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Han D, Hyun MC, Miller RJH, Gransar H, Slomka PJ, Dey D, Hayes SW, Friedman JD, Thomson LEJ, Berman DS, Rozanski A. 10-year experience of utilizing a stress-first SPECT myocardial perfusion imaging. Int J Cardiol 2024; 401:131863. [PMID: 38365012 DOI: 10.1016/j.ijcard.2024.131863] [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] [Received: 08/09/2023] [Revised: 01/24/2024] [Accepted: 02/12/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Despite its potential benefits, the utilization of stress-only protocol in clinical practice has been limited. We report utilizing stress-first single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). METHODS We assessed 12,472 patients who were referred for SPECT-MPI between 2013 and 2020. The temporal changes in frequency of stress-only imaging were assessed according to risk factors, mode of stress, prior coronary artery disease (CAD) history, left ventricular function, and symptom status. The clinical endpoint was all-cause mortality. RESULTS In our lab, stress/rest SPECT-MPI in place of rest/stress SPECT-MPI was first introduced in November 2011 and was performed more commonly than rest/stress imaging after 2013. Stress-only SPECT-MPI scanning has been performed in 30-34% of our SPECT-MPI studies since 2013 (i.e.. 31.7% in 2013 and 33.6% in 2020). During the study period, we routinely used two-position imaging (additional prone or upright imaging) to reduce attenuation and motion artifact and introduced SPECT/CT scanner in 2018. The rate of stress-only study remained consistent before and after implementing the SPECT/CT scanner. The frequency of stress-only imaging was 43% among patients without a history of prior CAD and 19% among those with a prior CAD history. Among patients undergoing treadmill exercise, the frequency of stress-only imaging was 48%, while 32% among patients undergoing pharmacologic stress test. In multivariate Cox analysis, there was no significant difference in mortality risk between stress-only and stress/rest protocols in patients with normal SPECT-MPI results (p = 0.271). CONCLUSION Implementation of a stress-first imaging protocol has consistently resulted in safe cancellation of 30% of rest SPECT-MPI studies.
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Affiliation(s)
- Donghee Han
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America.
| | - Mark C Hyun
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Piotr J Slomka
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Damini Dey
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Alan Rozanski
- The Division of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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Hage FG, Einstein AJ, Ananthasubramaniam K, Bourque JM, Case J, DePuey EG, Hendel RC, Henzlova MJ, Shah NR, Abbott BG, Al Jaroudi W, Better N, Doukky R, Duvall WL, Malhotra S, Pagnanelli R, Peix A, Reyes E, Saeed IM, Sanghani RM, Slomka PJ, Thompson RC, Veeranna V, Williams KA, Winchester DE. Quality metrics for single-photon emission computed tomography myocardial perfusion imaging: an ASNC information statement. J Nucl Cardiol 2023; 30:864-907. [PMID: 36607538 DOI: 10.1007/s12350-022-03162-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Fadi G Hage
- Section of Cardiology, Birmingham VA Medical Center, Birmingham, AL, USA.
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 446 GSB, 520 19Th Street South, Birmingham, AL, 35294, USA.
| | - Andrew J Einstein
- Seymour, Paul and Gloria Milstein Division of Cardiology, Department of Medicine and Department of Radiology, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY, USA
| | | | - Jamieson M Bourque
- Department of Medicine (Cardiology), University of Virginia Health System, Charlottesville, VA, USA
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA
| | - James Case
- Cardiovascular Imaging Technologies, Kansas City, MO, USA
| | - E Gordon DePuey
- Mount Sinai Morningside Hospital, New York, NY, USA
- Bay Ridge Medical Imaging, Brooklyn, NY, USA
| | - Robert C Hendel
- Department of Medicine, Division of Cardiology, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Nishant R Shah
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Brian G Abbott
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Wael Al Jaroudi
- Division of Cardiovascular Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Nathan Better
- Department of Nuclear Medicine and Cardiology, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Rami Doukky
- Division of Cardiology, Cook County Health and Hospitals System, Chicago, IL, USA
| | - W Lane Duvall
- Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health and Hospitals System, Chicago, IL, USA
| | | | - Amalia Peix
- Nuclear Medicine Department, Institute of Cardiology and Cardiovascular Surgery, La Habana, Cuba
| | - Eliana Reyes
- Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ibrahim M Saeed
- Virginia Heart, Falls Church, VA, USA
- INOVA Heart and Vascular Institute, Falls Church, VA, USA
- University of Missouri, Kansas City, MO, USA
| | - Rupa M Sanghani
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | | | - Randall C Thompson
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Vikas Veeranna
- Division of Cardiology, Department of Medicine, New England Heart and Vascular Institute, Manchester, NH, USA
| | - Kim A Williams
- Department of Medicine, University of Louisville Department of Medicine, Louisville, KY, USA
| | - David E Winchester
- Malcom Randall VA Medical Center, Gainesville, FL, USA
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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3
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McMahon SR, Patel EK, Duvall WL. Stress-First Myocardial Perfusion Imaging. Cardiol Clin 2023; 41:163-175. [PMID: 37003674 DOI: 10.1016/j.ccl.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Stress-first approaches to myocardial perfusion imaging provide diagnostically and prognostically accurate perfusion data equivalent to a full rest-stress study while saving time in the imaging laboratory and reducing the radiation exposure to patients and laboratory staff. Unfortunately, implementing a stress-first approach in a nuclear cardiology laboratory involves significant challenges such as the need for attenuation correction, triage of patients to an appropriate protocol, real-time review of stress images, and consideration of differential reimbursement. Despite it being best practice for both the patient and the laboratory, these impediments have kept the proportions of studies performed stress-first relatively unchanged in North America and world-wide in the last 10 years.
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Affiliation(s)
- Sean R McMahon
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
| | - Etee K Patel
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
| | - W Lane Duvall
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA.
