1
|
Selvaraj S, Bravo PE. How to prepare a patient for 18F-fluorodeoxyglucose positron emission tomography imaging to assess myocardial inflammation. J Nucl Cardiol 2024:101888. [PMID: 38830570 DOI: 10.1016/j.nuclcard.2024.101888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/06/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024]
Affiliation(s)
- Senthil Selvaraj
- From the Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA; Duke Molecular Physiology Institute, Durham, NC, USA; Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Cardiovascular Institute, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. https://twitter.com/@senthil_selv
| | - Paco E Bravo
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Cardiovascular Institute, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Division of Nuclear Medicine, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
2
|
Cheng RK, Kittleson MM, Beavers CJ, Birnie DH, Blankstein R, Bravo PE, Gilotra NA, Judson MA, Patton KK, Rose-Bovino L. Diagnosis and Management of Cardiac Sarcoidosis: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1197-e1216. [PMID: 38634276 DOI: 10.1161/cir.0000000000001240] [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] [Indexed: 04/19/2024]
Abstract
Cardiac sarcoidosis is an infiltrative cardiomyopathy that results from granulomatous inflammation of the myocardium and may present with high-grade conduction disease, ventricular arrhythmias, and right or left ventricular dysfunction. Over the past several decades, the prevalence of cardiac sarcoidosis has increased. Definitive histological confirmation is often not possible, so clinicians frequently face uncertainty about the accuracy of diagnosis. Hence, the likelihood of cardiac sarcoidosis should be thought of as a continuum (definite, highly probable, probable, possible, low probability, unlikely) rather than in a binary fashion. Treatment should be initiated in individuals with clinical manifestations and active inflammation in a tiered approach, with corticosteroids as first-line treatment. The lack of randomized clinical trials in cardiac sarcoidosis has led to treatment decisions based on cohort studies and consensus opinions, with substantial variation observed across centers. This scientific statement is intended to guide clinical practice and to facilitate management conformity by providing a framework for the diagnosis and management of cardiac sarcoidosis.
Collapse
|
3
|
Özütemiz C, Koksel Y, Froelich JW, Rubin N, Bhargava M, Roukoz H, Cogswell R, Markowitz J, Perlman DM, Steinberger D. The active papillary muscle sign in 18F-FDG PET/CT cardiac sarcoidosis exams and its relationship with myocardial suppression. Ann Nucl Med 2024; 38:391-399. [PMID: 38430406 DOI: 10.1007/s12149-024-01910-y] [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: 10/04/2023] [Accepted: 01/25/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Papillary muscle (PM) activity may demonstrate true active cardiac sarcoidosis (CS) or mimic CS in 18FDG-PET/CT if adequate myocardial suppression (MS) is not achieved. We aim to examine whether PM uptake can be used as a marker of failed MS and measure the rate of PM activity presence in active CS with different dietary preparations. MATERIALS AND METHODS We retrospectively reviewed PET/CTs obtained with three different dietary preparations. Diet-A: 24-h ketogenic diet with overnight fasting (n = 94); Diet-B: 18-h fasting (n = 44); and Diet-C: 72-h daytime ketogenic diet with 3-day overnight fasting (n = 98). Each case was evaluated regarding CS diagnosis (negative, positive, and indeterminant) and presence of PM activity. MaxSUV was measured from bloodpool, liver, and the most suppressed normal myocardium. Linear mixed-effects models were used to compare these factors between those with PM activity and those without. RESULTS PM activity was markedly lower in the Diet-C group compared with others: Diet-C: 6 (6.1%), Diet-A: 36 (38.3%), and Diet-B: 26 (59.1%) (p < 0.001). MyocardiumMaxSUV was higher, and MyocardiummaxSUV/BloodpoolmaxSUV, MyocardiummaxSUV/LivermaxSUV ratios were significantly higher in the cases with PM activity (p < 0.001). Among cases that used Diet-C and had PM activity, 66.7% were positive and 16.7% were indeterminate. If Diet-A or Diet-B was used, those with PM activity had a higher proportion of indeterminate cases (Diet-A: 61.1%, Diet-B: 61.5%) than positive cases (Diet-A: 36.1%, Diet-B: 38.5%). CONCLUSION Lack of PM activity can be a sign of appropriate MS. PM activity is less common with a specific dietary preparation (72-h daytime ketogenic diet with 3-day overnight fasting), and if it is present with this particular preparation, the likelihood that the case being true active CS might be higher than the other traditional dietary preparations.
