1
|
Garefa C, Sager DF, Heiniger PS, Markendorf S, Albertini T, Jurisic S, Gajic M, Gebhard C, Benz DC, Pazhenkottil AP, Giannopoulos AA, Kaufmann PA, Slomka PJ, Buechel RR. Duration of adenosine-induced myocardial hyperemia - Insights from quantitative 13N-ammonia positron emission tomography myocardial perfusion imaging. Eur Heart J Cardiovasc Imaging 2024:jeae096. [PMID: 38584491 DOI: 10.1093/ehjci/jeae096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/25/2024] [Accepted: 04/03/2024] [Indexed: 04/09/2024] Open
Abstract
AIMS To assess the impact of adenosine on quantitative myocardial blood flow (MBF) in a rapid stress-rest protocol compared to a rest-stress protocol using 13N-ammonia positron emission tomography (PET) myocardial perfusion imaging (MPI) and to gain insights into the time dependency of such effects. METHODS AND RESULTS Quantitative MBF at rest (rMBF), during adenosine-induced stress (sMBF) and myocardial flow reserve (MFR) were obtained from 331 retrospectively identified patients who underwent 13N-ammonia PET-MPI for suspected chronic coronary syndrome and who all exhibited no perfusion defects. Of these, 146 (44.1%) underwent a rapid stress-rest protocol with a time interval (Δtstress-rest) of 20 ± 4 minutes between adenosine infusion offset and rest-imaging, as per clinical routine. The remaining 185 (55.9%) patients underwent a rest-stress protocol and served as the reference. Groups did not differ regarding demographics, risk factors, medication, left ventricular function, and calcium scores. rMBF was significantly higher in the stress-rest vs. the rest-stress group (0.80 [IQR 0.66-1.00] vs. 0.70 [0.58-0.83] ml·min-1·g-1, p < 0.001) and, as sMBF was identical between groups (2.52 [2.20-2.96] vs. 2.50 [1.96-3.11], p = 0.347), MFR was significantly lower in the stress-rest group (3.07 [2.43-3.88] vs. 3.50 [2.63-4.10], p < 0.001). There was a weak correlation between Δtstress-rest and rMBF (r = -0.259, p = 0.002) and between Δtstress-rest and MFR (r = 0.163, p = 0.049), and the proportion of patients with abnormally high rMBF was significantly decreasing with increasing Δtstress-rest. CONCLUSIONS Intravenously applied adenosine induces a long-lasting hyperemic effect on the myocardium. Consequently, rapid stress-rest protocols could lead to an overestimation of rMBF and an underestimation of MFR.
Collapse
Affiliation(s)
- Chrysoula Garefa
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Dominik F Sager
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Pascal S Heiniger
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Susanne Markendorf
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Tobia Albertini
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Stjepan Jurisic
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Marko Gajic
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| | - Piotr J Slomka
- Division of Artificial Intelligence in Medicine, Imaging, and Biomedical Sciences, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
2
|
Giannopoulos AA, Bolt B, Benz DC, Messerli M, Von Felten E, Patriki D, Gebhard C, Pazhenkottil AP, Gräni C, Kaufmann PA, Buechel RR, Gaemperli O. Non-Invasive Assessment of Endothelial Shear Stress in Myocardial Bridges Using Coronary Computed Tomography Angiography. Angiology 2024; 75:367-374. [PMID: 36786297 PMCID: PMC10870693 DOI: 10.1177/00033197231156637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Myocardial bridging (MB) is a segment of coronary arteries with an intramural course, typically spared from atherosclerosis, while the adjacent proximal segment is reported to be atherosclerosis-prone, a phenomenon contributed to local endothelial shear stress (ESS). We aimed to describe the ESS milieu in coronaries with MBs combining coronary computed tomography angiography with computational fluid dynamics and to investigate the association of atherosclerosis presence proximal to MBs with hemorheological characteristics. Patients (n = 36) were identified and 36 arteries with MBs (11 deep and 25 superficial) were analyzed. ESS did not fluctuate 5 mm proximally to MBs vs 5 mm within MBs (0.94 vs 1.06 Pa, p = .56). There was no difference when comparing ESS in the proximal versus mid versus distal MB segments (1.48 vs 1.37 vs 1.9 Pa, p = ns). In arteries with plaques (n = 12), no significant ESS variances were observed around the MB entrance, when analyzing all arteries (p = .81) and irrespective of morphological features of the bridged segment (deep MBs; p = .65, superficial MBs; p = .84). MBs are characterized by homogeneous, atheroprotective ESS, possibly explaining the absence of atherosclerosis within bridged segments. The interplay between ESS and atherosclerosis is potentially not different in arteries with MB compared with arteries without bridges.
Collapse
Affiliation(s)
- Andreas A. Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Basil Bolt
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Dominik C. Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Elia Von Felten
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri Patriki
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Aju P. Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiology, Inselspital Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital Bern, Bern, Switzerland
| | - Philipp A. Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Ronny R. Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | | |
Collapse
|
3
|
Schaab JA, Candreva A, Rossi A, Markendorf S, Sager D, Messerli M, Pazhenkottil AP, Benz DC, Kaufmann PA, Buechel RR, Stähli BE, Giannopoulos AA. A simple coronary CT angiography-based jeopardy score for the identification of extensive coronary artery disease: Validation against invasive coronary angiography. Diagn Interv Imaging 2024; 105:151-158. [PMID: 38007373 DOI: 10.1016/j.diii.2023.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/03/2023] [Accepted: 11/08/2023] [Indexed: 11/27/2023]
Abstract
PURPOSE The invasive British Cardiovascular Intervention Society Jeopardy Score (iBCIS-JS) is a simple angiographic scoring system, enabling quantification of the extent of jeopardized myocardium related to clinically significant coronary artery disease (CAD). The purpose of this study was to develop and validate the coronary CT angiography-based BCIS-JS (CT-BCIS-JS) against the iBCIS-JS in patients with suspected or stable CAD. MATERIALS AND METHODS Patients who underwent coronary CT angiography followed by invasive coronary angiography, within 90 days were retrospectively included. CT-BCIS-JS and iBCIS-JS were calculated, with a score ≥ 6 indicating extensive CAD. Correlation between the CT-BCIS-JS and iBCIS-JS was searched for using Spearman's coefficient, and agreement with weighted Kappa (κ) analyses. RESULTS A total of 122 patients were included. There were 102 men and 20 women with a median age of 62 years (Q1, Q3: 54, 68; age range: 19-83 years). No differences in median CT-BCIS-JS (4; Q1, Q3: 0, 8) and median iBCIS-JS (4; Q1, Q3: 0, 8) were found (P = 0.18). Extensive CAD was identified in 53 (43.4%) and 52 (42.6%) patients using CT-BCIS-JS and iBCIS-JS, respectively (P = 0.88). CT-based and iBCIS-JS showed excellent correlation (r = 0.98; P < 0.001) and almost perfect agreement (κ = 0.93; 95% confidence interval: 0.90-0.97). Agreement for identification of an iBCIS-JS ≥ 6 was almost perfect (κ = 0.94; 95 % confidence interval: 0.87-0.99). CONCLUSION The CT-BCIS-JS represents a feasible, and accurate method for quantification of CAD, with capabilities not different from those of iBCIS-JS. It enables simple, non-invasive identification of patients with anatomically extensive CAD.