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4
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Henzlova MJ, Duvall L. Is the CZT technology the future of nuclear cardiology? J Nucl Cardiol 2022; 29:737-740. [PMID: 33128127 DOI: 10.1007/s12350-020-02399-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
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5
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Zoccarato O, Matheoud R, Lecchi M, Scabbio C, Claudio M, Brambilla M. Optimal 99mTc activity ratio in the single-day stress-rest myocardial perfusion imaging protocol: A multi-SPECT phantom study. J Nucl Cardiol 2021; 28:338-349. [PMID: 32720060 PMCID: PMC7384561 DOI: 10.1007/s12350-020-02290-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND This investigation used image data generated by an anthropomorphic phantom to determine the minimal 99mTc rest-stress activity concentration ratio (R) able to minimize the ghosting effect in the single-day stress-first myocardial perfusion imaging, using different positions of the perfusion defect (PD), scanners and reconstruction protocols. METHODS A cardiac phantom with a simulated PD was imaged under different R using different gamma cameras and reconstruction algorithms. The residual activity from precedent stress administration was simulated by modeling effective half-times in each compartment of the phantom and assuming a delay of 3 hours between the stress and rest studies. The net contrast (NC) of the PD in the rest study was assessed for different R, PD positions and scanner/software combinations. The optimal R will be the one that minimize the NC in the rest images RESULTS: The activity concentration ratio R, the position of the PD and the scanner/software combinations were all main effects with a statistically significant impact on the NC, in decreasing order of relevance. The NC diminished significantly only for R values up to 2. No further improvement was observed for NC for R values above 2 and up to 3. NC was significantly higher in anteroseptal than in posterolateral positions of the PD and higher for solid-state cameras. CONCLUSIONS A rest-stress activity concentration ratio R of 2 in single-day stress-first myocardial perfusion imaging is enough to achieve the maximum net contrast in the PD. This ratio should be used to optimize patient's radiation exposure.
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Affiliation(s)
- Orazio Zoccarato
- Department of Nuclear Medicine, S. Maugeri Foundation, IRCCS, Scientific Institute of Veruno (NO), Veruno, Italy
| | - Roberta Matheoud
- Department of Medical Physics, University Hospital ‘Maggiore della Carità’, Novara, Italy
| | - Michela Lecchi
- Health Physics Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | | | - Marcassa Claudio
- Department of Cardiology, S. Maugeri Foundation, IRCCS, Scientific Institute of Veruno (NO), Veruno, Italy
| | - Marco Brambilla
- Department of Medical Physics, University Hospital ‘Maggiore della Carità’, Novara, Italy
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Daubert MA, Tailor T, James O, Shaw LJ, Douglas PS, Koweek L. Multimodality cardiac imaging in the 21st century: evolution, advances and future opportunities for innovation. Br J Radiol 2020; 94:20200780. [PMID: 33237824 DOI: 10.1259/bjr.20200780] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular imaging has significantly evolved since the turn of the century. Progress in the last two decades has been marked by advances in every modality used to image the heart, including echocardiography, cardiac magnetic resonance, cardiac CT and nuclear cardiology. There has also been a dramatic increase in hybrid and fusion modalities that leverage the unique capabilities of two imaging techniques simultaneously, as well as the incorporation of artificial intelligence and machine learning into the clinical workflow. These advances in non-invasive cardiac imaging have guided patient management and improved clinical outcomes. The technological developments of the past 20 years have also given rise to new imaging subspecialities and increased the demand for dedicated cardiac imagers who are cross-trained in multiple modalities. This state-of-the-art review summarizes the evolution of multimodality cardiac imaging in the 21st century and highlights opportunities for future innovation.
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Affiliation(s)
- Melissa A Daubert
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Tina Tailor
- Division of Cardiothoracic Imaging, Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Olga James
- Division of Cardiothoracic Imaging, Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Leslee J Shaw
- Department of Radiology, Cornell Medical Center, New York, New York, USA
| | - Pamela S Douglas
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Lynne Koweek
- Division of Cardiothoracic Imaging, Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
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7
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A Clinical Tool to Identify Candidates for Stress-First Myocardial Perfusion Imaging. JACC Cardiovasc Imaging 2020; 13:2193-2202. [PMID: 32563652 DOI: 10.1016/j.jcmg.2020.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study sought to develop a clinical model that identifies a lower-risk population for coronary artery disease that could benefit from stress-first myocardial perfusion imaging (MPI) protocols and that can be used at point of care to risk stratify patients. BACKGROUND There is an increasing interest in stress-first and stress-only imaging to reduce patient radiation exposure and improve patient workflow and experience. METHODS A secondary analysis was conducted on a single-center cohort of patients undergoing single-photon emission computed tomography (SPECT) and positron emission tomography (PET) studies. Normal MPI was defined by the absence of perfusion abnormalities and other ischemic markers and the presence of normal left ventricular wall motion and left ventricular ejection fraction. A model was derived using a cohort of 18,389 consecutive patients who underwent SPECT and was validated in a separate cohort of patients who underwent SPECT (n = 5,819), 1 internal cohort of patients who underwent PET (n=4,631), and 1 external PET cohort (n = 7,028). RESULTS Final models were made for men and women and consisted of 9 variables including age, smoking, hypertension, diabetes, dyslipidemia, typical angina, prior percutaneous coronary intervention, prior coronary artery bypass graft, and prior myocardial infarction. Patients with a score ≤1 were stratified as low risk. The model was robust with areas under the curve of 0.684 (95% confidence interval [CI]: 0.674 to 0.694) and 0.681 (95% CI: 0.666 to 0.696) in the derivation cohort, 0.745 (95% CI: 0.728 to 0.762) and 0.701 (95% CI: 0.673 to 0.728) in the SPECT validation cohort, 0.672 (95% CI: 0.649 to 0.696) and 0.686 (95% CI: 0.663 to 0.710) in the internal PET validation cohort, and 0.756 (95% CI: 0.740 to 0.772) and 0.737 (95% CI: 0.716 to 0.757) in the external PET validation cohort in men and women, respectively. Men and women who scored ≤1 had negative likelihood ratios of 0.48 and 0.52, respectively. CONCLUSIONS A novel model, based on easily obtained clinical variables, is proposed to identify patients with low probability of having abnormal MPI results. This point-of-care tool may be used to identify a population that might qualify for stress-first MPI protocols.
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8
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Slomka PJ, Miller RJ, Hu LH, Germano G, Berman DS. Solid-State Detector SPECT Myocardial Perfusion Imaging. J Nucl Med 2019; 60:1194-1204. [DOI: 10.2967/jnumed.118.220657] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/18/2019] [Indexed: 02/07/2023] Open
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9
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Massalha S, Almufleh A, Small G, Marvin B, Keidar Z, Israel O, Kennedy JA. Strategies for Minimizing Occupational Radiation Exposure in Cardiac Imaging. Curr Cardiol Rep 2019; 21:71. [PMID: 31227929 DOI: 10.1007/s11886-019-1157-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Radiation safety has been at the center of interest of both researchers and healthcare institutions. This review will summarize and shed light on the various techniques adapted to reduce staff exposure to ionizing radiation (IR) in the field of cardiac imaging. RECENT FINDINGS In the last years, with the advance of awareness and the development of new technologies, there have been several tools and techniques adapted. The breakthrough of several technologies to lower radiation dose and shorten the duration of diagnostic tests associated with IR, the use of protection devices by staff members, and mostly the awareness of exposure to IR are the hallmark of these advances. Using all these measures has led to a significant decrease in staff exposure to IR. Reducing staff exposure to meet the "As Low As Reasonably Achievable" principle is feasible. This review introduces the most important strategies applied in cardiac imaging.
