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Alonso Martinez LM, Naim N, Saiz AH, Simard JM, Boudjemeline M, Juneau D, DaSilva JN. A Reliable Production System of Large Quantities of [ 13N]Ammonia for Multiple Human Injections. Molecules 2023; 28:molecules28114517. [PMID: 37298995 DOI: 10.3390/molecules28114517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/25/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
[13N]Ammonia is one of the most commonly used Positron Emission Tomography (PET) radiotracers in humans to assess myocardial perfusion and measure myocardial blood flow. Here, we report a reliable semi-automated process to manufacture large quantities of [13N]ammonia in high purity by proton-irradiation of a 10 mM aqueous ethanol solution using an in-target process under aseptic conditions. Our simplified production system is based on two syringe driver units and an in-line anion-exchange purification for up to three consecutive productions of ~30 GBq (~800 mCi) (radiochemical yield = 69 ± 3% n.d.c) per day. The total manufacturing time, including purification, sterile filtration, reformulation, and quality control (QC) analyses performed before batch release, is approximately 11 min from the End of Bombardment (EOB). The drug product complies with FDA/USP specifications and is supplied in a multidose vial allowing for two doses per patient, two patients per batch (4 doses/batch) on two separate PET scanners simultaneously. After four years of use, this production system has proved to be easy to operate and maintain at low costs. Over the last four years, more than 1000 patients have been imaged using this simplified procedure, demonstrating its reliability for the routine production of large quantities of current Good Manufacturing Practices (cGMP)-compliant [13N]ammonia for human use.
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Affiliation(s)
- Luis Michel Alonso Martinez
- Radiochemistry and Cyclotron Platform, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Rue Saint Denis, Montréal, QC H2X 0A9, Canada
| | - Nabil Naim
- Radiochemistry and Cyclotron Platform, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Rue Saint Denis, Montréal, QC H2X 0A9, Canada
| | - Alejandro Hernandez Saiz
- Radiochemistry and Cyclotron Platform, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Rue Saint Denis, Montréal, QC H2X 0A9, Canada
| | - José-Mathieu Simard
- Radiochemistry and Cyclotron Platform, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Rue Saint Denis, Montréal, QC H2X 0A9, Canada
- Radiopharmaceutical Science Laboratory, CHU de Québec, 2250 Boul. Henri-Bourassa, Québec, QC G1J 5B3, Canada
| | - Mehdi Boudjemeline
- Radiochemistry and Cyclotron Platform, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Rue Saint Denis, Montréal, QC H2X 0A9, Canada
- Radiopharmaceutical Science Laboratory, CHU de Québec, 2250 Boul. Henri-Bourassa, Québec, QC G1J 5B3, Canada
| | - Daniel Juneau
- Radiochemistry and Cyclotron Platform, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Rue Saint Denis, Montréal, QC H2X 0A9, Canada
- Department of Radiology, Radio-Oncology and Nuclear Medicine, UdeM, Pavillon Roger-Gaudry S-716, 2900 Boul. Édouard Montpetit, Montréal, QC H3C 3J7, Canada
| | - Jean N DaSilva
- Radiochemistry and Cyclotron Platform, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Rue Saint Denis, Montréal, QC H2X 0A9, Canada
- Department of Radiology, Radio-Oncology and Nuclear Medicine, UdeM, Pavillon Roger-Gaudry S-716, 2900 Boul. Édouard Montpetit, Montréal, QC H3C 3J7, Canada
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2
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Nye JA, Cooke CD. Accounting for residual activity in the estimate of myocardial blood flow with PET. J Nucl Cardiol 2022; 29:2271-2273. [PMID: 34918236 DOI: 10.1007/s12350-021-02873-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Jonathon A Nye
- Department of Radiology and Imaging Sciences, Emory School of Medicine, Emory University, 1841 Clifton Rd. NE, Atlanta, GA, 30329, USA.