Collapse
Affiliation(s)
- Can Özütemiz
- Department of Radiology, University of Minnesota, 420 Delaware St. SE, MMC 292, Minneapolis, MN, 55455, USA.
| | - Yasemin Koksel
- Department of Radiology, University of Minnesota, 420 Delaware St. SE, MMC 292, Minneapolis, MN, 55455, USA
| | - Jerry W Froelich
- Department of Radiology, University of Minnesota, 420 Delaware St. SE, MMC 292, Minneapolis, MN, 55455, USA
| | - Nathan Rubin
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, 717 Delaware Street SE, Second Floor, Minneapolis, MN, 55414, USA
| | - Maneesh Bhargava
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, 420 Delaware Street SE, MMC 276, Minneapolis, MN, 55455, USA
| | - Henri Roukoz
- Department of Medicine, Division of Cardiovascular Medicine, University of Minnesota, 420 Delaware Street SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Rebecca Cogswell
- Department of Medicine, Division of Cardiovascular Medicine, University of Minnesota, 420 Delaware Street SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Jeremy Markowitz
- Department of Medicine, Division of Cardiovascular Medicine, University of Minnesota, 420 Delaware Street SE, MMC 508, Minneapolis, MN, 55455, USA
| | - David M Perlman
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, 420 Delaware Street SE, MMC 276, Minneapolis, MN, 55455, USA
| | - Daniel Steinberger
- Department of Radiology, University of Minnesota, 420 Delaware St. SE, MMC 292, Minneapolis, MN, 55455, USA
| |
Collapse
|
4
|
Hutt E, Goldar G, Jaber WA, Cremer PC. Standardized ketogenic dietary preparation for metabolic PET imaging in suspected and known cardiac sarcoidosis. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2024; 2:qyae037. [PMID: 39045194 PMCID: PMC11195761 DOI: 10.1093/ehjimp/qyae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/20/2024] [Indexed: 07/25/2024]
Abstract
Aims A major limitation of cardiac positron emission tomography (PET) with F18-fluorodeoxyglucose (F18-FDG) for the evaluation of cardiac sarcoidosis (CS) is associated with physiologic myocardial glucose uptake. The optimal dietary protocol to suppress physiologic myocardial F18-FDG uptake is not well-established. We aimed to evaluate the diagnostic performance of a novel dietary preparation using a ketone-based infant formula. Methods and results Between 2018 and 2021, consecutive studies using a ketogenic dietary preparation were identified (n = 198). The rate of non-diagnostic studies due to failure to suppress myocardial glucose was 7.1% (n = 14) with a similar incidence in diabetics (n = 6, 8.1%). Among studies reported to have no inflammation (n = 137), 130 studies (66%) had mean myocardial standardized uptake value (SUV) less than or equal to mean blood pool SUV. Conclusion Patient preparation with a ketone-based infant formula resulted in low rate of inappropriate myocardial glucose suppression in patients undergoing F18-FDG cardiac PET to evaluate CS.
