Molecular cardiovascular imaging

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.

Cardiac positron emission tomography

Positron emission tomography (PET) is a powerful, quantitative imaging modality that has been used for decades to noninvasively investigate cardiovascular biology and physiology. Due to limited availability, methodologic complexity, and high costs, it has long been seen as a research tool and as a reference method for validation of other diagnostic approaches. This perception, fortunately, has changed significantly within recent years. Increasing diversity of therapeutic options for coronary artery disease, and increasing specificity of novel therapies for certain biologic pathways, has resulted in a clinical need for more accurate and specific diagnostic techniques. At the same time, the number of PET centers continues to grow, stimulated by PET's success in oncology. Methodologic advances as well as improved radiotracer availability have further contributed to more widespread use. Evidence for diagnostic and prognostic usefulness of myocardial perfusion and viability assessment by PET is increasing. Some studies suggest overall cost-effectiveness of the technique despite higher costs of a single study, because unnecessary follow-up procedures can be avoided. The advent of hybrid PET-computed tomography (CT), which enables integration of PET-derived biologic information with multislice CT-derived morphologic information, and the key role of PET in the development and translation of novel molecular-targeted imaging compounds, have further contributed to more widespread acceptance. Today, PET promises to play a leading diagnostic role on the pathway toward a future of high-powered, comprehensive, personalized, cardiovascular medicine. This review summarizes the state-of-the-art in current imaging methodology and clinical application, and outlines novel developments and future directions.

Serial noninvasive targeted imaging of peripheral angiogenesis: validation and application of a semiautomated quantitative approach

Previous studies by our group have demonstrated the feasibility of noninvasive imaging of alpha(v) integrin to assess temporal and spatial changes in peripheral and myocardial angiogenesis. In this study, we validate the reproducibility, accuracy, and applicability of a new semiautomated noninvasive approach for serial quantitative evaluation of targeted micro-SPECT/CT images of peripheral angiogenesis in wild-type and endothelial nitric oxide sythase (eNOS)-deficient (eNOS-/-) mice subjected to hindlimb ischemia.

METHODS

Mice (n = 15) underwent surgical ligation of the right femoral artery to induce unilateral hindlimb ischemia. One week after ligation, a (99m)Tc-labeled cyclic-Arg-Gly-Asp peptide targeted at alpha(v) integrin (NC100692, n = 10) or a (99m)Tc-labeled negative control (AH-111744, n = 5) was injected, and 60 min later in vivo micro-SPECT/CT images were acquired. Mice were euthanized, tissue from proximal and distal hindlimb was excised for gamma-well counting (GWC) of radiotracer activity, and ischemic-to-nonischemic (I/NI) ratio was calculated. Micro-SPECT/CT images were analyzed using a new semiautomated approach that applies complex volumes of interest (VOIs) derived from segmentation of the micro-CT images onto micro-SPECT images to calculate I/NI activity ratios for the proximal and distal hindlimb. Studies were reprocessed for determination of intra- and interobserver variability. To compare 3-dimensional (3D) VOI analysis with traditional manual 2-dimensional region-of-interest (ROI) analysis of maximum-intensity-projection images, micro-SPECT images were summed onto a single anterior-posterior projection. Rectangular ROIs were manually drawn and I/NI ratio calculated. Our new 3D analysis approach was applied to additional groups of mice (eNOS-/-, n = 5; wild-type, n = 3) imaged before and 1 and 4 wk after femoral artery resection.

RESULTS

Our new semiautomated approach for the evaluation of images of alpha(v) integrin targeted with micro-SPECT/CT demonstrated both a high intra- and interobserver variability (R(2) = 0.997) and an accuracy (R(2) = 0.780) for estimation of relative radiotracer activity relative to GWC. Analysis of serial micro-SPECT/CT images demonstrated a significant increase in relative NC100692 retention in the ischemic hindlimb of both wild-type and eNOS-/- mice at 1 wk after surgery. There was a significant (approximately 25%) decrease in radiotracer uptake in eNOS-/- mice relative to wild-type animals, which was not observed at baseline or 4 wk after ligation.

CONCLUSION

A new semiautomated analysis of images of alpha(v) integrin targeted with micro-SPECT/CT provides a noninvasive approach for serial quantitative evaluation of peripheral angiogenesis. The reproducibility and accuracy of this approach allows for quantitative analysis of serial targeted molecular images of lower extremities, has applicability to other targeted SPECT or PET radiotracers, and may have implications for clinical imaging in patients with peripheral arterial disease.

Quantitative FDG-uptake by positron emission tomography in progressive hypertrophy of rat hearts in vivo

BACKGROUND

Quantitative myocardial fluorodeoxyglucose positron emission tomography (FDG-PET) for assessing glucose uptake in vivo is reliable in normal rat heart.