Collapse
Affiliation(s)
- Jan A Schaab
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Alessandro Candreva
- Department of Cardiology, University Heart Center, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Susanne Markendorf
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Dominik Sager
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, CH-8091 Zurich, Switzerland; Department of Cardiology, University Heart Center, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, CH-8091 Zurich, Switzerland; Department of Cardiology, University Heart Center, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Barbara E Stähli
- Department of Cardiology, University Heart Center, University Hospital Zurich, CH-8091 Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, CH-8091 Zurich, Switzerland.
| |
Collapse
|
4
|
Anwer S, Nussbaum S, E Winkler N, C Benz D, Zuercher D, G Donati T, Tsiourantani G, Wilzeck V, M Michel J, M Kasel A, C Tanner F. Left ventricular global work index and prediction of cardiovascular mortality after transcatheter aortic valve implantation. Int J Cardiol 2024; 399:131660. [PMID: 38160913 DOI: 10.1016/j.ijcard.2023.131660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/20/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Echocardiography is used for assessment of patients after transcatheter aortic valve implantation (TAVI). Global work index (GWI) integrates LV deformation throughout the cardiac cycle and LV afterload and may be advantageous for long-term follow-up. METHODS We analysed 144 patients with severe aortic stenosis who underwent TAVI and echocardiography within two weeks afterwards. GE EchoPAC v2.6 was applied for determining LV ejection fraction, global longitudinal strain (GLS), stroke work (SW), cardiac power output (CPO), and GWI. The endpoint was cardiovascular mortality. RESULTS During median follow-up of 625 [IQR: 511-770] days, 20 (14%) patients died. Clinical baseline characteristics were comparable between non-survivors and survivors. GWI (p = 0.003) and LVEF (p = 0.039) were lower in non-survivors, while GLS, SW, and CPO were not different. In Kaplan-Meier analysis patients with GWI ≤1234 mmHg% exhibited a lower survival probability (P = 0.006). In univariable Cox regression, a significant mortality association was identified for GWI (P = 0.004), weaker for LVEF (P = 0.014), but not for the other parameters. In multivariable Cox regression, GWI independently improved an LV systolic function model including LVEF and GLS. Similarly, GWI but not LVEF independently improved outcome association of different clinical models. CONCLUSIONS GWI was lower in non-survivors than survivors, differentiated non-survivors from survivors, was associated with mortality independent of clinical or LV parameters, and improved the fitness of clinical or LV prediction models. In contrast, GLS, SW, and CPO did not show any of these properties. GWI provides added value for follow-up after TAVI possibly by integrating LV deformation throughout the cardiac cycle.
Collapse
Affiliation(s)
- Shehab Anwer
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
| | - Sinuhe Nussbaum
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Neria E Winkler
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Dominik C Benz
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Dominik Zuercher
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Thierry G Donati
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Glykeria Tsiourantani
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Verena Wilzeck
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Jonathan M Michel
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Albert M Kasel
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Felix C Tanner
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
| |
Collapse
|
5
|
Bernhard B, Joss P, Greisser N, Stark AW, Schütze J, Shiri I, Safarkhanlo Y, Fischer K, Guensch DP, Bastiaansen JAM, Pavlicek M, Benz DC, Kwong RY, Gräni C. Prognostic value of visual and quantitative CMR regional myocardial function in patients with suspected myocarditis. Int J Cardiovasc Imaging 2024:10.1007/s10554-024-03059-1. [PMID: 38427272 DOI: 10.1007/s10554-024-03059-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/17/2024] [Indexed: 03/02/2024]
Abstract
According to updated Lake-Louise Criteria, impaired regional myocardial function serves as a supportive criterion in diagnosing myocarditis. This study aimed to assess visual regional wall motional abnormalities (RWMA) and novel quantitative regional longitudinal peak strain (RLS) for risk stratification in the clinical setting of myocarditis. In patients undergoing CMR and meeting clinical criteria for suspected myocarditis global longitudinal strain (GLS), late gadolinium enhancement (LGE), RWMA and RLS were assessed in the anterior, septal, inferior, and lateral regions and correlated to the occurrence of major adverse cardiac events (MACE), including heart failure hospitalization, sustained ventricular tachycardia, recurrent myocarditis, and all-cause death. In 690 consecutive patients (age: 48.0 ± 16.0 years; 37.7% female) with suspected myocarditis impaired RLS was correlated with RWMA and LV-GLS but not with the presence of LGE. At median follow up of 3.8 years, MACE occurred in 116 (16.8%) patients. Both, RWMA and RLS in anterior-, septal-, inferior-, and lateral- locations were univariately associated with outcomes (all p < 0.001), but not after adjusting for clinical characteristics and LV-GLS. In the subgroup of patients with normal LV function, RWMA were not predictive of outcomes, whereas septal RLS had incremental and independent prognostic value over clinical characteristics (HRadjusted = 1.132, 95% CI 1.020-1.256; p = 0.020). RWMA and RLS can be used to assess regional impairment of myocardial function in myocarditis but are of limited prognostic value in the overall population. However, in the subgroup of patients with normal LV function, septal RLS represents a distinctive marker of regional LV dysfunction, offering potential for risk-stratification.
Collapse
Affiliation(s)
- Benedikt Bernhard
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philippe Joss
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Noah Greisser
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anselm W Stark
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan Schütze
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Isaac Shiri
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yasaman Safarkhanlo
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kady Fischer
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Dominik P Guensch
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jessica A M Bastiaansen
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Translation Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland
| | - Maryam Pavlicek
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominik C Benz
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Department of Cardiology, University Hospital Bern, Freiburgstrasse, CH - 3010, Bern, Switzerland.
| |
Collapse
|
6
|
von Känel R, Princip M, Holzgang SA, Garefa C, Rossi A, Benz DC, Giannopoulos AA, Kaufmann PA, Buechel RR, Zuccarella-Hackl C, Pazhenkottil AP. Correction: Coronary microvascular function in male physicians with burnout and job stress: an observational study. BMC Med 2024; 22:71. [PMID: 38365651 PMCID: PMC10873929 DOI: 10.1186/s12916-024-03290-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Affiliation(s)
- Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Culmannstrasse 8, CH-8091, Zurich, Switzerland.
| | - Mary Princip
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Culmannstrasse 8, CH-8091, Zurich, Switzerland
| | - Sarah A Holzgang
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Culmannstrasse 8, CH-8091, Zurich, Switzerland
| | - Chrysoula Garefa
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Alexia Rossi
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Dominik C Benz
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ronny R Buechel
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Claudia Zuccarella-Hackl
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Culmannstrasse 8, CH-8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Culmannstrasse 8, CH-8091, Zurich, Switzerland
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| |
Collapse
|
7
|
Alwan L, Benz DC, Cuddy SAM, Dobner S, Shiri I, Caobelli F, Bernhard B, Stämpfli SF, Eberli F, Reyes M, Kwong RY, Falk RH, Dorbala S, Gräni C. Current and Evolving Multimodality Cardiac Imaging in Managing Transthyretin Amyloid Cardiomyopathy. JACC Cardiovasc Imaging 2024; 17:195-211. [PMID: 38099914 DOI: 10.1016/j.jcmg.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 01/29/2024]
Abstract
Amyloid transthyretin (ATTR) amyloidosis is a protein-misfolding disease characterized by fibril accumulation in the extracellular space that can result in local tissue disruption and organ dysfunction. Cardiac involvement drives morbidity and mortality, and the heart is the major organ affected by ATTR amyloidosis. Multimodality cardiac imaging (ie, echocardiography, scintigraphy, and cardiac magnetic resonance) allows accurate diagnosis of ATTR cardiomyopathy (ATTR-CM), and this is of particular importance because ATTR-targeting therapies have become available and probably exert their greatest benefit at earlier disease stages. Apart from establishing the diagnosis, multimodality cardiac imaging may help to better understand pathogenesis, predict prognosis, and monitor treatment response. The aim of this review is to give an update on contemporary and evolving cardiac imaging methods and their role in diagnosing and managing ATTR-CM. Further, an outlook is presented on how artificial intelligence in cardiac imaging may improve future clinical decision making and patient management in the setting of ATTR-CM.