| | - C David Cooke
- Department of Radiology and Imaging Sciences, Emory School of Medicine, Emory University, 1841 Clifton Rd. NE, Atlanta, GA, 30329, USA
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3
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Poitrasson-Rivière A, Moody JB, Renaud JM, Hagio T, Arida-Moody L, Buckley C, Weinberg RL, Ficaro EP, Murthy VL. Impact of residual subtraction on myocardial blood flow and reserve estimates from rapid dynamic PET protocols. J Nucl Cardiol 2022; 29:2262-2270. [PMID: 34780036 DOI: 10.1007/s12350-021-02837-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 09/27/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND 13N-ammonia and 18F-flurpiridaz require longer delays between rest and stress studies to allow for decay, lowering clinical throughput. In this study, we investigated the impact of residual subtraction on MBF and MFR estimates, as well as its effects on diagnostic accuracy. METHODS We retrospectively analyzed 63 patients who underwent a dynamic ammonia rest/stress study and 231 patients from the flurpiridaz 301 trial. Residual subtraction was performed by subtracting the mean pre-injection activity in each sampled region from that region's time activity curve. Corrected and uncorrected MBF and MFR were analyzed. Diagnostic accuracy was compared to quantitative coronary angiograms (QCA) for the flurpiridaz population. RESULTS With delays between injections above 3 half-lives, and a doubled stress dose, residual activity did not meaningfully increase ammonia MBF (< 5%). For shorter injection delays, stress MBF was overestimated by 13.6% ± 5.0% (P < .001). Residual activity had a large effect on flurpiridaz stress MBF, overestimating it by 37.9% ± 23.2% (P < .001). Comparison to QCA showed a significant improvement in AUC with residual subtraction (from 0.748 to 0.831, P = .001). MFR yielded similar results. CONCLUSIONS Accounting for residual activity has a marked impact on stress MBF and MFR and improves diagnostic accuracy relative to QCA.
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Affiliation(s)
| | - Jonathan B Moody
- INVIA Medical Imaging Solutions, 3025 Boardwalk Drive, Suite 200, Ann Arbor, MI, 48108, USA
| | - Jennifer M Renaud
- INVIA Medical Imaging Solutions, 3025 Boardwalk Drive, Suite 200, Ann Arbor, MI, 48108, USA
| | - Tomoe Hagio
- INVIA Medical Imaging Solutions, 3025 Boardwalk Drive, Suite 200, Ann Arbor, MI, 48108, USA
| | - Liliana Arida-Moody
- Division of Cardiovascular Medicine, Department of Internal Medicine and Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | | | - Richard L Weinberg
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Edward P Ficaro
- INVIA Medical Imaging Solutions, 3025 Boardwalk Drive, Suite 200, Ann Arbor, MI, 48108, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine and Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Venkatesh L Murthy
- Division of Cardiovascular Medicine, Department of Internal Medicine and Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
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Harland DR, Galazka PZ, Rasmussen J, Mahlum D, Falk J, Port SC. Feasibility of exercise treadmill 13N-ammonia positron emission tomography myocardial perfusion imaging using an off-site cyclotron. J Nucl Cardiol 2022; 29:938-945. [PMID: 33073320 DOI: 10.1007/s12350-020-02366-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Myocardial perfusion imaging with treadmill exercise nitrogen-13 (13N)-ammonia positron emission tomography (PET) presents a logistical challenge. We investigated the feasibility of exercise treadmill (GXT) 13N-ammonia PET MPI using an off-site cyclotron for production of 13N-ammonia. METHODS Thirty-three patients underwent GXT 13N-ammonia PET MPI over 23 months. 13N-ammonia doses were prepared at an off-site cyclotron. Patients underwent 13N-ammonia resting and 13N-ammonia GXT emission and transmission scans at our facility. Image quality, perfusion data, and clinical variables were evaluated. RESULTS We analyzed 33 patients (7/26 female/male). Mean age was 63 ± 12 years and mean BMI was 33.7 ± 6.9. GXT PET was feasible in all patients. Image quality was good in 29 patients, adequate in 3, and severely compromised in 1 patient. Summed stress score was 4.5 ± 5.7. Resting and GXT left ventricular ejection fractions were 63.7 ± 10.9% and 66.3 ± 13.1%. TID ratio was 1.0 ± 0.1. CONCLUSIONS Treadmill exercise 13N-ammonia PET is feasible in a large medical center without access to an on-site cyclotron. This technique requires close coordination with an off-site cyclotron but expands the role of PET to patients for whom exercise is more appropriate than pharmacologic stress imaging.