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Affiliation(s)
- Samia Massalha
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada. .,Department of Cardiology, Rambam Health Care Campus, Haifa, Israel. .,Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel.
| | - Aws Almufleh
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
| | - Garry Small
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
| | - Brian Marvin
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, K1Y 4W7, Canada
| | - Zohar Keidar
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Ora Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - John A Kennedy
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel.,Faculty of Biomedical Engineering, Technion - Israel Institute of Technology, Haifa, Israel
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Abstract
Cardiac SPECT continues to play a critical role in detecting and managing cardiovascular disease, in particularly coronary artery disease (CAD) (Jaarsma et al 2012 J. Am. Coll. Cardiol. 59 1719-28), (Agostini et al 2016 Eur. J. Nucl. Med. Mol. Imaging 43 2423-32). While conventional dual-head SPECT scanners using parallel-hole collimators and scintillation crystals with photomultiplier tubes are still the workhorse of cardiac SPECT, they have the limitations of low photon sensitivity (~130 count s-1 MBq-1), poor image resolution (~15 mm) (Imbert et al 2012 J. Nucl. Med. 53 1897-903), relatively long acquisition time, inefficient use of the detector, high radiation dose, etc. Recently our field observed an exciting growth of new developments of dedicated cardiac scanners and collimators, as well as novel imaging algorithms for quantitative cardiac SPECT. These developments have opened doors to new applications with potential clinical impact, including ultra-low-dose imaging, absolute quantification of myocardial blood flow (MBF) and coronary flow reserve (CFR), multi-radionuclide imaging, and improved image quality as a result of attenuation, scatter, motion, and partial volume corrections (PVCs). In this article, we review the recent advances in cardiac SPECT instrumentation and imaging methods. This review mainly focuses on the most recent developments published since 2012 and points to the future of cardiac SPECT from an imaging physics perspective.
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Affiliation(s)
- Jing Wu
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, United States of America
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Costa PF, Testanera G, Camoni L, Terwinghe C, Bailey EA, Bolus NE, Alden TM. Technologist Approach to Global Dose Optimization. J Nucl Med Technol 2018; 47:75-82. [PMID: 30413598 DOI: 10.2967/jnmt.118.218131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/25/2018] [Indexed: 01/15/2023] Open
Abstract
Nuclear medicine technologists are specialized health professionals who cover a wide range of tasks from clinical routine (including image acquisition and processing, radiopharmaceutical dispensing and administration, patient care, and radioprotection tasks) to leading clinical research in the field of nuclear medicine. As a fundamental concern in all radiation sciences applied to medicine, protection of individuals against the harmful effects of ionizing radiation must be constantly revised and applied by the professionals involved in medical exposures. The acknowledgment that nuclear medicine technologists play a prominent role in patient management and several procedural steps, both in diagnostic and in therapeutic nuclear medicine applications, carries the duty to be trained and knowledgeable on the topic of radiation protection and dose optimization. An overview on selected topics related to dose optimization is presented in this article, reflecting the similarities and particularities of dose reduction-related principles, initiatives, and practicalities from a global perspective.
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Affiliation(s)
- Pedro Fragoso Costa
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Giorgio Testanera
- Barts Health NHS Trust, Department of Nuclear Medicine, St. Bartholomew's Hospital, London, United Kingdom
| | - Luca Camoni
- Nuclear Medicine Unit, Department of Nuclear Medicine, Spedali Civili of Brescia, Brescia, Italy
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12
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Bhusal N, Dey J, Xu J, Kalluri K, Konik A, Mukherjee JM, Pretorius PH. Performance analysis of a high-sensitivity multi-pinhole cardiac SPECT system with hemi-ellipsoid detectors. Med Phys 2018; 46:116-126. [PMID: 30407634 DOI: 10.1002/mp.13277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 10/19/2018] [Accepted: 10/19/2018] [Indexed: 11/11/2022] Open
Abstract
PURPOSE Single-photon emission computed tomography (SPECT) is a noninvasive imaging modality, used in myocardial perfusion imaging. The challenges facing the majority of clinical SPECT systems are low sensitivity, poor resolution, and the relatively high radiation dose to the patient. New generation systems (GE Discovery, DSPECT) dedicated to cardiac imaging improve sensitivity by a factor of 5-8. This improvement can be used to decrease acquisition time and/or dose. However, in the case of ultra-low dose (~3 mCi) injections, acquisition times are still significantly long, taking 10-12 min. The purpose of this work is to investigate a new gamma camera design with 21 hemi-ellipsoid detectors each with a pinhole collimator for cardiac SPECT for further improvement in sensitivity and resolution and reduced patient exposures and imaging times. METHODS To evaluate the resolution of our hemi-ellipsoid system, GATE Monte-Carlo simulations were performed on point-sources, rod-sources, and NCAT phantoms. For average full-width-half-maximum (FWHM) equivalence with base flat-detector, the pinhole-diameter for the curved hemi-ellipsoid detector was found to be 8.68 mm, an operating pinhole-diameter nominally expected to be ~3 times more sensitive than state-of-the-art systems. Rod-sources equally spaced within the region of interest were acquired with a 21-detector system and reconstructed with our multi-pinhole (MPH) iterative OSEM algorithm with collimator resolution recovery. The results were compared with the results of a state-of-the-art system (GE Discovery) available in the literature. The system was also evaluated using the mathematical anthropomorphic NCAT (NURBS-based Cardiac Torso; Segars et al. IEEE Trans Nucl Sci. 1999;46:503-506) phantom with a full (clinical)-dose acquisition (25 mCi) for 2 min and an ultra-low dose acquisition of 3 mCi for 5.44 min. The estimated left ventricle (LV) counts were compared with the available literature on a state-of-the-art system (DSPECT). FWHM of the LV wall on MPH-OSEM-reconstructed images with collimator resolution recovery was estimated. RESULTS On acquired rod-sources, the average resolution (FWHM) after reconstruction with resolution recovery in the entire region of interest (ROI) for cardiac imaging was on the average 4.44 mm (±2.84), compared to 6.9 mm (±1 mm) reported for GE Discovery (Kennedy et al., J Nucl Cardiol. 2014:21:443-452). For NCAT studies, improved sensitivity allowed a full-dose (25 mCi) 2-min acquisition (Ell8.68mmFD) which yielded 3.79 M LV counts. This is ~3.35 times higher compared to 1.13 M LV counts acquired in 2 min for clinical full dose for state-of-the-art DSPECT. The increased sensitivity also allowed an ultra-low dose acquisition protocol (Ell8.68 mmULD), 3 mCi (eight times less injected dose) in 5.44 min. This ultra-low dose protocol yielded ~1.23 M LV counts which was comparable to the full-dose 2-min acquisition for DSPECT. The estimated NCAT average FWHM at the LV wall after 12 iterations of the OSEM reconstruction was 4.95 and 5.66 mm around the mid-short-axis slices for Ell8.68mmFD and Ell8.68mmULD, respectively. CONCLUSION Our Monte-Carlo simulation studies and reconstruction suggest using (inverted wineglass sized) hemi-ellipsoid detectors with pinhole collimators can increase the sensitivity ~3.35 times over the new generation of dedicated cardiac SPECT systems, while also improving the reconstructed resolution for rod-sources with an average of 4.44 mm in region of interest. The extra sensitivity may be used for ultra-low dose imaging (3 mCi) at ~5.44 min for comparable clinical counts as state-of-the-art systems.