Collapse
Affiliation(s)
- Louhai Alwan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominik C Benz
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiac Imaging, Department of Cardiology and Nuclear Medicine, Zurich University Hospital, Zurich, Switzerland
| | - Sarah A M Cuddy
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephan Dobner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Isaac Shiri
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Federico Caobelli
- University Clinic of Nuclear Medicine, Inselspital, Bern University Hospital, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Simon F Stämpfli
- Department of Cardiology, Heart Centre Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Franz Eberli
- Department of Cardiology, Triemli Hospital (Triemlispital), Zurich, Switzerland
| | - Mauricio Reyes
- Insel Data Science Center, Inselspital, Bern University Hospital, Bern, Switzerland; Artificial Intelligence in Medical Imaging, ARTORG Center for Biomedical Research, University of Bern, Bern, Switzerland
| | - Raymond Y Kwong
- CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rodney H Falk
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| |
Collapse
|
8
|
Datar Y, Clerc OF, Cuddy SAM, Kim S, Taylor A, Neri JC, Benz DC, Bianchi G, Yee AJ, Sanchorawala V, Ruberg FL, Landau H, Liao R, Kijewski MF, Jerosch-Herold M, Kwong RY, Di Carli MF, Falk RH, Dorbala S. Quantification of Right Ventricular Amyloid Burden with 18F-florbetapir PET/CT and its Association with Right Ventricular Dysfunction and Outcomes in Light-Chain Amyloidosis. Eur Heart J Cardiovasc Imaging 2024:jead350. [PMID: 38193678 DOI: 10.1093/ehjci/jead350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 01/10/2024] Open
Abstract
AIMS In systemic light-chain (AL) amyloidosis, quantification of right ventricular (RV) amyloid burden has been limited and the pathogenesis of RV dysfunction is poorly understood. Using 18F-florbetapir positron emission tomography/computed tomography (PET/CT), we aimed to quantify RV amyloid, correlate RV amyloid with RV structure and function, determine the independent contributions of RV, left ventricular (LV) and lung amyloid to RV function, and to associate RV amyloid with major adverse cardiac events (MACE: death, heart failure hospitalization, cardiac transplantation). METHODS AND RESULTS We prospectively enrolled 106 participants with AL amyloidosis (median age 62 years, 55% males) who underwent 18F-florbetapir PET/CT, magnetic resonance imaging and echocardiography. 18F-florbetapir PET/CT identified RV amyloid in 63% of those with, and 40% of those without cardiac involvement by conventional criteria. RV amyloid burden correlated with RV ejection fraction (EF), RV free wall longitudinal strain (FWLS), RV wall thickness, RV mass index, NT-proBNP, troponin T, LV amyloid and lung amyloid (each p<0.001). In multivariable analysis, RV amyloid burden, but not LV or lung amyloid burden, predicted RV dysfunction (EF p=0.014; FWLS p<0.001). During a median follow-up of 28 months, RV amyloid burden predicted MACE (p<0.001). CONCLUSIONS This study shows for the first time that 18F-florbetapir PET/CT identifies early RV amyloid in systemic AL amyloidosis prior to alterations in RV structure and function. Increasing RV amyloid on 18F-florbetapir PET/CT is associated with worse RV structure and function, predicts RV dysfunction and predicts MACE. These results imply a central role for RV amyloid in the pathogenesis of RV dysfunction.
Collapse
Affiliation(s)
- Yesh Datar
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Olivier F Clerc
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Sarah A M Cuddy
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Sirwoo Kim
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Alexandra Taylor
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Jocelyn Canseco Neri
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Dominik C Benz
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Giada Bianchi
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Andrew J Yee
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Vaishali Sanchorawala
- Section of Hematology, Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Heather Landau
- Division of Medical Oncology, Memorial Sloan Kettering Medical Center, New York, NY
| | - Ronglih Liao
- Amyloidosis Program, Stanford University, Stanford, CA
| | - Marie Foley Kijewski
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Michael Jerosch-Herold
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Raymond Y Kwong
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Marcelo F Di Carli
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Sharmila Dorbala
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
9
|
Benz DC, Gräni C, Antiochos P, Heydari B, Gissler MC, Ge Y, Cuddy SAM, Dorbala S, Kwong RY. Cardiac magnetic resonance biomarkers as surrogate endpoints in cardiovascular trials for myocardial diseases. Eur Heart J 2023; 44:4738-4747. [PMID: 37700499 PMCID: PMC11032206 DOI: 10.1093/eurheartj/ehad510] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 07/05/2023] [Accepted: 07/25/2023] [Indexed: 09/14/2023] Open
Abstract
Cardiac magnetic resonance offers multiple facets in the diagnosis, risk stratification, and management of patients with myocardial diseases. Particularly, its feature to precisely monitor disease activity lends itself to quantify response to novel therapeutics. This review critically appraises the value of cardiac magnetic resonance imaging biomarkers as surrogate endpoints for prospective clinical trials. The primary focus is to comprehensively outline the value of established cardiac magnetic resonance parameters in myocardial diseases. These include heart failure, cardiac amyloidosis, iron overload cardiomyopathy, hypertrophic cardiomyopathy, cardio-oncology, and inflammatory cardiomyopathies like myocarditis and sarcoidosis.
Collapse
Affiliation(s)
- Dominik C Benz
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Panagiotis Antiochos
- Cardiology and Cardiac MR Centre, University Hospital Lausanne, Lausanne, Switzerland
| | - Bobak Heydari
- Cardiovascular Division, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mark Colin Gissler
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Yin Ge
- Terrence Donnelly Heart Center, St Michael’s Hospital, Toronto, Canada
| | - Sarah A M Cuddy
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Sharmila Dorbala
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Raymond Y Kwong
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
| |
Collapse
|
10
|
Lima BB, Benz DC. Casting aside the creep: harnessing cardiorespiratory dynamics to optimize myocardial flow assessment in cardiac PET. J Nucl Cardiol 2023; 30:2301-2302. [PMID: 37731013 DOI: 10.1007/s12350-023-03376-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Bruno B Lima
- Division of Cardiovascular Medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dominik C Benz
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
11
|
von Känel R, Princip M, Holzgang SA, Garefa C, Rossi A, Benz DC, Giannopoulos AA, Kaufmann PA, Buechel RR, Zuccarella-Hackl C, Pazhenkottil AP. Coronary microvascular function in male physicians with burnout and job stress: an observational study. BMC Med 2023; 21:477. [PMID: 38041159 PMCID: PMC10693019 DOI: 10.1186/s12916-023-03192-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/22/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND As a professional group, physicians are at increased risk of burnout and job stress, both of which are associated with an increased risk of coronary heart disease that is at least as high as that of other professionals. This study aimed to examine the association of burnout and job stress with coronary microvascular function, a predictor of major adverse cardiovascular events. METHODS Thirty male physicians with clinical burnout and 30 controls without burnout were included. Burnout was assessed with the Maslach Burnout Inventory and job stress with the effort-reward imbalance and overcommitment questionnaire. All participants underwent myocardial perfusion positron emission tomography to quantify endothelium-dependent (cold pressor test) and endothelium-independent (adenosine challenge) coronary microvascular function. Burnout and job stress were regressed on coronary flow reserve (primary outcome) and two additional measures of coronary microvascular function in the same model while adjusting for age and body mass index. RESULTS Burnout and job stress were significantly and independently associated with endothelium-dependent microvascular function. Burnout was positively associated with coronary flow reserve, myocardial blood flow response, and hyperemic myocardial blood flow (r partial = 0.28 to 0.35; p-value = 0.008 to 0.035). Effort-reward ratio (r partial = - 0.32 to - 0.38; p-value = 0.004 to 0.015) and overcommitment (r partial = - 0.30 to - 0.37; p-value = 0.005 to 0.022) showed inverse associations with these measures. CONCLUSIONS In male physicians, burnout and high job stress showed opposite associations with coronary microvascular endothelial function. Longitudinal studies are needed to show potential clinical implications and temporal relationships between work-related variables and coronary microvascular function. Future studies should include burnout and job stress for a more nuanced understanding of their potential role in cardiovascular health.