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Affiliation(s)
- Daniel R Harland
- Advocate Aurora Health Care, Aurora Sinai/Aurora St. Luke's Medical Centers, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI, 53215, USA.
| | - Patrycja Z Galazka
- Advocate Aurora Health Care, Aurora Sinai/Aurora St. Luke's Medical Centers, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI, 53215, USA
| | | | - Debra Mahlum
- Advocate Aurora Health Care, Aurora Sinai/Aurora St. Luke's Medical Centers, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI, 53215, USA
| | - Janelle Falk
- Advocate Aurora Health Care, Aurora Sinai/Aurora St. Luke's Medical Centers, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI, 53215, USA
| | - Steven C Port
- Advocate Aurora Health Care, Aurora Sinai/Aurora St. Luke's Medical Centers, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI, 53215, USA
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Rozanski A, Berman DS, Iskandrian AE. The imperative to assess physical function among all patients undergoing stress myocardial perfusion imaging. J Nucl Cardiol 2022; 29:946-951. [PMID: 33073319 DOI: 10.1007/s12350-020-02378-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Alan Rozanski
- Department of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and The Icahn School of Medicine at Mount Sinai, 1111 Amsterdam Avenue, New York, NY, 10025, USA.
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ami E Iskandrian
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
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Crișan G, Moldovean-Cioroianu NS, Timaru DG, Andrieș G, Căinap C, Chiș V. Radiopharmaceuticals for PET and SPECT Imaging: A Literature Review over the Last Decade. Int J Mol Sci 2022; 23:5023. [PMID: 35563414 PMCID: PMC9103893 DOI: 10.3390/ijms23095023] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/23/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
Positron emission tomography (PET) uses radioactive tracers and enables the functional imaging of several metabolic processes, blood flow measurements, regional chemical composition, and/or chemical absorption. Depending on the targeted processes within the living organism, different tracers are used for various medical conditions, such as cancer, particular brain pathologies, cardiac events, and bone lesions, where the most commonly used tracers are radiolabeled with 18F (e.g., [18F]-FDG and NA [18F]). Oxygen-15 isotope is mostly involved in blood flow measurements, whereas a wide array of 11C-based compounds have also been developed for neuronal disorders according to the affected neuroreceptors, prostate cancer, and lung carcinomas. In contrast, the single-photon emission computed tomography (SPECT) technique uses gamma-emitting radioisotopes and can be used to diagnose strokes, seizures, bone illnesses, and infections by gauging the blood flow and radio distribution within tissues and organs. The radioisotopes typically used in SPECT imaging are iodine-123, technetium-99m, xenon-133, thallium-201, and indium-111. This systematic review article aims to clarify and disseminate the available scientific literature focused on PET/SPECT radiotracers and to provide an overview of the conducted research within the past decade, with an additional focus on the novel radiopharmaceuticals developed for medical imaging.
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Affiliation(s)
- George Crișan
- Faculty of Physics, Babeş-Bolyai University, Str. M. Kogălniceanu 1, 400084 Cluj-Napoca, Romania; (G.C.); (N.S.M.-C.); (D.-G.T.)
- Department of Nuclear Medicine, County Clinical Hospital, Clinicilor 3-5, 400006 Cluj-Napoca, Romania;
| | | | - Diana-Gabriela Timaru
- Faculty of Physics, Babeş-Bolyai University, Str. M. Kogălniceanu 1, 400084 Cluj-Napoca, Romania; (G.C.); (N.S.M.-C.); (D.-G.T.)
| | - Gabriel Andrieș
- Department of Nuclear Medicine, County Clinical Hospital, Clinicilor 3-5, 400006 Cluj-Napoca, Romania;
| | - Călin Căinap
- The Oncology Institute “Prof. Dr. Ion Chiricuţă”, Republicii 34-36, 400015 Cluj-Napoca, Romania;
| | - Vasile Chiș
- Faculty of Physics, Babeş-Bolyai University, Str. M. Kogălniceanu 1, 400084 Cluj-Napoca, Romania; (G.C.); (N.S.M.-C.); (D.-G.T.)
- Institute for Research, Development and Innovation in Applied Natural Sciences, Babeș-Bolyai University, Str. Fântânele 30, 400327 Cluj-Napoca, Romania
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Kamar F, Kovacs MS, Hicks JW. Low cost and open source purification apparatus for GMP [ 13N]Ammonia production. Appl Radiat Isot 2022; 185:110214. [PMID: 35397362 DOI: 10.1016/j.apradiso.2022.110214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/14/2022] [Accepted: 03/20/2022] [Indexed: 11/26/2022]
Abstract
Nitrogen-13 labeled ammonia ([13N]NH3) has been used for myocardial perfusion imaging with Positron Emission Tomography for decades. Recent increases to regulatory oversight have led to stricter adherence to Good Manufacturing Practice (GMP) when producing this short half-life (9.97 min) radiopharmaceutical. This has increased production costs. Our cyclotron facility initially developed a manual GMP production method, but it was prone to human error. With increased costs in mind, we developed and validated an Arduino-based device to purifying [13N]NH3 for clinical use. Construction, programming, and GMP validation results are discussed. The automated method was found to produce equivalent quality radiopharmaceutical but was more reproducible and robust.