Collapse
Affiliation(s)
- Erika Hutt
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Ghazaleh Goldar
- Department of Cardiovascular Disease, University of Iowa Health Care, Iowa City, IA, USA
| | - Wael A Jaber
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Paul C Cremer
- Department of Cardiology and Radiology, Northwestern Medicine, Chicago, IL, USA
| |
Collapse
|
5
|
Wilk B, Smailovic H, Sullivan R, Sistermans ER, Butler J, Jago H, Kovacs M, Wisenberg G, Thiessen JD, Prato FS. Myocardial glucose suppression may interfere with the detection of inflammatory cells with FDG-PET as suggested in a canine model of myocardial infarction. EJNMMI Res 2023; 13:90. [PMID: 37823919 PMCID: PMC10570261 DOI: 10.1186/s13550-023-01040-y] [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: 04/05/2023] [Accepted: 10/04/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND After myocardial infarction, fibrosis and an ongoing dysregulated inflammatory response have been shown to lead to adverse cardiac remodeling. FDG PET is an imaging modality sensitive to inflammation as long as suppression protocols are observed while gadolinium enhanced MRI can be used to determine extracellular volume (ECV), a measure of fibrosis. In patients, glucose suppression is achieved variously through a high fat diet, fasting and injection of heparin. To emulate this process in canines, a heparin injection and lipid infusion are used, leading to similar fatty acids in the blood. The aim of this study was to examine the effect of glucose suppression on the uptake of FDG in the infarcted myocardial tissue and also on the determination of ECV in both the infarcted tissue and in the myocardium remote to the zone of infarction during a long constant infusion of FDG and Gd-DTPA. RESULTS Extracellular volume was affected neither by suppression nor the length of the constant infusion in remote and infarcted tissue. Metabolic rate of glucose in infarcted tissue decreased during and after suppression of glucose uptake by lipid infusion and heparin injection. An increase in fibrosis and inflammatory cells was found in the center of the infarct as compared to remote tissue. CONCLUSION The decrease in the metabolic rate of glucose in the infarcted tissue suggests that inflammatory cells may be affected by glucose suppression through heparin injection and lipid infusion.
Collapse
Affiliation(s)
- Benjamin Wilk
- Department of Imaging, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada.
- Medical Biophysics, Western University, London, ON, Canada.
| | - Haris Smailovic
- Department of Imaging, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Medical Biophysics, Western University, London, ON, Canada
| | - Rebecca Sullivan
- Department of Imaging, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Medical Biophysics, Western University, London, ON, Canada
| | - Erik R Sistermans
- Department of Imaging, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
| | - John Butler
- Department of Imaging, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
| | - Hannah Jago
- Department of Imaging, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
| | - Michael Kovacs
- Department of Imaging, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Medical Biophysics, Western University, London, ON, Canada
| | - Gerald Wisenberg
- Department of Imaging, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Medical Biophysics, Western University, London, ON, Canada
- MyHealth Centre, Arva, ON, Canada
| | - Jonathan D Thiessen
- Department of Imaging, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Medical Biophysics, Western University, London, ON, Canada
| | - Frank S Prato
- Department of Imaging, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Medical Biophysics, Western University, London, ON, Canada
| |
Collapse
|
6
|
Tersalvi G, Beltrani V, Grübler MR, Molteni A, Cristoforetti Y, Pedrazzini G, Treglia G, Biasco L. Positron Emission Tomography in Heart Failure: From Pathophysiology to Clinical Application. J Cardiovasc Dev Dis 2023; 10:220. [PMID: 37233187 PMCID: PMC10218989 DOI: 10.3390/jcdd10050220] [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: 03/31/2023] [Revised: 05/13/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023] Open
Abstract
Imaging modalities are increasingly being used to evaluate the underlying pathophysiology of heart failure. Positron emission tomography (PET) is a non-invasive imaging technique that uses radioactive tracers to visualize and measure biological processes in vivo. PET imaging of the heart uses different radiopharmaceuticals to provide information on myocardial metabolism, perfusion, inflammation, fibrosis, and sympathetic nervous system activity, which are all important contributors to the development and progression of heart failure. This narrative review provides an overview of the use of PET imaging in heart failure, highlighting the different PET tracers and modalities, and discussing fields of present and future clinical application.