Collapse
Affiliation(s)
- Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Culmannstrasse 8, CH-8091, Zurich, Switzerland.
| | - Mary Princip
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Culmannstrasse 8, CH-8091, Zurich, Switzerland
| | - Sarah A Holzgang
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Culmannstrasse 8, CH-8091, Zurich, Switzerland
| | - Chrysoula Garefa
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Alexia Rossi
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Dominik C Benz
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ronny R Buechel
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Claudia Zuccarella-Hackl
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Culmannstrasse 8, CH-8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Culmannstrasse 8, CH-8091, Zurich, Switzerland
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| |
Collapse
|
12
|
Clerc OF, Cuddy SAM, Jerosch-Herold M, Benz DC, Katznelson E, Canseco Neri J, Taylor A, Kijewski MF, Bianchi G, Ruberg FL, Di Carli MF, Liao R, Kwong RY, Falk RH, Dorbala S. Myocardial Characterization for Early Diagnosis, Treatment Response Monitoring, and Risk Assessment in Systemic Light-Chain Amyloidosis. medRxiv 2023:2023.10.04.23296572. [PMID: 37873250 PMCID: PMC10593053 DOI: 10.1101/2023.10.04.23296572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Aims In systemic light-chain (AL) amyloidosis, cardiac involvement portends poor prognosis. Using myocardial characteristics on magnetic resonance imaging (MRI), this study aimed to detect early myocardial alterations, to analyze temporal changes with plasma cell therapy, and to predict risk of major adverse cardiac events (MACE) in AL amyloidosis. Methods and Results Participants with recently diagnosed AL amyloidosis were prospectively enrolled. Presence of AL cardiomyopathy (AL-CMP vs. AL-non-CMP) was determined by abnormal cardiac biomarkers. MRI was performed at baseline and 6 months, with 12-month imaging in AL-CMP cohort. MACE was defined as all-cause death, heart failure hospitalization, or cardiac transplantation. Mayo AL stage was based on troponin T, NT-proBNP, and difference in free light chains. The study cohort included 80 participants (median age 62 years, 58% males). Median left ventricular extracellular volume (ECV) was significantly higher in AL-CMP (53% vs. 30%, p<0.001). ECV was abnormal (>32%) in all AL-CMP and in 47% of AL-non-CMP. ECV tended to increase at 6 months and decreased significantly from 6 to 12 months in AL-CMP (median -3%, p=0.011). ECV was strongly associated with MACE (p<0.001), and improved MACE prediction when added to Mayo AL stage (p=0.002). ECV≤32% identified a cohort without MACE, while ECV>48% identified a cohort with 74% MACE. Conclusions In AL amyloidosis, ECV detects subclinical cardiomyopathy. ECV tends to increase from baseline to 6 months and decreases significantly from 6 and 12 months of plasma cell therapy in AL-CMP. ECV provides excellent risk stratification and offers additional prognostic performance over Mayo AL stage.
Collapse
|
13
|
Buechel RR, Ciancone D, Bakula A, von Felten E, Schmidt GA, Patriki D, Gräni C, Wahl A, Manka R, Heidecker B, Benz DC, Giannopoulos AA, Pazhenkottil AP, Kaufmann PA. Long-term impact of myocardial inflammation on quantitative myocardial perfusion-a descriptive PET/MR myocarditis study. Eur J Nucl Med Mol Imaging 2023; 50:3609-3618. [PMID: 37391545 PMCID: PMC10547808 DOI: 10.1007/s00259-023-06314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/17/2023] [Indexed: 07/02/2023]
Abstract
PURPOSE Whether myocardial inflammation causes long-term sequelae potentially affecting myocardial blood flow (MBF) is unknown. We aimed to assess the effect of myocardial inflammation on quantitative MBF parameters, as assessed by 13N-ammonia positron emission tomography myocardial perfusion imaging (PET-MPI) late after myocarditis. METHODS Fifty patients with a history of myocarditis underwent cardiac magnetic resonance (CMR) imaging at diagnosis and PET/MR imaging at follow-up at least 6 months later. Segmental MBF, myocardial flow reserve (MFR), and 13N-ammonia washout were obtained from PET, and segments with reduced 13N-ammonia retention, resembling scar, were recorded. Based on CMR, segments were classified as remote (n = 469), healed (inflammation at baseline but no late gadolinium enhancement [LGE] at follow-up, n = 118), and scarred (LGE at follow-up, n = 72). Additionally, apparently healed segments but with scar at PET were classified as PET discordant (n = 18). RESULTS Compared to remote segments, healed segments showed higher stress MBF (2.71 mL*min-1*g-1 [IQR 2.18-3.08] vs. 2.20 mL*min-1*g-1 [1.75-2.68], p < 0.0001), MFR (3.78 [2.83-4.79] vs. 3.36 [2.60-4.03], p < 0.0001), and washout (rest 0.24/min [0.18-0.31] and stress 0.53/min [0.40-0.67] vs. 0.22/min [0.16-0.27] and 0.46/min [0.32-0.63], p = 0.010 and p = 0.021, respectively). While PET discordant segments did not differ from healed segments regarding MBF and MFR, washout was higher by ~ 30% (p < 0.014). Finally, 10 (20%) patients were diagnosed by PET-MPI as presenting with a myocardial scar but without a corresponding LGE. CONCLUSION In patients with a history of myocarditis, quantitative measurements of myocardial perfusion as obtained from PET-MPI remain altered in areas initially affected by inflammation. CMR = cardiac magnetic resonance; PET = positron emission tomography; LGE = late gadolinium enhancement.