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Affiliation(s)
- Farah Kamar
- Medical Biophysics, Western University, London, ON, Canada
| | - Michael S Kovacs
- Medical Biophysics, Western University, London, ON, Canada; Medical Imaging, Western University, London, ON, Canada; Cyclotron and Radiochemistry Facility, Lawson Health Research Institute, London, ON, Canada
| | - Justin W Hicks
- Medical Biophysics, Western University, London, ON, Canada; Cyclotron and Radiochemistry Facility, Lawson Health Research Institute, London, ON, Canada.
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8
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Alnabelsi T, Thakkar A, Ahmed AI, Han Y, Al-Mallah MH. PET/CT Myocardial Perfusion Imaging Acquisition and Processing: Ten Tips and Tricks to Help You Succeed. Curr Cardiol Rep 2021; 23:39. [PMID: 33694057 DOI: 10.1007/s11886-021-01476-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW Positron emission tomography (PET) is a leading non-invasive modality for the diagnosis of coronary artery disease due to its diagnostic accuracy and high image quality. With the latest advances in PET systems, clinicians are able to assess for myocardial ischemia and myocardial blood flow while exposing patients to extremely low radiation doses. This review will focus on the basics of acquisition and processing of hybrid PET/CT systems from appropriate patient selection to common artifacts and pitfalls. RECENT FINDINGS The continued development of hybrid PET/CT technology is producing scanners with exquisite sensitivity capable of generating high-quality images while exposing patients to low radiation doses. List mode acquisition is an essential component in all modern PET/CT scanners allowing simultaneous dynamic and ECG-gated imaging without lengthening scan duration. Various PET radiotracers are currently being developed but rubidium-82 and 13N-ammonia remain the most commonly used perfusion radiotracers. The development of mini 13N-ammonia cyclotrons is a promising tool that should increase access to this radiotracer. Misregistration, attenuation from extra-cardiac activity, and patient motion are the most common causes of artifacts during perfusion imaging. Techniques to automatically realign images and correct respiratory or patient motion artifacts continue to evolve. Despite the continuous evolution of PET imaging techniques, basic knowledge of scan parameters, acquisition techniques, and post processing tools remains essential to ensure high-quality images are produced and artifacts are recognized and corrected. Future research should focus on optimizing scanners to allow for shorter scan protocols and lower radiation exposure as well as continue developing techniques to minimize and correct for motion and misregistration artifacts.
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Affiliation(s)
- Talal Alnabelsi
- Houston Methodist Academic Institute, Houston Methodist Debakey Heart & Vascular Center, Houston Methodist Hospital, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Akanksha Thakkar
- Houston Methodist Academic Institute, Houston Methodist Debakey Heart & Vascular Center, Houston Methodist Hospital, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Ahmed Ibrahim Ahmed
- Houston Methodist Academic Institute, Houston Methodist Debakey Heart & Vascular Center, Houston Methodist Hospital, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Yushui Han
- Houston Methodist Academic Institute, Houston Methodist Debakey Heart & Vascular Center, Houston Methodist Hospital, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Mouaz H Al-Mallah
- Houston Methodist Academic Institute, Houston Methodist Debakey Heart & Vascular Center, Houston Methodist Hospital, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
- Weill Cornell Medicine, New York, NY, USA.
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9
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Horgan SJ, Heller GV. Widening the availability of ammonia to increase the footprint of cardiac PET. J Nucl Cardiol 2021; 28:300-302. [PMID: 31875287 DOI: 10.1007/s12350-019-01986-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Stephen J Horgan
- Division of Cardiovascular Medicine, Morristown Medical Center, Gagnon Cardiovascular Institute, Morristown, USA.