Collapse
Affiliation(s)
- Gregorio Tersalvi
- Department of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
- Department of Internal Medicine, Ente Ospedaliero Cantonale, 6850 Mendrisio, Switzerland
| | - Vittorio Beltrani
- Department of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
- Department of Internal Medicine, Ente Ospedaliero Cantonale, 6850 Mendrisio, Switzerland
| | - Martin R. Grübler
- Department of Cardiology, Regional Hospital Neustadt, 2700 Wiener Neustadt, Austria
- Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Alessandra Molteni
- Department of Internal Medicine, Ente Ospedaliero Cantonale, 6850 Mendrisio, Switzerland
| | - Yvonne Cristoforetti
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), 6900 Lugano, Switzerland
| | - Giovanni Pedrazzini
- Department of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), 6900 Lugano, Switzerland
| | - Giorgio Treglia
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), 6900 Lugano, Switzerland
- Clinic of Nuclear Medicine, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1015 Lausanne, Switzerland
| | - Luigi Biasco
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), 6900 Lugano, Switzerland
- Division of Cardiology, Azienda Sanitaria Locale Torino 4, 10073 Ospedale di Ciriè, Italy
| |
Collapse
|
7
|
Ueberham L, Hagendorff A, Klingel K, Paetsch I, Jahnke C, Kluge T, Ebbinghaus H, Hindricks G, Laufs U, Dinov B. Pathophysiological Gaps, Diagnostic Challenges, and Uncertainties in Cardiac Sarcoidosis. J Am Heart Assoc 2023; 12:e027971. [PMID: 36892055 PMCID: PMC10111513 DOI: 10.1161/jaha.122.027971] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Cardiac sarcoidosis can mimic any cardiomyopathy in different stages. Noncaseating granulomatous inflammation can be missed, because of the nonhomogeneous distribution in the heart. The current diagnostic criteria show discrepancies and are partly nonspecific and insensitive. Besides the diagnostic pitfalls, there are controversies in the understanding of the causes, genetic and environmental background, and the natural evolution of the disease. Here, we review the current pathophysiological aspects and gaps that are relevant for future cardiac sarcoidosis diagnostics and research.
Collapse
Affiliation(s)
- Laura Ueberham
- Klinik und Poliklinik für Kardiologie Universitätsklinikum Leipzig Leipzig Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie Universitätsklinikum Leipzig Leipzig Germany
| | - Karin Klingel
- Cardiopathology Institute for Pathology, Eberhard Karls Universität Tübingen Tübingen Germany
| | - Ingo Paetsch
- Department of Electrophysiology Heart Center Leipzig at University of Leipzig Leipzig Germany
| | - Cosima Jahnke
- Department of Electrophysiology Heart Center Leipzig at University of Leipzig Leipzig Germany
| | - Theresa Kluge
- Klinik und Poliklinik für Nuklearmedizin Universitätsklinikum Leipzig Leipzig Germany
| | - Hans Ebbinghaus
- Department of Electrophysiology Heart Center Leipzig at University of Leipzig Leipzig Germany
| | - Gerhard Hindricks
- Department of Electrophysiology Heart Center Leipzig at University of Leipzig Leipzig Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie Universitätsklinikum Leipzig Leipzig Germany
| | - Borislav Dinov
- Department of Electrophysiology Heart Center Leipzig at University of Leipzig Leipzig Germany
| |
Collapse
|
8
|
Singh SB, Ng SJ, Lau HC, Khanal K, Bhattarai S, Paudyal P, Shrestha BB, Naseer R, Sandhu S, Gokhale S, Raynor WY. Emerging PET Tracers in Cardiac Molecular Imaging. Cardiol Ther 2023; 12:85-99. [PMID: 36593382 PMCID: PMC9986170 DOI: 10.1007/s40119-022-00295-1] [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: 10/12/2022] [Accepted: 11/26/2022] [Indexed: 01/04/2023] Open
Abstract
18F-fluorodeoxyglucose (FDG) and 18F-sodium fluoride (NaF) represent emerging PET tracers used to assess atherosclerosis-related inflammation and molecular calcification, respectively. By localizing to sites with high glucose utilization, FDG has been used to assess myocardial viability for decades, and its role in evaluating cardiac sarcoidosis has come to represent a major application. In addition to determining late-stage changes such as loss of perfusion or viability, by targeting mechanisms present in atherosclerosis, PET-based techniques have the ability to characterize atherogenesis in the early stages to guide intervention. Although it was once thought that FDG would be a reliable indicator of ongoing plaque formation, micro-calcification as portrayed by NaF-PET/CT appears to be a superior method of monitoring disease progression. PET imaging with NaF has the additional advantage of being able to determine abnormal uptake due to coronary artery disease, which is obscured by physiologic myocardial activity on FDG-PET/CT. In this review, we discuss the evolving roles of FDG, NaF, and other PET tracers in cardiac molecular imaging.