Collapse
Affiliation(s)
- Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, NUK A 12, 8091, Zurich, Switzerland.
| | - Domenico Ciancone
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, NUK A 12, 8091, Zurich, Switzerland
| | - Adam Bakula
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, NUK A 12, 8091, Zurich, Switzerland
| | - Elia von Felten
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, NUK A 12, 8091, Zurich, Switzerland
| | - Gian-Andrea Schmidt
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, NUK A 12, 8091, Zurich, Switzerland
| | - Dimitri Patriki
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, NUK A 12, 8091, Zurich, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Wahl
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert Manka
- Department of Cardiology, University and University Hospital of Zurich, Zurich, Switzerland
- Diagnostic and Interventional Radiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Bettina Heidecker
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, NUK A 12, 8091, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, NUK A 12, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, NUK A 12, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, NUK A 12, 8091, Zurich, Switzerland
| |
Collapse
|
14
|
Clerc OF, Datar Y, Cuddy SA, Bianchi G, Taylor A, Benz DC, Robertson M, Kijewski MF, Jerosch-Herold M, Kwong RY, Ruberg FL, Liao R, Di Carli MF, Falk RH, Dorbala S. Prognostic Value of Left Ventricular 18 F-Florbetapir Uptake in Systemic Light-Chain Amyloidosis. medRxiv 2023:2023.09.13.23295520. [PMID: 37745589 PMCID: PMC10516059 DOI: 10.1101/2023.09.13.23295520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Background Myocardial immunoglobulin light-chain (AL) amyloid deposits trigger heart failure, cardiomyocyte stretch and myocardial injury, leading to adverse cardiac outcomes. Positron emission tomography/computed tomography (PET/CT) with 18 F-florbetapir, a novel amyloid-targeting radiotracer, can quantify left ventricular (LV) amyloid burden, but its prognostic value is not known. Therefore, we aimed to evaluate the prognostic value of LV amyloid burden quantified by 18 F-florbetapir PET/CT and to identify mechanistic pathways mediating its association with outcomes. Methods Eighty-one participants with newly-diagnosed systemic AL amyloidosis were prospectively enrolled and underwent 18 F-florbetapir PET/CT. LV amyloid burden was quantified using 18 F-florbetapir LV percent injected dose (%ID). Mayo AL stage was determined using troponin T, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and difference between involved and uninvolved free light chain levels. Major adverse cardiac events (MACE) were defined as all-cause death, heart failure hospitalization, or cardiac transplantation within 12 months. Results Among participants (median age 61 years, 57% males), 36% experienced MACE. Incidence of MACE increased across tertiles of LV amyloid burden from 7% to 63% (p<0.001). LV amyloid burden was significantly associated with MACE in univariable analysis (hazard ratio 1.45, 95% confidence interval 1.15-1.82, p=0.002). However, this association became non-significant in multivariable analyses adjusted for Mayo AL stage. Mediation analysis showed that the association between 18 F-florbetapir LV %ID and MACE was primarily mediated by NT-proBNP (p<0.001), a marker of cardiomyocyte stretch and component of Mayo AL stage. Conclusion In this first study to link cardiac 18 F-florbetapir uptake to subsequent outcomes, LV amyloid burden estimated by LV %ID predicted MACE in AL amyloidosis. But this effect was not independent of Mayo AL stage. LV amyloid burden was associated with MACE primarily via NT-pro-BNP, a marker of cardiomyocyte stretch and component of Mayo AL stage. These findings provide novel insights into the mechanism through which myocardial AL amyloid leads to MACE. Clinical Perspective In systemic light-chain (AL) amyloidosis, cardiac involvement is the key determinant of adverse outcomes. Usually, prognosis is based on the Mayo AL stage, determined by troponin T, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and the difference between involved and uninvolved immunoglobulin free light chain levels (dFLC). Cardiac amyloid burden is not considered in this staging. In the present study, we used the amyloid-specific radiotracer 18 F-florbetapir to quantify left ventricular (LV) amyloid burden in 81 participants with newly-diagnosed AL amyloidosis and evaluated its prognostic value on major adverse outcomes (MACE: all-cause death, heart failure hospitalization, or cardiac transplantation within 12 months). We found that higher LV amyloid burden by 18 F-florbetapir positron emission tomography/computed tomography (PET/CT) was strongly associated with MACE. However, this association became non-significant after adjustment for the Mayo AL stage. Mediation analysis offered novel pathophysiological insights, implying that LV amyloid burden leads to MACE predominantly through cardiomyocyte stretch and light chain toxicity (by NT-proBNP), rather than through myocardial injury (by troponin T), also considering the severity of plasma cell dyscrasia (by dFLC). This mediation by NT-proBNP may explain why the association with outcomes was non-significant with adjustment for Mayo AL stage. Together, these results establish quantitative 18 F-florbetapir PET/CT as a valid method to predict adverse outcomes in AL amyloidosis. These results support the use of 18 F-florbetapir PET/CT to measure the effects of novel fibril-depleting therapies, in addition to plasma cell therapy, to improve outcomes in systemic AL amyloidosis.
Collapse
|
15
|
Bernhard B, Tanner G, Garachemani D, Schnyder A, Fischer K, Huber AT, Safarkhanlo Y, Stark AW, Guensch DP, Schütze J, Greulich S, Bastiaansen JAM, Pavlicek-Bahlo M, Benz DC, Kwong RY, Gräni C. Predictive value of cardiac magnetic resonance right ventricular longitudinal strain in patients with suspected myocarditis. J Cardiovasc Magn Reson 2023; 25:49. [PMID: 37587516 PMCID: PMC10433613 DOI: 10.1186/s12968-023-00957-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Recent evidence underlined the importance of right (RV) involvement in suspected myocarditis. We aim to analyze the possible incremental prognostic value from RV global longitudinal strain (GLS) by CMR. METHODS Patients referred for CMR, meeting clinical criteria for suspected myocarditis and no other cardiomyopathy were enrolled in a dual-center register cohort study. Ejection fraction (EF), GLS and tissue characteristics were assessed in both ventricles to assess their association to first major adverse cardiovascular events (MACE) including hospitalization for heart failure (HF), ventricular tachycardia (VT), recurrent myocarditis and death. RESULTS Among 659 patients (62.8% male; 48.1 ± 16.1 years), RV GLS was impaired (> - 15.4%) in 144 (21.9%) individuals, of whom 76 (58%), 108 (77.1%), 27 (18.8%) and 40 (32.8%) had impaired right ventricular ejection fraction (RVEF), impaired left ventricular ejection fraction (LVEF), RV late gadolinium enhancement (LGE) or RV edema, respectively. After a median observation time of 3.7 years, 45 (6.8%) patients were hospitalized for HF, 42 (6.4%) patients died, 33 (5%) developed VT and 16 (2.4%) had recurrent myocarditis. Impaired RV GLS was associated with MACE (HR = 1.07, 95% CI 1.04-1.10; p < 0.001), HF hospitalization (HR = 1.17, 95% CI 1.12-1.23; p < 0.001), and death (HR = 1.07, 95% CI 1.02-1.12; p = 0.004), but not with VT and recurrent myocarditis in univariate analysis. RV GLS lost its association with outcomes, when adjusted for RVEF, LVEF, LV GLS and LV LGE extent. CONCLUSION RV strain is associated with MACE, HF hospitalization and death but has neither independent nor incremental prognostic value after adjustment for RV and LV function and tissue characteristics. Therefore, assessing RV GLS in the setting of myocarditis has only limited value.
Collapse
Affiliation(s)
- Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Giulin Tanner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Davide Garachemani
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Aaron Schnyder
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Kady Fischer
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Adrian T Huber
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yasaman Safarkhanlo
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Anselm W Stark
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Dominik P Guensch
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jonathan Schütze
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Simon Greulich
- Department of Cardiology and Angiology, University of Tübingen, Tübingen, Germany
| | - Jessica A M Bastiaansen
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maryam Pavlicek-Bahlo
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Dominik C Benz
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.