| | - Gary V Heller
- Division of Cardiovascular Medicine, Morristown Medical Center, Gagnon Cardiovascular Institute, Morristown, USA
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10
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Slomka PJ, Moody JB, Miller RJH, Renaud JM, Ficaro EP, Garcia EV. Quantitative clinical nuclear cardiology, part 2: Evolving/emerging applications. J Nucl Cardiol 2021; 28:115-127. [PMID: 33067750 DOI: 10.1007/s12350-020-02337-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Abstract
Quantitative analysis has been applied extensively to image processing and interpretation in nuclear cardiology to improve disease diagnosis and risk stratification. This is Part 2 of a two-part continuing medical education article, which will review the potential clinical role for emerging quantitative analysis tools. The article will describe advanced methods for quantifying dyssynchrony, ventricular function and perfusion, and hybrid imaging analysis. This article discusses evolving methods to measure myocardial blood flow with positron emission tomography and single-photon emission computed tomography. Novel quantitative assessments of myocardial viability, microcalcification and in patients with cardiac sarcoidosis and cardiac amyloidosis will also be described. Lastly, we will review the potential role for artificial intelligence to improve image analysis, disease diagnosis, and risk prediction. The potential clinical role for all these novel techniques will be highlighted as well as methods to optimize their implementation.
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Affiliation(s)
- Piotr J Slomka
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | | | - Robert J H Miller
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | | | - Edward P Ficaro
- INVIA Medical Imaging Solutions, Ann Arbor, MI, USA
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
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Slomka PJ, Moody JB, Miller RJH, Renaud JM, Ficaro EP, Garcia EV. Quantitative clinical nuclear cardiology, part 2: Evolving/emerging applications. J Nucl Med 2020; 62:168-176. [PMID: 33067339 DOI: 10.2967/jnumed.120.242537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/28/2020] [Indexed: 01/15/2023] Open
Abstract
Quantitative analysis has been applied extensively to image processing and interpretation in nuclear cardiology to improve disease diagnosis and risk stratification. This is Part 2 of a two-part continuing medical education article, which will review the potential clinical role for emerging quantitative analysis tools. The article will describe advanced methods for quantifying dyssynchrony, ventricular function and perfusion, and hybrid imaging analysis. This article discusses evolving methods to measure myocardial blood flow with positron emission tomography and single-photon emission computed tomography. Novel quantitative assessments of myocardial viability, microcalcification and in patients with cardiac sarcoidosis and cardiac amyloidosis will also be described. Lastly, we will review the potential role for artificial intelligence to improve image analysis, disease diagnosis, and risk prediction. The potential clinical role for all these novel techniques will be highlighted as well as methods to optimize their implementation. (J Nucl Cardiol 2020).
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Affiliation(s)
- Piotr J Slomka
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Robert J H Miller
- Department of Imaging (Division of Nuclear Medicine), Medicine, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | | | - Edward P Ficaro
- INVIA Medical Imaging Solutions, Ann Arbor, MI.,Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; and
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA
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12
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Yokell DL, Rice PA, Neelamegam R, El Fakhri G. Development, validation and regulatory acceptance of improved purification and simplified quality control of [ 13N] Ammonia. EJNMMI Radiopharm Chem 2020; 5:11. [PMID: 32405797 PMCID: PMC7221112 DOI: 10.1186/s41181-020-00097-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/04/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND [13N]Ammonia is a cyclotron produced myocardial perfusion imaging agent. With the development of high-yielding [13N]ammonia cyclotron targets using a solution of 5 mM ethanol in water, there was a need to develop and validate an automated purification and formulation system for [13N]ammonia to be in a physiological compatible formulation of 0.9% sodium chloride since there is no widely available commercial system at this time. Due to its short half-life of 10 min, FDA and USP regulations allow [13N]ammonia to be tested in quality control (QC) sub-batches with limited quality control testing performed on the sub-batches for patient use. The current EP and the original USP method for the determination of the radiochemical purity and identity of [13N]ammonia depended on an HPLC method using a conductivity detector and a solvent free of other salts. This HPLC method created issues in a modern cGMP high volume PET manufacturing facility where the HPLC is used with salt containing mobile phase buffers for quality control analysis of other PET radiopharmaceuticals. Flushing of the HPLC system of residual salt buffers which may interfere with the [13N]ammonia assay can take several hours of instrument time. Since there are no mass limits on [13N]ammonia, a simplified TLC assay to determine radiochemical identity and purity could be developed to simplify and streamline QC. RESULTS We have developed and validated a streamlined automated synthesis for [13N]ammonia which provides the drug product in 8 mL of 0.9% sodium chloride for injection. A novel radio-TLC method was developed and validated to demonstrate feasibility to quantitate [13N]ammonia and separate it from all known radiochemical impurities. CONCLUSIONS The process for automated synthesis of [13N]ammonia simplifies and automates the purification and formulation of [13N]ammonia in a cGMP compliant manner needed for high-throughput manufacture of [13N]ammonia. The novel radio-TLC method has simplified [13N]ammonia quality control (QC) and now enables it to be tested using the same QC equipment as [18F]fludeoxyglucose (FDA/USP recognized name for 2-[18F]fluoro-2-deoxy-D-glucose). Both the streamlined automated synthesis of [13N]ammonia and the novel radio-TLC method have been accepted and approved by the US Food and Drug Administration (FDA) for the cGMP manufacture of [13N]ammonia.