Collapse
Affiliation(s)
- Shashi Bhushan Singh
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Sze Jia Ng
- Department of Medicine, Crozer-Chester Medical Center, 1 Medical Center Boulevard, Upland, PA, 19013, USA
| | - Hui Chong Lau
- Department of Medicine, Crozer-Chester Medical Center, 1 Medical Center Boulevard, Upland, PA, 19013, USA
| | - Kishor Khanal
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Division of Cardiology, Memorial Healthcare System, 3501 Johnson Street, Hollywood, FL, 33021, USA
| | - Sanket Bhattarai
- Department of Medicine, KIST Medical College, Mahalaxmi 01, Lalitpur, Bagmati, Nepal
| | - Pranita Paudyal
- West China Hospital, Sichuan University, 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Bimash Babu Shrestha
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Rizwan Naseer
- Department of Medicine, Crozer-Chester Medical Center, 1 Medical Center Boulevard, Upland, PA, 19013, USA
| | - Simran Sandhu
- College of Health and Human Development, Pennsylvania State University, 10 East College Avenue, University Park, PA, 16802, USA
| | - Saket Gokhale
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - William Y Raynor
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
- Department of Radiology, Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, MEB #404, New Brunswick, NJ, 08901, USA.
| |
Collapse
|
9
|
The utility of beta-hydroxybutyrate in detecting myocardial glucose uptake suppression in patients undergoing inflammatory [18F]-FDG PET studies. Eur J Nucl Med Mol Imaging 2023; 50:1103-1110. [PMID: 36474124 DOI: 10.1007/s00259-022-06062-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE We evaluated whether serum beta-hydroxybutyrate (BHB) can identify adequate suppression of the left ventricle (LV) among patients undergoing [18F]-fluorodeoxyglucose positron emission tomography ([18F]-FDG PET) for cardiac inflammatory/infectious studies. METHODS Consecutive patients who underwent [18F]-FDG PET imaging were included. Serum BHB levels were measured in all patients on the day of imaging prior to injecting [18F]-FDG. Myocardial [18F]-FDG suppression was defined if [18F]-FDG uptake in the walls of myocardium, measured using standardized uptake values (SUV), was lower than the blood pool. The optimal threshold of BHB to identify myocardial suppression was based on receiver operating characteristics (ROC) in a random 30% sample of the study population (derivation cohort) and tested in the remaining 70% of sample (validation cohort). RESULTS A total of 256 images from 220 patients were included. Patients with sufficient LV suppression had significantly higher BHB levels compared to those with non-suppressed myocardium (median (IQR) BHB 0.6 (0.3-0.8) vs. 0.2 (0.2-0.3) mmol/l, p < 0.001, respectively). BHB level ≥ 0.335 mmol/l had a sensitivity of 84.90% and a specificity of 92.60% to identify adequate LV suppression in the validation cohort. All patients (100%) with BHB ≥ 0.41 mmol/l had adequate myocardial suppression compared to 29.63% of patients with BHB ≤ 0.20 mmol/l. CONCLUSION Serum BHB level can be used at the point of care to identify sufficient LV suppression in patients undergoing [18F]-FDG PET cardiac inflammatory/infectious studies. Central illustration (image to the right) shows representative cases of patient images and BHB and, in the image to the left, shows the sensitivity and specificity to identify left myocardial suppression using BHB in validation group.