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Affiliation(s)
- Narayan Bhusal
- Department of Physics and Astronomy, LSU, Baton Rouge, LA, 70803, USA
| | - Joyoni Dey
- Department of Physics and Astronomy, LSU, Baton Rouge, LA, 70803, USA
| | - Jingzhu Xu
- Department of Physics and Astronomy, LSU, Baton Rouge, LA, 70803, USA
| | - Kesava Kalluri
- Department of Radiology, UMass Medical School (UMMS), Worcester, MA, 01655, USA
| | - Arda Konik
- Department of Radiology, UMass Medical School (UMMS), Worcester, MA, 01655, USA
| | - Joyeeta M Mukherjee
- Department of Radiology, UMass Medical School (UMMS), Worcester, MA, 01655, USA.,Mathworks, Natick, MA, USA
| | - P Hendrik Pretorius
- Department of Radiology, UMass Medical School (UMMS), Worcester, MA, 01655, USA
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13
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Dorbala S, Ananthasubramaniam K, Armstrong IS, Chareonthaitawee P, DePuey EG, Einstein AJ, Gropler RJ, Holly TA, Mahmarian JJ, Park MA, Polk DM, Russell R, Slomka PJ, Thompson RC, Wells RG. Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging Guidelines: Instrumentation, Acquisition, Processing, and Interpretation. J Nucl Cardiol 2018; 25:1784-1846. [PMID: 29802599 DOI: 10.1007/s12350-018-1283-y] [Citation(s) in RCA: 211] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Sharmila Dorbala
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | | | | | | | | | - Andrew J Einstein
- Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | | | - Thomas A Holly
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John J Mahmarian
- Houston Methodist Hospital and Weill Cornell Medical College, Houston, TX, USA
| | | | - Donna M Polk
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | - R Glenn Wells
- University of Ottawa Heart Institute, Ottawa, Canada
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Henzlova MJ, Duvall WL. Tl-201 dosing for CZT SPECT: More new information. J Nucl Cardiol 2018; 25:955-957. [PMID: 28176253 DOI: 10.1007/s12350-017-0808-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 12/30/2016] [Indexed: 10/20/2022]
Affiliation(s)
- M J Henzlova
- Department of Cardiology, Mount Sinai Medical Center, New York, NY, USA.
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15
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Gutstein A, Bental T, Solodky A, Mats I, Zafrir N. Prognosis of stress-only SPECT myocardial perfusion imaging with prone imaging. J Nucl Cardiol 2018; 25:809-816. [PMID: 27671493 DOI: 10.1007/s12350-016-0617-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/16/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stress-only single-photon emission computed tomography myocardial perfusion imaging (SO SPECT MPI) is associated with similarly benign prognosis as stress-rest SPECT MPI. However, previous studies have used attenuation correction rather than prone imaging to increase the rate of SO studies. OBJECTIVES To assess the prognosis of SO SPECT MPI performed with prone imaging. METHODS We performed a retrospective cohort analysis of all patients who underwent a Tc-99m gated SPECT MPI over a 58-month period. RESULTS Two thousand four hundred and sixty five patients were followed up. Of them, 1114 (45.2%) patients had a SO supine test, 388 (15.7%) underwent a SO supine and prone test, and the remaining 963 (39.1%) patients underwent a full stress-rest SPECT MPI. There was a similar annual mortality rate between the SO supine/prone group (1.3%), the SO supine (1.5%), and the stress-rest (1.5%) group (P = 0.47). Patients in the stress-rest group were significantly more likely to suffer from myocardial infarction (MI) as compared to the other two groups with an annual rate of 0.7% as compared to 0.4% (P = 0.049). CONCLUSIONS Normal supine-prone SO SPECT MPI is associated with a similarly benign prognosis as stress-rest SPECT MPI. The adjunction of prone imaging to the stress supine significantly increases the rate of SO SPECT MPI.
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Affiliation(s)
- Ariel Gutstein
- Rabin Medical Center, Tel-Aviv University, Petach Tikva, Israel.
| | - Tamir Bental
- Rabin Medical Center, Tel-Aviv University, Petach Tikva, Israel
| | | | - Israel Mats
- Rabin Medical Center, Tel-Aviv University, Petach Tikva, Israel
| | - Nili Zafrir
- Rabin Medical Center, Tel-Aviv University, Petach Tikva, Israel.
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16
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Wells RG, Trottier M, Premaratne M, Vanderwerf K, Ruddy TD. Single CT for attenuation correction of rest/stress cardiac SPECT perfusion imaging. J Nucl Cardiol 2018; 25:616-624. [PMID: 27858346 DOI: 10.1007/s12350-016-0720-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/12/2016] [Indexed: 10/20/2022]
Abstract
Common practice is to use separate CT scans acquired during rest and stress for attenuation correction of SPECT myocardial perfusion imaging (MPI). We evaluated using a single CT scan to correct both rest and stress SPECT scans. Studies from 154 patients were reprocessed using one CT acquired at stress to correct both rest and stress scans (1CT) and compared to correction of each scan with its own CT (2CT). Two expert readers independently read the images and determined summed stress (SSS), rest (SRS), and difference (SDS) scores. The correlation in SRS between 2CT and 1CT was r ≥ 0.88. The concordance in SDS was ≥0.84 (kappa ≥ 0.62). The mean SDS difference between 2CT and 1CT for the averaged observer was not significantly different from zero (p > 0.31). 1CT images had a small but significant increase in SRS and an increase in SDS variability. However, the mean SDS difference was similar to the mean inter-observer SDS difference for the 2CT approach (-0.08 vs -0.23, p = 0.46) and had less uncertainty (1.02 vs 2.05, p < 0.001). Thus, the differences between 1CT and 2CT are unlikely to be clinically significant, and the 1CT approach is feasible for SPECT MPI.