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Affiliation(s)
- Daniel L. Yokell
- Department of Radiology, Gordon Center for Medical Imaging, Massachusetts General Hospital, 55 Fruit Street, Edwards 019B, Boston, MA 02114 USA
- Department of Radiology, Harvard Medical School, Boston, MA USA
| | - Peter A. Rice
- Department of Radiology, Gordon Center for Medical Imaging, Massachusetts General Hospital, 55 Fruit Street, Edwards 019B, Boston, MA 02114 USA
| | - Ramesh Neelamegam
- Department of Radiology, Gordon Center for Medical Imaging, Massachusetts General Hospital, 55 Fruit Street, Edwards 019B, Boston, MA 02114 USA
- Department of Radiology, Harvard Medical School, Boston, MA USA
| | - Georges El Fakhri
- Department of Radiology, Gordon Center for Medical Imaging, Massachusetts General Hospital, 55 Fruit Street, Edwards 019B, Boston, MA 02114 USA
- Department of Radiology, Harvard Medical School, Boston, MA USA
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13
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Klein R, Celiker-Guler E, Rotstein BH, deKemp RA. PET and SPECT Tracers for Myocardial Perfusion Imaging. Semin Nucl Med 2020; 50:208-218. [PMID: 32284107 DOI: 10.1053/j.semnuclmed.2020.02.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Coronary artery disease has been the leading cause of death since the 1960s, which has motivated the research and development of myocardial perfusion imaging (MPI) agents for early diagnosis and to guide treatment. MPI with SPECT has been the clinical workhorse for MPI, but over the past two decades PET MPI is experiencing growth due to enhanced image quality that results in superior diagnostic accuracy over SPECT. Furthermore, dynamic PET imaging of the tracer distribution process from time of tracer administration to tracer accumulation in the myocardium has enabled routine quantification of myocardial blood flow (MBF) and myocardial flow reserve (MFR) in absolute units. MBF and MFR incrementally improve diagnostic and prognostic accuracy over MPI alone. In some cases (eg, rubidium PET imaging with pharmacologic stress) MPI, MBF, and MFR can be acquired simultaneously without incremental cost, radiation exposure, or significant processing time. Nuclear cardiology clinics have been looking to incorporate MBF quantification into clinical routine, but traditional SPECT and MPI tracers are inadequate for this challenge. Cardiac dedicated SPECT scanners can also perform dynamic imaging and have stimulated research into MBF quantification using SPECT tracers. New perfusion tracers must be tailored for emerging clinical needs (including MBF quantification), technical capabilities of imaging instrumentation, market constraints, and supply chain feasibility. Because these conditions have been evolving, tracers previously considered inferior may be reconsidered for future applications and some recently developed tracers may be suboptimal. This article reviews current, clinically-available tracers and those under development showing greatest potential. It discusses for each tracer the rationale for development, physiological mechanism of uptake by the myocardium, published evaluation results and development state. Finally, it gauges the suitability of each tracer for clinical application. The article demonstrates an acceleration in the pace of perfusion radiotracer development due to better understanding of the relevant physiology, better chemistry tools and small animal imaging. Consequently, bad tracers may fail faster and with less wasted investment, and good tracers may translate more efficiently from bench to bedside.
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Affiliation(s)
- Ran Klein
- University of Ottawa Heart Institute, Division of Cardiology, Ottawa, ON, Canada; The Ottawa Hospital, Division of Nuclear Medicine, Ottawa, ON, Canada
| | - Emel Celiker-Guler
- University of Ottawa Heart Institute, Division of Cardiology, Ottawa, ON, Canada
| | - Benjamin H Rotstein
- University of Ottawa Heart Institute, Division of Cardiology, Ottawa, ON, Canada; Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON, Canada
| | - Robert A deKemp
- University of Ottawa Heart Institute, Division of Cardiology, Ottawa, ON, Canada.
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Pelletier-Galarneau M, Dilsizian V. Microvascular Angina Diagnosed by Absolute PET Myocardial Blood Flow Quantification. Curr Cardiol Rep 2020; 22:9. [DOI: 10.1007/s11886-020-1261-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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