OBJECTIVE

To assess the applicability of myocardial FDG-PET on multiple occasions in the longitudinal disease process of progressive hypertrophy of rat heart.

METHODS

Six salt-sensitive Dahl rats (Dahl-S) developing progressive hypertrophy with subsequent dilated cardiomyopathy were compared with salt-resistant Dahl rats (controls). FDG-PET was applied twice at early stage (ES: 14-18 weeks) and at late stage (LS: 22-26 weeks) of hypertrophy. Standardized uptake value (SUV) was calculated for comparing between different animal weights and different injection dosages of FDG. For validating the quantitative study, radioactivity of a total of 36 tissue samples was compared with the corresponding PET values.

RESULTS

The left ventricular mass in Dahl-S increased by 17% at ES and by 25% at LS. The SUV in Dahl-S was 95% of controls at ES and reduced to 62% at LS (P=0.023). The heart function started to deteriorate after LS. Linear regression analysis showed a good correlation between the radioactivity of tissue samples and PET values (Y=1.20X, P<0.0001, R2=0.979).

CONCLUSIONS

Small animal PET studies on longitudinal multiple occasions in vivo were feasible and useful for the repeating assessment of glucose uptake. The reduction of glucose uptake in progressive hypertrophy of heart over time may precede its progression to heart failure.

Biomedical imaging research opportunities workshop IV: a white paper

The Fourth Biomedical Imaging Research Opportunities Workshop (BIROW IV) was held on February 24-25, 2006, in North Bethesda, MD. The workshop focused on opportunities for research and development in four areas of imaging: imaging of rodent models; imaging in drug development; imaging of chronic metabolic disease: diabetes; and image guided intervention in the fourth dimension-time. These topics were examined by four keynote speakers in plenary sessions and then discussed in breakout sessions devoted to identifying research opportunities and challenges in the individual topics. This paper synthesizes these discussions into a strategy for future research directions in biomedical imaging.

Nuclear Cardiology: Present and Future

Nuclear cardiology has made significant advances since the first reports of planar scintigraphy for the evaluation of left ventricular perfusion and function. While the current "state of the art" of gated myocardial perfusion single-photon emission computed tomographic (SPECT) imaging offers invaluable diagnostic and prognostic information for the evaluation of patients with suspected or known coronary artery disease (CAD), advances in the cellular and molecular biology of the cardiovascular system have helped to usher in a new modality in nuclear cardiology, namely, molecular imaging. In this review, we will discuss the current state of the art in nuclear cardiology, which includes SPECT and positron emission tomographic evaluation of myocardial perfusion, evaluation of left ventricular function by gated myocardial perfusion SPECT and gated blood pool SPECT, and the evaluation of myocardial viability with PET and SPECT methods. In addition, we will discuss the future of nuclear cardiology and the role that molecular imaging will play in the early detection of CAD at the level of the vulnerable plaque, the evaluation of cardiac remodeling, and monitoring of important new therapies including gene therapy and stem cell therapy.

Third Annual Mario S. Verani, MD, Memorial Lecture: The future of clinical nuclear cardiology

It is a great honor and privilege to present the Third Annual Mario S. Verani, MD, Memorial Lecture. Mario Verani (1943-2001) will be remembered foremost for his major contributions to the field of nuclear cardiology (Figure 1). For instance, he was one of the first investigators to recognize that fixed thallium defects were often not just scar but could be reversed by coronary revascularization. This led to an extensive revision of accepted traditional concepts on the meaning of image patterns. Mario's work on risk stratification by myocardial perfusion and function imaging after acute myocardial infarction was equally pioneering. He also laid out the basic principles for the safe use of adenosine for pharmacologic stress testing. Adenosine is now the preferred procedure all over the world in millions of patients. Dr Verani was a founding member and past president (1996-1997) of the American Society of Nuclear Cardiology (ASNC). The day before he died, he received the ASNC Distinguished Service Award. Personally, I will remember Mario as a very dear friend. We spent many hours together at meetings and gatherings all over the world. I still miss his outgoing personality, his warmth, his humor, and his enthusiasm. Above all, I enjoyed his comfortable friendship. That this friendship extended itself naturally to our wives, Regina and Marjan, made it all the more special. One of the best times we had was during a cardiology meeting in Recife, in the country of his birth, Brazil. I was greatly amused and, at the same time, impressed by the admiration and respect bestowed on him by his fellow Brazilians. One evening, we were going some place in the street on foot. We could not walk down the street without Mario being stopped by one or another Brazilian cardiologist who wanted to speak and consult with him. He was clearly greatly admired and appreciated in his country. I jokingly called him "King of Recife," and the king was holding audience. We arrived rather late where we were going... . I will always cherish the memories of our times together. I am grateful that I could visit Mario at his sickbed on the day before he passed away. He was so fragile and, at the same time, so courageous. I felt sad that there was so much that we could have discussed that we did not. Life seems sometimes full of missed opportunities... .