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Affiliation(s)
- R Glenn Wells
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada.
| | - Mikael Trottier
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Manuja Premaratne
- Frankston Hospital, Frankston, Australia
- Monash University, Clayton, VIC, Australia
| | - Karen Vanderwerf
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
- Division of Nuclear Medicine, Ottawa Hospital, Ottawa, ON, Canada
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17
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Verberne HJ, Scholtens AM. The very hungry caterpillar and the ongoing effort to reduce radiation in myocardial perfusion scintigraphy: Have we become the beautiful butterfly? J Nucl Cardiol 2018; 25:36-38. [PMID: 28822086 DOI: 10.1007/s12350-017-1024-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 07/20/2017] [Indexed: 10/24/2022]
Affiliation(s)
- Hein J Verberne
- Department of Radiology and Nuclear Medicine, F2-238, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Asbjørn M Scholtens
- Department of Nuclear Medicine, Meander Medical Center, Amersfoort, The Netherlands
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18
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Henzlova MJ. SPECT: Workhorse of state of the art nuclear cardiology. J Nucl Cardiol 2018; 25:195-197. [PMID: 28730415 DOI: 10.1007/s12350-017-1001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 03/30/2017] [Indexed: 10/19/2022]
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19
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van Dijk JD, Borren NM, Mouden M, van Dalen JA, Ottervanger JP, Jager PL. Effect of a patient-specific minimum activity in stress myocardial perfusion imaging using CZT-SPECT: Prognostic value, radiation dose, and scan outcome. J Nucl Cardiol 2018; 25:26-35. [PMID: 28822102 DOI: 10.1007/s12350-017-1011-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 05/31/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND SPECT Myocardial perfusion imaging (MPI) is associated with a relatively high radiation burden and decreasing image quality in heavy patients. Patient-specific low-activity protocols (PLAPs) are suggested but follow-up data is lacking. Our aim was to compare the use of a standard fixed-activity protocol (FAP) with a PLAP in cadmium zinc telluride (CZT)-SPECT MPI. METHODS We retrospectively included 1255 consecutive patients who underwent CZT-SPECT stress-optional rest MPI. 668 Patients were scanned using FAP (370 MBq) and 587 patients using PLAP (2.25 MBq·kg-1). Percentage of scans interpreted as normal, radiation dose, and 1-year follow-up including hard event rates (all-cause death or non-fatal myocardial infarction) were collected and compared. RESULTS The percentage of scans interpreted as normal was 67% in FAP and 70% in PLAP groups (P = .29). The annualized hard event rates in these patients were 1.0% in the FAP and 0.9% in the PLAP group (P = .86). However, the mean radiation dose decreased by 23% for stress-only and by 15% to 2.6 mSv for stress-optional rest MPI after introduction of the PLAP (p<0.001). CONCLUSIONS Introduction of a patient-specific low-activity protocol does not affect the percentage of scans interpreted as normal or prognosis but significantly lowers the radiation dose for CZT-SPECT MPI.
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Affiliation(s)
- J D van Dijk
- Department of Nuclear Medicine, Isala Hospital, PO Box 10400, 8000 GK, Zwolle, The Netherlands.
- MIRA: Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands.
| | - N M Borren
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | - M Mouden
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | - J A van Dalen
- Department of Medical Physics, Isala Hospital, Zwolle, The Netherlands
| | - J P Ottervanger
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | - P L Jager
- Department of Nuclear Medicine, Isala Hospital, PO Box 10400, 8000 GK, Zwolle, The Netherlands
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20
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Gimelli A, Achenbach S, Buechel RR, Edvardsen T, Francone M, Gaemperli O, Hacker M, Hyafil F, Kaufmann PA, Lancellotti P, Nieman K, Pontone G, Pugliese F, Verberne HJ, Gutberlet M, Bax JJ, Neglia D, Gerber B, Donal E, Flachskampf F, Haugaa K, Delgado V, Knuuti J, Knaapen P, Maurovich-Horvat P, Schroeder S. Strategies for radiation dose reduction in nuclear cardiology and cardiac computed tomography imaging: a report from the European Association of Cardiovascular Imaging (EACVI), the Cardiovascular Committee of European Association of Nuclear Medicine (EANM), and the European Society of Cardiovascular Radiology (ESCR). Eur Heart J 2017; 39:286-296. [DOI: 10.1093/eurheartj/ehx582] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/26/2017] [Indexed: 12/23/2022] Open
Affiliation(s)
- Alessia Gimelli
- Fondazione Toscana/CNR Gabriele Monasterio, Via Moruzzi 1, 56124 Pisa, Italy
| | - Stephan Achenbach
- Department of Internal Medicine 2 (Cardiology), Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Thor Edvardsen
- Oslo University Hospital, Department of Cardiology, Rikshospitalet and University of Oslo, Oslo, Norway
| | - Marco Francone
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Oliver Gaemperli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Fabien Hyafil
- Department of Nuclear Medicine, Bichat University Hospital, Assistance Publique—Hôpitaux de Paris, Inserm 1148, DHU FIRE, University Paris 7 Diderot, Paris, France
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Patrizio Lancellotti
- Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, University of Liège Hospital, GIGA Cardiovascular Sciences, Liège, Belgium
- Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | - Koen Nieman
- Departments of Cardiovascular Medicine and Radiology, Stanford University, School of Medicine, Stanford, CA, USA
| | - Gianluca Pontone
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Yonsei University Health System, Seoul, South Korea
| | - Francesca Pugliese
- NIHR Barts BRC, Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Jeroen J Bax
- Heart Lung Center Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Danilo Neglia
- Fondazione Toscana/CNR Gabriele Monasterio, Via Moruzzi 1, 56124 Pisa, Italy
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21
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Mahmarian JJ. Implementation of stress-only imaging: What will it take? J Nucl Cardiol 2017; 24:821-825. [PMID: 26670458 DOI: 10.1007/s12350-015-0346-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 11/06/2015] [Indexed: 02/03/2023]
Affiliation(s)
- John J Mahmarian
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, 6550 Fannin Street, Suite 677, Houston, TX, 77030, USA.
