathepsin B.

CONCLUSIONS

FMT-CT is a robust and observer-independent tool for noninvasive assessment of inflammatory murine atherosclerosis. Reporter-containing nanomaterials may have unique advantages over small molecule agents for in vivo imaging.

New molecular imaging targets to characterize myocardial biology

Molecular imaging represents a targeted approach to noninvasively assess biologic (both physiologic and pathologic) processes in vivo. Ideally the goal of molecular imaging is not just to provide diagnostic and prognostic information based on identification of the molecular events associated with a pathologic process but rather to guide individually tailored pharmacologic, cell-based, or genetic therapeutic regimens. This article reviews the recent advances in myocardial molecular imaging in the context of the cardiovascular processes of angiogenesis, apoptosis, inflammation, and ventricular remodeling. The focus is on radiotracer-based single photon emission computed tomography and positron emission tomography molecular imaging approaches.

Clinical cardiovascular molecular imaging

Molecular imaging holds the promise of becoming a key diagnostic modality in cardiovascular medicine by allowing visualization of specific targets and pathways that precede or underlie changes in morphology, physiology, and function. As such, molecular imaging aims at detecting precursors or early stages of cardiovascular disease and at monitoring and guiding novel, increasingly specific and versatile cardiovascular therapies. Imaging of myocardial metabolism and autonomic innervation are already used in current practice, and a wide variety of other targets and probes is on the horizon. This focused review provides an overview of the opportunities and challenges that molecular imaging faces to fulfill its promises in clinical cardiovascular medicine.