Collapse
|
10
|
Chareonthaitawee P, Gutberlet M. Clinical Utilization of Multimodality Imaging for Myocarditis and Cardiac Sarcoidosis. Circ Cardiovasc Imaging 2023; 16:e014091. [PMID: 36649452 DOI: 10.1161/circimaging.122.014091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Myocarditis is defined as inflammation of the myocardium according to clinical, histological, biochemical, immunohistochemical, or imaging findings. Inflammation can be categorized histologically by cell type or pattern, and many causes have been implicated, including infectious, most commonly viral, systemic autoimmune diseases, vaccine-associated processes, environmental factors, toxins, and hypersensitivity to drugs. Sarcoid myocarditis is increasingly recognized as an important cause of cardiomyopathy and has important diagnostic, prognostic, and therapeutic implications in patients with systemic sarcoidosis. The clinical presentation of myocarditis may include an asymptomatic, subacute, acute, fulminant, or chronic course and may have focal or diffuse involvement of the myocardium depending on the cause and time point of the disease. For most causes of myocarditis except sarcoidosis, myocardial biopsy is the gold standard but is limited due to risk, cost, availability, and variable sensitivity. Diagnostic criteria have been established for both myocarditis and cardiac sarcoidosis and include clinical and imaging findings particularly the use of cardiac magnetic resonance and positron emission tomography. Beyond diagnosis, imaging findings may also provide prognostic value. This case-based review focuses on the current state of multimodality imaging for the diagnosis and management of myocarditis and cardiac sarcoidosis, highlighting multimodality imaging approaches with practical clinical vignettes, with a discussion of knowledge gaps and future directions.
Collapse
|
11
|
Germaini M, Boursier C, Goehringer F, Selton-Suty C, Lefevre B, Roch V, Imbert L, Claudin M, Chevalier E, Marie PY. The detection of infectious endocarditis may be enhanced by a repeat FDG-PET while maintaining patients on a ketogenic diet. J Nucl Cardiol 2022; 29:3256-3262. [PMID: 35194753 DOI: 10.1007/s12350-022-02921-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/24/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND This study aims to determine whether the suppression of myocardial FDG uptake and detection of infectious endocarditis (IE) may be enhanced when FDG-PET is repeated on the next day while maintaining patients on a ketogenic diet in the interim. METHODS Seventeen patients with definite IE underwent FDG-PET investigations both after a conventional metabolic preparation (> 12-hour fast after a low-carbohydrate evening meal) and a subsequent 12-hour extension of the low-carbohydrate diet followed by an additional > 12-hour fast. RESULTS Plasma biomarkers showed increased ketogenic metabolism between the two FDG-PET scans. A myocardial FDG uptake persisted on the 1st PET in 9 patients (53%) for whom myocardial FDG uptake decreased significantly on the 2nd PET (SUVmax: 6.05 ± 3.25 vs 4.32 ± 3.47, P = 0.021), resulting in an enhancement in the diagnostic confidence of IE in 6 cases. These enhancements were not documented in the 8 patients exhibiting a total suppression of myocardial FDG uptake on the 1st PET. CONCLUSIONS Better suppression of myocardial uptake and enhanced detection of IE may be achieved when an FDG-PET, showing an incomplete suppression of the myocardial FDG uptake, is repeated as soon as the next day, while maintaining patients on a ketogenic diet in the interim.