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22
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Chaudhry W, Hussain N, Ahlberg AW, Croft LB, Fernandez AB, Parker MW, Swales HH, Slomka PJ, Henzlova MJ, Duvall WL. Multicenter evaluation of stress-first myocardial perfusion image triage by nuclear technologists and automated quantification. J Nucl Cardiol 2017; 24:809-820. [PMID: 26566774 PMCID: PMC4866908 DOI: 10.1007/s12350-015-0291-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/02/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND A stress-first myocardial perfusion imaging (MPI) protocol saves time, is cost effective, and decreases radiation exposure. A limitation of this protocol is the requirement for physician review of the stress images to determine the need for rest images. This hurdle could be eliminated if an experienced technologist and/or automated computer quantification could make this determination. METHODS Images from consecutive patients who were undergoing a stress-first MPI with attenuation correction at two tertiary care medical centers were prospectively reviewed independently by a technologist and cardiologist blinded to clinical and stress test data. Their decision on the need for rest imaging along with automated computer quantification of perfusion results was compared with the clinical reference standard of an assessment of perfusion images by a board-certified nuclear cardiologist that included clinical and stress test data. RESULTS A total of 250 patients (mean age 61 years and 55% female) who underwent a stress-first MPI were studied. According to the clinical reference standard, 42 (16.8%) and 208 (83.2%) stress-first images were interpreted as "needing" and "not needing" rest images, respectively. The technologists correctly classified 229 (91.6%) stress-first images as either "needing" (n = 28) or "not needing" (n = 201) rest images. Their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 66.7%, 96.6%, 80.0%, and 93.5%, respectively. An automated stress TPD score ≥1.2 was associated with optimal sensitivity and specificity and correctly classified 179 (71.6%) stress-first images as either "needing" (n = 31) or "not needing" (n = 148) rest images. Its sensitivity, specificity, PPV, and NPV were 73.8%, 71.2%, 34.1%, and 93.1%, respectively. In a model whereby the computer or technologist could correct for the other's incorrect classification, 242 (96.8%) stress-first images were correctly classified. The composite sensitivity, specificity, PPV, and NPV were 83.3%, 99.5%, 97.2%, and 96.7%, respectively. CONCLUSION Technologists and automated quantification software had a high degree of agreement with the clinical reference standard for determining the need for rest images in a stress-first imaging protocol. Utilizing an experienced technologist and automated systems to screen stress-first images could expand the use of stress-first MPI to sites where the cardiologist is not immediately available for interpretation.
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Affiliation(s)
- Waseem Chaudhry
- Henry Low Heart Center, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Nasir Hussain
- Henry Low Heart Center, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Alan W Ahlberg
- Henry Low Heart Center, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Lori B Croft
- Mount Sinai Division of Cardiology (Mount Sinai Heart), New York, NY, USA
| | - Antonio B Fernandez
- Henry Low Heart Center, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Mathew W Parker
- Henry Low Heart Center, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Heather H Swales
- Henry Low Heart Center, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | | | - Milena J Henzlova
- Mount Sinai Division of Cardiology (Mount Sinai Heart), New York, NY, USA
| | - W Lane Duvall
- Henry Low Heart Center, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
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23
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Mahmarian JJ. Regadenoson stress during low-level exercise: The EXERRT trial-does it move the needle? J Nucl Cardiol 2017; 24:803-808. [PMID: 28508268 DOI: 10.1007/s12350-017-0873-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 03/24/2017] [Indexed: 11/26/2022]
Affiliation(s)
- John J Mahmarian
- Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Suite 677, Houston, TX, 77030-2717, USA.
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24
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Pourmoghaddas A, Wells RG. Analytically based photon scatter modeling for a multipinhole cardiac SPECT camera. Med Phys 2017; 43:6098. [PMID: 27806581 DOI: 10.1118/1.4965806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Dedicated cardiac SPECT scanners have improved performance over standard gamma cameras allowing reductions in acquisition times and/or injected activity. One approach to improving performance has been to use pinhole collimators, but this can cause position-dependent variations in attenuation, sensitivity, and spatial resolution. CT attenuation correction (AC) and an accurate system model can compensate for many of these effects; however, scatter correction (SC) remains an outstanding issue. In addition, in cameras using cadmium-zinc-telluride-based detectors, a large portion of unscattered photons is detected with reduced energy (low-energy tail). Consequently, application of energy-based SC approaches in these cameras leads to a higher increase in noise than with standard cameras due to the subtraction of true counts detected in the low-energy tail. Model-based approaches with parallel-hole collimator systems accurately calculate scatter based on the physics of photon interactions in the patient and camera and generate lower-noise estimates of scatter than energy-based SC. In this study, the accuracy of a model-based SC method was assessed using physical phantom studies on the GE-Discovery NM530c and its performance was compared to a dual energy window (DEW)-SC method. METHODS The analytical photon distribution (APD) method was used to calculate the distribution of probabilities that emitted photons will scatter in the surrounding scattering medium and be subsequently detected. APD scatter calculations for 99mTc-SPECT (140 ± 14 keV) were validated with point-source measurements and 15 anthropomorphic cardiac-torso phantom experiments and varying levels of extra-cardiac activity causing scatter inside the heart. The activity inserted into the myocardial compartment of the phantom was first measured using a dose calibrator. CT images were acquired on an Infinia Hawkeye (GE Healthcare) SPECT/CT and coregistered with emission data for AC. For comparison, DEW scatter projections (120 ± 6 keV ) were also extracted from the acquired list-mode SPECT data. Either APD or DEW scatter projections were subtracted from corresponding 140 keV measured projections and then reconstructed with AC (APD-SC and DEW-SC). Quantitative accuracy of the activity measured in the heart for the APD-SC and DEW-SC images was assessed against dose calibrator measurements. The difference between modeled and acquired projections was measured as the root-mean-squared-error (RMSE). APD-modeled projections for a clinical cardiac study were also evaluated. RESULTS APD-modeled projections showed good agreement with SPECT measurements and had reduced noise compared to DEW scatter estimates. APD-SC reduced mean error in activity measurement compared to DEW-SC in images and the reduction was statistically significant where the scatter fraction (SF) was large (mean SF = 28.5%, T-test p = 0.007). APD-SC reduced measurement uncertainties as well; however, the difference was not found to be statistically significant (F-test p > 0.5). RMSE comparisons showed that elevated levels of scatter did not significantly contribute to a change in RMSE (p > 0.2). CONCLUSIONS Model-based APD scatter estimation is feasible for dedicated cardiac SPECT scanners with pinhole collimators. APD-SC images performed better than DEW-SC images and improved the accuracy of activity measurement in high-scatter scenarios.
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Affiliation(s)
- Amir Pourmoghaddas
- Physics Department, Carleton University, Ottawa, Ontario K1S 5B6, Canada and Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y-4W7, Canada
| | - R Glenn Wells
- Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y-4W7, Canada
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25
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Slomka P, Hung GU, Germano G, Berman DS. Novel SPECT Technologies and Approaches in Cardiac Imaging. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016; 2:31-46. [PMID: 29034066 PMCID: PMC5640436 DOI: 10.15212/cvia.2016.0052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Recent novel approaches in myocardial perfusion single photon emission CT (SPECT) have been facilitated by new dedicated high-efficiency hardware with solid-state detectors and optimized collimators. New protocols include very low-dose (1 mSv) stress-only, two-position imaging to mitigate attenuation artifacts, and simultaneous dual-isotope imaging. Attenuation correction can be performed by specialized low-dose systems or by previously obtained CT coronary calcium scans. Hybrid protocols using CT angiography have been proposed. Image quality improvements have been demonstrated by novel reconstructions and motion correction. Fast SPECT acquisition facilitates dynamic flow and early function measurements. Image processing algorithms have become automated with virtually unsupervised extraction of quantitative imaging variables. This automation facilitates integration with clinical variables derived by machine learning to predict patient outcome or diagnosis. In this review, we describe new imaging protocols made possible by the new hardware developments. We also discuss several novel software approaches for the quantification and interpretation of myocardial perfusion SPECT scans.