| |
Collapse
|
16
|
Benz DC, Dorbala S. Multimodality imaging of cardiac amyloidosis. Heart 2023:heartjnl-2022-321115. [PMID: 37586824 PMCID: PMC10869633 DOI: 10.1136/heartjnl-2022-321115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Affiliation(s)
- Dominik C Benz
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
17
|
Benz DC, Dorbala S. Quantitative PYP metrics: separating the wheat from the chaff. J Nucl Cardiol 2023; 30:1382-1384. [PMID: 36977896 DOI: 10.1007/s12350-023-03249-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Dominik C Benz
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Sharmila Dorbala
- CV Imaging Program, Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
18
|
Benz DC, Dorbala S, Pazhenkottil AP. Quantifying the burden of cardiac amyloid: The future is about numbers! J Nucl Cardiol 2023; 30:112-115. [PMID: 35672568 DOI: 10.1007/s12350-022-03011-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 01/15/2023]
Affiliation(s)
- Dominik C Benz
- Cardiac Imaging, Department of Cardiology and Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- CV Imaging Program, Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Sharmila Dorbala
- CV Imaging Program, Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Aju P Pazhenkottil
- Cardiac Imaging, Department of Cardiology and Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
19
|
Benz DC, Nagao M, Gräni C. Digital positron emission tomography - Making cardiac risk stratification fit for the future. Int J Cardiol 2023; 371:486-487. [PMID: 36179906 DOI: 10.1016/j.ijcard.2022.09.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/21/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Dominik C Benz
- CV Imaging Program, Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Michinobu Nagao
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawadacho, Shinjuku-ku, Tokyo 162-8666, Japan
| | - Christoph Gräni
- Department of Cardiology, University Hospital Bern, Bern, Switzerland.
| |
Collapse
|
20
|
Gennari AG, Grünig H, Benz DC, Skawran S, Maurer A, Abukwaik AMA, Rossi A, Gebhard C, Buechel RR, Messerli M. Low-dose CT from myocardial perfusion SPECT/CT allows the detection of anemia in preoperative patients. J Nucl Cardiol 2022; 29:3236-3247. [PMID: 35175556 PMCID: PMC9834113 DOI: 10.1007/s12350-021-02899-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/14/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND To assess whether low-dose CT for attenuation correction of myocardial perfusion single-photon emission computed tomography (SPECT) allows for identification of anemic patients and grading anemia severity. METHODS AND RESULTS Patients who underwent a preoperative blood-test and low-dose CT scan, as a part of a cardiac SPECT exam, between 01 January 2015 and 31 December 2017 were enrolled in this retrospective study. Hemoglobin (Hb) levels and hematocrit were derived from clinical records. CT images were visually assessed (qualitative analysis) for the detection of inter-ventricular septum sign (IVSS) and aortic rim sign (ARS) and quantitative analysis were performed. The diagnostic accuracy for detecting anemia was compared using Hb values as the standard of reference. A total of 229 patients were included (110 with anemia; 57 mild; 46 moderate; 7 severe). The AUC of IVSS and ARS were 0.830 and 0.669, respectively (p<0.0001). The quantitative analysis outperformed ARS and IVSS; (AUC of 0.893, p=0.29). The optimal anemia cut-off using Youden index was 4.5 HU. CONCLUSION Quantitative analysis derived from low-dose CT images, as a part of cardiac SPECT exams, have a diagnostic accuracy similar to that of hematocrit for the detection of anemia and may allow discriminating different anemia severities.
Collapse
Affiliation(s)
- Antonio G Gennari
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Hannes Grünig
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Stephan Skawran
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Alexander Maurer
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Ahmad M A Abukwaik
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
- University of Zurich, Zurich, Switzerland.
- Maastricht UMC+, Heart and Vascular Center, Maastricht, The Netherlands.
| |
Collapse
|
21
|
Benz DC, Kaufmann PA, Dorbala S. Transmural perfusion: A new direction for myocardial blood flow. J Nucl Cardiol 2022; 29:1952-1955. [PMID: 35292939 DOI: 10.1007/s12350-022-02945-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/13/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Dominik C Benz
- CV Imaging Program, Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Philipp A Kaufmann
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Sharmila Dorbala
- CV Imaging Program, Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| |
Collapse
|
22
|
Bakula A, Patriki D, von Felten E, Benetos G, Sustar A, Benz DC, Wiedemann-Buser M, Treyer V, Pazhenkottil AP, Gräni C, Gebhard C, Kaufmann PA, Buechel RR, Fuchs TA. Splenic switch-off as a novel marker for adenosine response in nitrogen-13 ammonia PET myocardial perfusion imaging: Cross-validation against CMR using a hybrid PET/MR device. J Nucl Cardiol 2022; 29:1205-1214. [PMID: 33354759 PMCID: PMC9163112 DOI: 10.1007/s12350-020-02448-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND No methodology is available to distinguish truly reduced myocardial flow reserve (MFR) in positron emission tomography myocardial perfusion imaging (PET MPI) from seemingly impaired MFR due to inadequate adenosine response. The adenosine-induced splenic switch-off (SSO) sign has been proposed as a potential marker for adequate adenosine response in cardiac magnetic resonance (CMR). We assessed the feasibility of detecting SSO in nitrogen-13 ammonia PET MPI using SSO in CMR as the standard of reference. METHODS AND RESULTS Fifty patients underwent simultaneous CMR and PET MPI on a hybrid PET/MR device with co-injection of a gadolinium-based contrast agent and nitrogen-13 ammonia during rest and adenosine-induced stress. In CMR, SSO was assessed visually (positive vs negative SSO) and quantitatively by calculating the ratio of the peak signal intensity of the spleen during stress over rest (SIR). In PET MPI, the splenic signal activity ratio (SAR) was calculated as the maximal standard uptake value of the spleen during stress over rest. The median SIR was significantly lower in patients with positive versus negative SSO in CMR (0.57 [IQR 0.49 to 0.62] vs 0.89 [IQR 0.76 to 0.98]; P < .001). Similarly, median SAR in PET MPI was significantly lower in patients with positive versus negative SSO (0.40 [IQR 0.32 to 0.45] vs 0.80 [IQR 0.47 to 0.98]; P < .001). CONCLUSION Similarly to CMR, SSO can be detected in nitrogen-13 ammonia PET MPI. This might help distinguish adenosine non-responders from patients with truly impaired MFR due to microvascular dysfunction or multivessel coronary artery disease.
Collapse
Affiliation(s)
- Adam Bakula
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Dimitri Patriki
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Elia von Felten
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Georgios Benetos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Aleksandra Sustar
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Muriel Wiedemann-Buser
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Valerie Treyer
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
23
|
Kamani CH, Huang W, Lutz J, Giannopoulos AA, Patriki D, von Felten E, Schwyzer M, Gebhard C, Benz DC, Fuchs TA, Gräni C, Pazhenkottil AP, Kaufmann PA, Buechel RR. Impact of Adaptive Statistical Iterative Reconstruction-V on Coronary Artery Calcium Scores Obtained From Low-Tube-Voltage Computed Tomography - A Patient Study. Acad Radiol 2022; 29 Suppl 4:S11-S16. [PMID: 33187851 DOI: 10.1016/j.acra.2020.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/16/2020] [Accepted: 10/24/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the impact of adaptive statistical iterative reconstruction-V (ASIR-V) on the accuracy of ultra-low-dose coronary artery calcium (CAC) scoring. MATERIALS AND METHOD One-hundred-and-three patients who underwent computed tomography (CT) for CAC scoring were prospectively included. All underwent standard scanning with 120-kilovolt-peak (kVp) and with 80- and 70-kVp tube voltage. ASiR-V was applied to the 80- and 70-kVp scans at different levels. The 120-kVp scans reconstructed with filtered back projection served as the standard of reference. Recently published novel kVp-adapted thresholds were used for calculation of CAC scores from 80- and 70-kVp scans and the resulting CAC scores were compared against the standard of reference. Patients were stratified into six CAC score risk categories: 0, 1-10, 11-100, 101-400, 401-1000, and >1000. RESULTS Increasing levels of ASIR-V led to an increasing underestimation of CAC scores with bias ranging from -128 to -118 and from -205 to -198 for the 80- and 70-kVp scans, respectively, when compared with the standard of reference. Reconstruction with 20% and 40% ASIR-V for the 80- and 70-kVp scans, respectively, yielded noise levels comparable to the standard of reference. Nevertheless, a change in risk-class was observed in 29 (28.6%) and 46 (44.7%) patients, exclusively to a lower risk-class, when CAC scores were derived from these reconstructions. CONCLUSION ASIR-V leads to noise reduction in CT scans acquired with low tube-voltages. However, ASIR-V introduces substantial inaccuracies and marked underestimation of ultra-low-dose CAC scoring as compared with standard-dose CAC scoring despite normalization of noise.