Collapse
Affiliation(s)
- Marine Germaini
- Department of Nuclear Medicine and Nancyclotep molecular imaging platform, CHRU-Nancy, Université de Lorraine, 54000, Nancy, France
| | - Caroline Boursier
- Department of Nuclear Medicine and Nancyclotep molecular imaging platform, CHRU-Nancy, Université de Lorraine, 54000, Nancy, France
| | | | | | - Benjamin Lefevre
- Université de Lorraine, APEMAC, 54000, Nancy, France
- Infectious and Tropical Diseases, CHRU-Nancy, 54000, Nancy, France
| | - Véronique Roch
- Department of Nuclear Medicine and Nancyclotep molecular imaging platform, CHRU-Nancy, Université de Lorraine, 54000, Nancy, France
| | - Laetitia Imbert
- Department of Nuclear Medicine and Nancyclotep molecular imaging platform, CHRU-Nancy, Université de Lorraine, 54000, Nancy, France
- Université de Lorraine, INSERM, UMR 1254, 54000, Nancy, France
| | - Marine Claudin
- Department of Nuclear Medicine and Nancyclotep molecular imaging platform, CHRU-Nancy, Université de Lorraine, 54000, Nancy, France
| | - Elodie Chevalier
- Department of Nuclear Medicine and Nancyclotep molecular imaging platform, CHRU-Nancy, Université de Lorraine, 54000, Nancy, France
| | - Pierre-Yves Marie
- Department of Nuclear Medicine and Nancyclotep molecular imaging platform, CHRU-Nancy, Université de Lorraine, 54000, Nancy, France.
- Université de Lorraine, INSERM, UMR 1116, 54000, Nancy, France.
| |
Collapse
|
12
|
Abstract
PURPOSE OF REVIEW PET has emerged as method to determine the location and extent of disease activity in sarcoidosis. As most clinicians do not routinely utilize PET in the management of sarcoidosis, an understanding of the imaging technique is needed to comprehend the impact that PET abnormalities have on diagnosis, prognosis, and treatment. RECENT FINDINGS Although PET can detect inflammation because of sarcoidosis throughout the body, it is most often utilized for the diagnosis of cardiac sarcoidosis for which it may provide information about prognosis and adverse events. Whenever PET is combined with cardiac magnetic resonance (CMR), clinicians may be able to increase the diagnostic yield of imaging. Furthermore, PET abnormalities have the potential to be utilized in the reduction or augmentation of therapy based on an individual's response to treatment. Although various biomarkers are used to monitor disease activity in sarcoidosis, an established and reproducible relationship between PET and biomarkers does not exist. SUMMARY PET has the potential to improve the diagnosis of sarcoidosis and alter treatment decisions but prospective trials are needed to define the role of PET while also standardizing the performance and interpretation of the imaging modality.
Collapse
Affiliation(s)
- Robert J. Vender
- Department of Thoracic Medicine & Surgery at Temple University Hospital
| | - Hamad Aldahham
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Rohit Gupta
- Department of Thoracic Medicine & Surgery, Lewis Katz School of Medicine at Temple University
| |
Collapse
|
13
|
Lu Y. Extensive Biventricular Cardiac Sarcoidosis Detected on FDG PET/CT Using a 72-Hour Ketogenic Diet Preparation Protocol. Clin Nucl Med 2022; 47:728-729. [PMID: 35261354 DOI: 10.1097/rlu.0000000000004119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT A 49-year-old man had right bundle-branch block, with decreased left ventricle ejection fraction of 43%. Cardiac MRI demonstrated abnormal multifocal delayed gadolinium enhancement involving both ventricles. Cardiac sarcoidosis was further confirmed at cardiac biopsy. Dedicated FDG PET/CT with 72-hour ketogenic diet preparation to suppress physiological myocardial uptake of FDG was performed for disease evaluation. PET/CT revealed multifocal abnormal uptake in both ventricles concordant with cardiac MRI findings, in addition to hypermetabolic lymphadenopathy. Six months later, posttreatment PET/CT with the same 72-hour ketogenic diet preparation showed good response with resolution of active inflammation.