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Affiliation(s)
- Piotr Slomka
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Guang-Uei Hung
- Department of Nuclear Medicine, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Guido Germano
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel S. Berman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Sharir T, Brodkin B, Kovalski G. Combined assessment of myocardial perfusion and left ventricular function by nuclear cardiology: The value of high-efficiency SPECT. J Nucl Cardiol 2016; 23:1262-1265. [PMID: 27311451 DOI: 10.1007/s12350-016-0570-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 05/31/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Tali Sharir
- Department of nuclear cardiology, Assuta Medical Centers, 96 Igal Alon, C Building, 67891, Tel Aviv, Israel.
| | - Boris Brodkin
- Department of nuclear cardiology, Assuta Medical Centers, 96 Igal Alon, C Building, 67891, Tel Aviv, Israel
- Department of cardiology, Barzilai Medical Center, Ashkelon, Israel
- Ben Gurion University of the Negev, Beersheba, Israel
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27
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Henzlova MJ, Duvall WL. Which SPECT for today, which SPECT for tomorrow? J Nucl Cardiol 2016; 23:803-6. [PMID: 27072000 DOI: 10.1007/s12350-016-0496-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 03/29/2016] [Indexed: 11/26/2022]
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28
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Feasibility of ultra low-dose thallium stress-redistribution protocol including prone imaging in obese patients using CZT camera. Int J Cardiovasc Imaging 2016; 32:1463-1469. [PMID: 27250348 DOI: 10.1007/s10554-016-0919-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/27/2016] [Indexed: 10/21/2022]
Abstract
High efficiency cadmium-zinc-telluride (CZT) cameras provide an opportunity to lower the injected activities of radiopharmaceuticals for single photon emission tomography (SPECT) myocardial perfusion imaging (MPI). The limits for reducing activities of thallium have not been determined, particularly in obese patients. After an injection of 0.7 megabecquerel (MBq) of thallium/kg, we collected an average 1.5 million counts for the 10-min acquisition in a pilot cohort of ten patients. After extrapolation, we reduced the administered activity to 0.5 MBq/kg to obtain the expected 1 million counts. We studied the image quality in 124 patients (86 men, 43 obese with body mass index over 30 kg/m2) referred for MPI. The quality of images was assessed by a number of recorded counts and visually by a four-grade scale (one-poor quality, four-excellent quality). In non-obese and obese patients, the average number of recorded counts was 1.1 vs. 1.07 million counts for the 10-min stress acquisition, 1.04 vs. 1.06 million counts for the 13-min rest acquisition, and the average quality score was 3.97 vs. 3.90, respectively (p = NS).The mean administered activity was 39.2 ± 7 MBq for non-obese and 48.7 ± 6 for obese patients (p < 0.0001), and the calculated effective dose was 4.0 ± 0.7 and 4.9 ± 0.6 mSv respectively (p < 0.0001). The ultra-low-dose thallium stress-redistribution protocol, including post-stress prone imaging, provides good quality of images with a low radiation burden, even in obese patients.
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Duvall WL, Henzlova MJ. Nuclear cardiology as it should look in the twenty-first century. J Nucl Cardiol 2016; 23:21-3. [PMID: 25971989 DOI: 10.1007/s12350-015-0169-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 04/24/2015] [Indexed: 11/28/2022]
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30
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Marcassa C, Zoccarato O. Radiation Dose Reduction from Radionuclide Myocardial Perfusion Imaging. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-015-9364-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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31
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Pourmoghaddas A, Wells RG. Quantitatively accurate activity measurements with a dedicated cardiac SPECT camera: Physical phantom experiments. Med Phys 2015; 43:44. [DOI: 10.1118/1.4937601] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Nabi F, Kassi M, Muhyieddeen K, Chang SM, Xu J, Peterson LE, Wray NP, Shirkey BA, Ashton CM, Mahmarian JJ. Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT. J Nucl Med 2015; 57:378-84. [DOI: 10.2967/jnumed.115.166595] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Stress-first approaches to myocardial perfusion imaging provide diagnostically and prognostically accurate perfusion data equivalent to a full rest-stress study, save time in the imaging laboratory, and reduce the radiation exposure to patients and laboratory staff. Converting a nuclear cardiology laboratory from a conventional rest-stress strategy to a stress-first approach involves challenges such as the need for attenuation correction, triage of patients to an appropriate protocol, real-time review of stress images, and consideration of differential reimbursement.
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Affiliation(s)
- Nasir Hussain
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
| | - Matthew W Parker
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
| | - Milena J Henzlova
- Mount Sinai Heart, Mount Hospital, One Gustave L Levy Place, New York, NY 10029, USA
| | - William Lane Duvall
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA.
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34
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Gunalp B. Role of cardiac ultrafast cameras with CZT solid-state detectors and software developments on radiation absorbed dose reduction to the patients. RADIATION PROTECTION DOSIMETRY 2015; 165:461-463. [PMID: 25848109 DOI: 10.1093/rpd/ncv096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Myocardial perfusion imaging (MPI) is one the most contributing nuclear medicine technique to the annual population dose. The purpose of this study is to compare radiation-absorbed doses to the patients examined by conventional cardiac SPECT (CSPECT) camera and ultrafast cardiac (UFC) camera with cadmium-zinc-telluride (CZT) solid-state detectors. Total injected activity was reduced by 50 % when both stress and rest images were acquired and by 75 % when only stress images were taken with UFC camera. As a result of this, the mean total effective dose was found significantly lower with UFC camera (2.2 ± 1.2 mSv) than CSPECT (7.7 ± 3.8 mSv) (p < 0.001). Further dose reduction was obtained by reducing equivocal test results and unnecessary additional examinations with UFC camera. Using UFC camera, MPI can be conveniently used for the detection of coronary artery disease (CAD) much less increasing annual population radiation dose as it had been before.