Collapse
Affiliation(s)
- Christel H Kamani
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Wenjie Huang
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Joel Lutz
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | | | - Dimitri Patriki
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Elia von Felten
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Moritz Schwyzer
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Catherine Gebhard
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Dominik C Benz
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Tobias A Fuchs
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | - Christoph Gräni
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND
| | | | | | - Ronny R Buechel
- University Hospital Zürich, Rämistrasse 100, 8091 Zürich, SWITZERLAND.
| |
Collapse
|
24
|
von Felten E, Benz DC, Benetos G, Giannopoulos AA, Messerli M, Gräni C, Fuchs TA, Gebhard C, Buechel RR, Kaufmann PA, Pazhenkottil AP. Transluminal attenuation gradient derived from coronary CT angiography to predict ischemia in SPECT myocardial perfusion imaging: Effect of coronary cross-sectional area. J Nucl Cardiol 2022; 29:350-358. [PMID: 32613474 DOI: 10.1007/s12350-020-02242-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 06/08/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Coronary computed tomography angiography (CCTA)-based transluminal attenuation gradient (TAG) was suggested to determine the functional significance of a stenosis. However, evidence that TAG acquired by wide-volume scanners can assess the hemodynamic significance of stenosis assessed by single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is lacking. Moreover, coronary cross-sectional area may influence TAG. Hence, we aimed at assessing the diagnostic value of TAG to predict ischemia in SPECT-MPI and the correlation between TAG and the transluminal cross-sectional area gradient (TCG). METHODS Patients undergoing CCTA and SPECT-MPI for suspected coronary artery disease were included. TAG and TCG were calculated measuring the mean vessel attenuation and the cross-sectional area along major coronary vessels at 5-mm intervals. RESULTS A total of 255 coronary arteries of 87 patients were included. TAG and TCG did not discriminate between coronary arteries with or without ischemia as assessed by SPECT-MPI (p = .44 and p = .25, respectively). The area under the curve to predict ischemia was not increased by adding TAG (0.88, 95% CI 0.83-0.92) or TCG (0.87, 95% CI 0.81-0.90) to CCTA alone (0.85, 95% CI 0.80-0.89). There was a significant correlation between TAG and TCG (r = 0.43; p < .001). CONCLUSIONS CCTA-derived TAG and TCG do not offer any value in predicting ischemia assessed by SPECT-MPI. TAG is partly affected by differences in the coronary luminal area.
Collapse
Affiliation(s)
- Elia von Felten
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Georgios Benetos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland.
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland.
| |
Collapse
|
25
|
Benz DC, Buechel RR, Dorbala S. (18)F-sodium fluoride PET in multiple myeloma: Linking cancer to atherosclerosis? J Nucl Cardiol 2021; 28:3055-3057. [PMID: 33398792 DOI: 10.1007/s12350-020-02447-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
- Department of Cardiology, University Heart Centre, University Hospital Zurich, Zurich, Switzerland.
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Sharmila Dorbala
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Radiology, CV Imaging Program, Brigham and Women's Hospital, Boston, MA, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
26
|
Benz DC, Ersözlü S, Mojon FLA, Messerli M, Mitulla AK, Ciancone D, Kenkel D, Schaab JA, Gebhard C, Pazhenkottil AP, Kaufmann PA, Buechel RR. Radiation dose reduction with deep-learning image reconstruction for coronary computed tomography angiography. Eur Radiol 2021; 32:2620-2628. [PMID: 34792635 PMCID: PMC8921160 DOI: 10.1007/s00330-021-08367-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/20/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022]
Abstract
Objectives Deep-learning image reconstruction (DLIR) offers unique opportunities for reducing image noise without degrading image quality or diagnostic accuracy in coronary CT angiography (CCTA). The present study aimed at exploiting the capabilities of DLIR to reduce radiation dose and assess its impact on stenosis severity, plaque composition analysis, and plaque volume quantification. Methods This prospective study includes 50 patients who underwent two sequential CCTA scans at normal-dose (ND) and lower-dose (LD). ND scans were reconstructed with Adaptive Statistical Iterative Reconstruction-Veo (ASiR-V) 100%, and LD scans with DLIR. Image noise (in Hounsfield units, HU) and quantitative plaque volumes (in mm3) were assessed quantitatively. Stenosis severity was visually categorized into no stenosis (0%), stenosis (< 20%, 20–50%, 51–70%, 71–90%, 91–99%), and occlusion (100%). Plaque composition was classified as calcified, non-calcified, or mixed. Results Reduction of radiation dose from ND scans with ASiR-V 100% to LD scans with DLIR at the highest level (DLIR-H; 1.4 mSv vs. 0.8 mSv, p < 0.001) had no impact on image noise (28 vs. 27 HU, p = 0.598). Reliability of stenosis severity and plaque composition was excellent between ND scans with ASiR-V 100% and LD scans with DLIR-H (intraclass correlation coefficients of 0.995 and 0.974, respectively). Comparison of plaque volumes using Bland–Altman analysis revealed a mean difference of − 0.8 mm3 (± 2.5 mm3) and limits of agreement between − 5.8 and + 4.1 mm3. Conclusion DLIR enables a reduction in radiation dose from CCTA by 43% without significant impact on image noise, stenosis severity, plaque composition, and quantitative plaque volume. Key Points •Deep-learning image reconstruction (DLIR) enables radiation dose reduction by over 40% for coronary computed tomography angiography (CCTA). •Image noise remains unchanged between a normal-dose CCTA reconstructed by ASiR-V and a lower-dose CCTA reconstructed by DLIR. •There is no impact on the assessment of stenosis severity, plaque composition, and quantitative plaque volume between the two scans. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08367-x.
Collapse
Affiliation(s)
- Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Sara Ersözlü
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - François L A Mojon
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Anna K Mitulla
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Domenico Ciancone
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - David Kenkel
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Jan A Schaab
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University and University Hospital Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland.
| |
Collapse
|
27
|
Markendorf S, Benz DC, Messerli M, Grossmann M, Giannopoulos AA, Patriki D, Fuchs TA, Gräni C, Pazhenkottil AP, Buechel RR, Kaufmann PA, Gaemperli O. Value of 12-lead electrocardiogram to predict myocardial scar on FDG PET in heart failure patients. J Nucl Cardiol 2021; 28:1364-1373. [PMID: 31399902 DOI: 10.1007/s12350-019-01841-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 07/17/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE A surface 12-lead electrocardiogram (ECG) is widely available, fast, inexpensive, and safe. However, its value to predict a true myocardial scar in patients with ischemic cardiomyopathy (ICM) has not been studied extensively yet. This study was conducted to assess whether Q waves on resting surface 12-lead ECG are predictive of non-viable myocardium in patients with ICM. METHODS We analyzed resting ECGs of 149 patients with ICM undergoing cardiac positron emission tomography (PET) with 13N-ammonia (NH3) and 18F-fluorodeoxyglucose (FDG) at our institution. Pathological Q waves and QS complexes were assigned to one of three coronary artery territories and compared to the PET findings. Myocardial scar was defined as 2 or more contiguous myocardial segments with an average (matched) reduction of NH3 and FDG uptake <50% of the maximum value. RESULTS Pathological Q waves had a sensitivity and specificity of 70% and 40%, respectively, and a PPV and NPV of 37% and 73%, respectively, to detect myocardial scar on FDG PET. For QS complexes, sensitivity and specificity were 46% and 59%, respectively, and PPV and NPV were 36% and 68%, respectively. Sensitivity was lower, but specificity was significantly higher in both the LCX and RCA compared to the LAD territory (p<0.001), particularly for QS complexes. CONCLUSION Pathological Q waves on resting 12-lead ECG have poor or at best moderate sensitivity and specificity to detect myocardial scar on FDG PET. These findings support the use of more advanced imaging techniques to assess myocardial viability in ICM.