Collapse
Affiliation(s)
- Yang Lu
- From the Division of Diagnostic Imaging, Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW Cardiac sarcoidosis (CS) is a potentially fatal condition when unrecognized or not treated adequately. The purpose of this review is to provide new strategies to increase clinical recognition of CS and to present an updated overview of the immunosuppressive treatments using most recent data published in the last 18 months. RECENT FINDINGS CS is an increasingly recognized pathology, and its diagnostic is made 20 times more often in the last two decades. Recent studies have shown that imaging alone usually lacks specificity to distinguish CS from other inflammatory cardiomyopathies. However, imaging can be used to increase significantly diagnostic yield of extracardiac and cardiac biopsy. Recent reviews have also demonstrated that nearly 25% of patients will be refractory to standard treatment with prednisone and that combined treatment with a corticosteroid-sparing agent is often necessary for a period that remains undetermined. SUMMARY CS is a complex pathology that should always require a biopsy attempt to have a histological proven diagnosis before starting immunosuppressive therapy consisting of corticosteroids with or without a corticosteroid-sparing agent.
Collapse
Affiliation(s)
- Sylvain Lemay
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | | | | |
Collapse
|
15
|
Lu Y, Sweiss NJ, Macapinlac HA. What Is the Optimal Method on Myocardial Suppression in FDG PET/CT Evaluation of Cardiac Sarcoidosis? Clin Nucl Med 2021; 46:904-905. [PMID: 34132675 DOI: 10.1097/rlu.0000000000003777] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Based on the recent publications, including large cohort retrospective study and prospective clinical trial data, we are commenting on the optimal methods on myocardial suppression in FDG PET/CT evaluation of patients with suspected cardiac sarcoidosis.
Collapse
Affiliation(s)
- Yang Lu
- From the Division of Diagnostic Imaging, Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nadera J Sweiss
- Department of Medicine, University of Illinois College of Medicine, Chicago, IL
| | - Homer A Macapinlac
- From the Division of Diagnostic Imaging, Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
16
|
Abstract
Sarcoidosis is a multisystem disease of unknown cause with heterogenous clinical manifestations and variable course. Spontaneous remissions occur in some patients while others have progressive disease impacting survival, organ function, and quality of life. Four high-risk sarcoidosis phenotypes associated with chronic inflammation have recently been identified as high-priority areas for research. These include treatment-refractory pulmonary disease, cardiac sarcoidosis, neurosarcoidosis and multiorgan sarcoidosis. Significant gaps currently exist in understanding of these high-risk manifestations of sarcoidosis, including their natural history, diagnostic criteria, biomarkers, and the treatment strategy such as the ideal agent, optimal dose and treatment duration. The use of registries with well-phenotyped patients is a critical first step to study high-risk sarcoidosis manifestations systematically. We review the diagnostic and treatment approach to high-risk sarcoidosis manifestations. Appropriately identifying these disease sub-groups will help enroll well-phenotyped patients in sarcoidosis registries and clinical trials, a necessary step to narrow existing gaps in understanding of this enigmatic disease.
Collapse
|
17
|
Abstract
Positron emission tomography and/or computed tomography (PET/CT) MPI is a powerful imaging modality for the assessment of cardiovascular diseases. It offers several advantages over single-photon emission computed tomography (SPECT) MPI including robust attenuation correction and absolute quantification of radiotracer activity. PET MPI has a large evidence base and is the only clinical tool to evaluate coronary microvascular dysfunction. In addition, the clinical use and evidence base for 2-deoxy-2-[18F]fluoro-D-g1ucose (18F-FDG) cardiac PET imaging for inflammation and metabolism imaging is rising exponentially. In order to gain from the advances of this sophisticated quantitative technique, a high-quality scan is critical. It is important for readers to recognize a poor-quality scan, identify artifacts contributing to the poor image quality, and understand how to correct them prior to reporting the results. In this review, we will discuss some normal variants and pitfalls in cardiac PET/CT radionuclide MPI, myocardial viability, and inflammation imaging.
Collapse
Affiliation(s)
- Vasvi Singh
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas City, MO
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
| |
Collapse
|