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Affiliation(s)
- Bengul Gunalp
- Department of Nuclear Medicine, Gulhane Military Medical Academy and Faculty, Ankara 06018, Turkey
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35
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Bateman TM. Twelfth annual Mario S. Verani, MD memorial lecture: Vision, leadership, and change-A reflection on the challenges and opportunities in the community-based practice of nuclear cardiology. J Nucl Cardiol 2015; 22:435-49. [PMID: 25894058 DOI: 10.1007/s12350-015-0126-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/09/2015] [Indexed: 12/23/2022]
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Dorbala S, Blankstein R, Skali H, Park MA, Fantony J, Mauceri C, Semer J, Moore SC, Di Carli MF. Approaches to reducing radiation dose from radionuclide myocardial perfusion imaging. J Nucl Med 2015; 56:592-9. [PMID: 25766891 DOI: 10.2967/jnumed.112.115097] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 02/27/2015] [Indexed: 11/16/2022] Open
Abstract
Radionuclide myocardial perfusion imaging (MPI) plays a vital role in the evaluation and management of patients with coronary artery disease. However, because of a steep growth in MPI in the mid 2000s, concerns about inappropriate use of MPI and imaging-related radiation exposure increased. In response, the professional societies developed appropriate-use criteria for MPI. Simultaneously, novel technology, image-reconstruction software for traditional scanners, and dedicated cardiac scanners emerged and facilitated the performance of MPI with low-dose and ultra-low-dose radiotracers. This paper provides a practical approach to performing low-radiation-dose MPI using traditional and novel technologies.
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Affiliation(s)
- Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ron Blankstein
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hicham Skali
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mi-Ae Park
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jolene Fantony
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Charles Mauceri
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - James Semer
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephen C Moore
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marcelo F Di Carli
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, the Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts
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37
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Timmins R, Ruddy TD, Wells RG. Patient position alters attenuation effects in multipinhole cardiac SPECT. Med Phys 2015; 42:1233-40. [DOI: 10.1118/1.4908015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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38
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Abstract
The practice of diagnostic nuclear medicine involves the use of ionizing radiation, and thus the potential risk associated with such exposure must be weighed against the benefits to the patient. This requires that the right test with the right dose be administered to the right patient at the right time. Therefore the procedure should be performed only if it is deemed most appropriate for the clinical question being asked. If appropriate, the procedure should be performed in the most optimum manner that keeps the radiation dose to the patient as low as possible while providing the patient's clinician with information that is needed to devise a plan of medical management. If this approach is followed, the benefits to the patient will far outweigh the small potential risks associate with the procedure. This article discusses these issues, particularly in the context of cardiovascular nuclear medicine and hybrid imaging including PET/CT and SPECT/CT.
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Affiliation(s)
- Frederic Fahey
- Department of Radiology, Boston Children׳s Hospital, Harvard Medical School, Boston, MA.
| | - Michael Stabin
- Department of Radiology and Radiological Sciences, Vanderbilt University, Nashville, TN
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39
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Gowd BMP, Heller GV, Parker MW. Stress-only SPECT myocardial perfusion imaging: a review. J Nucl Cardiol 2014; 21:1200-12. [PMID: 25005348 DOI: 10.1007/s12350-014-9944-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 06/10/2014] [Indexed: 11/26/2022]
Abstract
Myocardial perfusion imaging (MPI) has enjoyed considerable success for decades due to its diagnostic accuracy and wealth of prognostic data. Despite this success several limitations such as lengthy protocols and radiation exposure remain. Advancements to address these shortcomings include abbreviated stress-only MPI (SO MPI) protocols, PET and both hardware and software methods to reduce radiation exposure and time. SO MPI has advantages in protocol time and radiation reduction with a wealth of supporting data in terms of diagnostic validity and prognostic value. Newer technologies such as attenuation correction, and advanced camera technologies have enabled SO MPI to be more efficient in reducing the time of acquisition and radiation dose and improving accuracy. This review examines the literature available, regarding accuracy, patient outcomes, implementation strategies, and newer developments associated with SO MPI.
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Affiliation(s)
- B M Pampana Gowd
- Henry Low Heart Center, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA,
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40
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Agarwal S, Parashar A, Ellis SG, Heupler FA, Lau E, Tuzcu EM, Kapadia SR. Measures to Reduce Radiation in a Modern Cardiac Catheterization Laboratory. Circ Cardiovasc Interv 2014; 7:447-55. [DOI: 10.1161/circinterventions.114.001499] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shikhar Agarwal
- From the Section of Interventional Cardiology, Department of Cardiovascular Medicine, Heart and Vascular Institute (S.A., S.G.E., F.A.H., E.L., E.M.T., S.R.K.), and Department of Internal Medicine (A.P.), Cleveland Clinic, OH
| | - Akhil Parashar
- From the Section of Interventional Cardiology, Department of Cardiovascular Medicine, Heart and Vascular Institute (S.A., S.G.E., F.A.H., E.L., E.M.T., S.R.K.), and Department of Internal Medicine (A.P.), Cleveland Clinic, OH
| | - Stephen G. Ellis
- From the Section of Interventional Cardiology, Department of Cardiovascular Medicine, Heart and Vascular Institute (S.A., S.G.E., F.A.H., E.L., E.M.T., S.R.K.), and Department of Internal Medicine (A.P.), Cleveland Clinic, OH
| | - Frederick A. Heupler
- From the Section of Interventional Cardiology, Department of Cardiovascular Medicine, Heart and Vascular Institute (S.A., S.G.E., F.A.H., E.L., E.M.T., S.R.K.), and Department of Internal Medicine (A.P.), Cleveland Clinic, OH
| | - Evan Lau
- From the Section of Interventional Cardiology, Department of Cardiovascular Medicine, Heart and Vascular Institute (S.A., S.G.E., F.A.H., E.L., E.M.T., S.R.K.), and Department of Internal Medicine (A.P.), Cleveland Clinic, OH
| | - E. Murat Tuzcu
- From the Section of Interventional Cardiology, Department of Cardiovascular Medicine, Heart and Vascular Institute (S.A., S.G.E., F.A.H., E.L., E.M.T., S.R.K.), and Department of Internal Medicine (A.P.), Cleveland Clinic, OH
| | - Samir R. Kapadia
- From the Section of Interventional Cardiology, Department of Cardiovascular Medicine, Heart and Vascular Institute (S.A., S.G.E., F.A.H., E.L., E.M.T., S.R.K.), and Department of Internal Medicine (A.P.), Cleveland Clinic, OH
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41
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Mahmarian JJ, Chang S, Nabi F. Nuclear Cardiology: 2014 Innovations and Developments. Methodist Debakey Cardiovasc J 2014; 10:163-71. [DOI: 10.14797/mdcj-10-3-163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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42
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Abstract
This article focuses on some of the most important studies published in the year 2013 in cardiac imaging related to ischemic heart disease. Many of the studies across the various imaging techniques addressed the prognostic impact of imaging data on outcome in patients with this disease.
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Affiliation(s)
- Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus Stuttgart, Auerbachstraße 110, Stuttgart 70376, Germany
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