Collapse
Affiliation(s)
- Susanne Markendorf
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland.
| | - Dominik C Benz
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland
| | - Michael Messerli
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland
| | - Marvin Grossmann
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri Patriki
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland
| | - Tobias A Fuchs
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Gräni
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland
| | - Ronny R Buechel
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland
| | - Oliver Gaemperli
- Cardiac Imaging, Nuclear Medicine Department, University Hospital Zurich, Zurich, Switzerland
- HeartClinic Hirslanden, Witellikerstrasse 40, 8032, Zurich, Switzerland
| |
Collapse
|
28
|
von Felten E, Benz DC, Benetos G, Baehler J, Patriki D, Rampidis GP, Giannopoulos AA, Bakula A, Gräni C, Pazhenkottil AP, Gebhard C, Fuchs TA, Kaufmann PA, Buechel RR. Prognostic value of regional myocardial flow reserve derived from 13N-ammonia positron emission tomography in patients with suspected coronary artery disease. Eur J Nucl Med Mol Imaging 2021; 49:311-320. [PMID: 34191100 PMCID: PMC8712296 DOI: 10.1007/s00259-021-05459-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/09/2021] [Indexed: 11/30/2022]
Abstract
Purpose To assess the prognostic value of regional quantitative myocardial flow measures as assessed by 13N-ammonia positron emission tomography (PET) myocardial perfusion imaging (MPI) in patients with suspected coronary artery disease (CAD). Methods We retrospectively included 150 consecutive patients with suspected CAD who underwent clinically indicated 13 N-ammonia PET-MPI and who did not undergo revascularization within 90 days of PET-MPI. The presence or absence of a decreased global myocardial flow reserve (i.e., MFR < 2) as well as decreased regional MFR (i.e., ≥ 2 adjacent segments with MFR < 2) was recorded, and patients were classified as having preserved global and regional MFR (MFR group 1), preserved global but decreased regional MFR (MFR group 2), or decreased global and regional MFR (MFR group 3). We obtained follow-up regarding major adverse cardiac events (MACE, i.e., a combined endpoint including all-cause death, non-fatal myocardial infarction, and late revascularization) and all-cause death. Results Over a median follow-up of 50 months (IQR 38–103), 30 events occurred in 29 patients. Kaplan–Meier analysis showed significantly reduced event-free and overall survival in MFR groups 2 and 3 compared to MFR group 1 (log-rank: p = 0.015 and p = 0.013). In a multivariable Cox regression analysis, decreased regional MFR was an independent predictor for MACE (adjusted HR 3.44, 95% CI 1.17–10.11, p = 0.024) and all-cause death (adjusted HR 4.72, 95% CI 1.07–20.7, p = 0.04). Conclusions A decreased regional MFR as assessed by 13 N-ammonia PET-MPI confers prognostic value by identifying patients at increased risk for future adverse cardiac outcomes and all-cause death. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-021-05459-0.
Collapse
Affiliation(s)
- Elia von Felten
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Georgios Benetos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Jessica Baehler
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Dimitri Patriki
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Georgios P Rampidis
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Adam Bakula
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistr. 100, CH-8091, Zurich, Switzerland.
| |
Collapse
|
29
|
Benz DC, Fuchs TA. How equilibrium radionuclide angiography can quantify tricuspid regurgitation. J Nucl Cardiol 2021; 28:873-875. [PMID: 31350716 DOI: 10.1007/s12350-019-01826-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/11/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Dominik C Benz
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Tobias A Fuchs
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
30
|
Benz DC, Ferro P, Safa N, Messerli M, von Felten E, Huang W, Patriki D, Giannopoulos AA, Fuchs TA, Gräni C, Gebhard C, Pazhenkottil AP, Kaufmann PA, Buechel RR. Role of quantitative myocardial blood flow and 13N-ammonia washout for viability assessment in ischemic cardiomyopathy. J Nucl Cardiol 2021; 28:263-273. [PMID: 30895563 DOI: 10.1007/s12350-019-01684-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Positron emission tomography (PET) integrating assessment of perfusion with 13N-ammonia (NH3) and viability with 18F-fluorodeoxyglucose (FDG) has high accuracy to identify viable, hibernating myocardium. We tested whether quantification of myocardial blood flow (MBF) and washout (k2) can predict myocardial viability using FDG as standard of reference. METHODS In 180 consecutive patients with ischemic cardiomyopathy, myocardium was categorized on a segment-level into normal, ischemic, hibernating, and scar. From dynamic images, stress MBF, rest MBF, and k2 were derived and myocardial flow reserve (MFR) and volume of distribution (VD) were calculated. RESULTS Across myocardial tissues, all parameters differed significantly. The area under the curve (AUC) was 0.564 (95% CI 0.527-0.601), 0.635 (0.599-0.671), 0.553 (0.516-0.591), 0.520 (0.482-0.559), and 0.560 (0.522-0.597) for stress MBF, rest MBF, MFR, k2, and VD. The generalized linear mixed model correctly classified 81% of scar as viable, hibernating myocardium. If the threshold of rest MBF to predict viability was set to 0.45 mL·min-1·g-1, sensitivity and specificity were 96% and 12%, respectively. CONCLUSION Quantitative NH3 PET parameters have low to moderate diagnostic performance to predict viability in ischemic cardiomyopathy. However, if rest MBF falls below 0.45 mL·min-1·g-1, viability testing by FDG-PET may be safely deferred.
Collapse
Affiliation(s)
- Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Paola Ferro
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Nico Safa
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Elia von Felten
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Wenjie Huang
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Dimitri Patriki
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
31
|
Benetos G, Benz DC, Rampidis GP, Giannopoulos AA, von Felten E, Bakula A, Sustar A, Fuchs TA, Pazhenkottil AP, Gebhard C, Kaufmann PA, Gräni C, Buechel RR. Coronary artery lumen volume index as a marker of flow-limiting atherosclerosis-validation against 13N-ammonia positron emission tomography. Eur Radiol 2021; 31:5116-5126. [PMID: 33454800 PMCID: PMC8213544 DOI: 10.1007/s00330-020-07586-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/02/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Coronary artery volume indexed to left myocardial mass (CAVi), derived from coronary computed tomography angiography (CCTA), has been proposed as an indicator of diffuse atherosclerosis. We investigated the association of CAVi with quantitative flow parameters and its ability to predict ischemia as derived from 13N-ammonia positron emission tomography myocardial perfusion imaging (PET-MPI). METHODS Sixty patients who underwent hybrid CCTA/PET-MPI due to suspected CAD were retrospectively included. CAVi was defined as total coronary artery lumen volume over myocardial mass, both derived from CCTA. From PET-MPI, quantitative stress and rest myocardial blood flow (MBF) and myocardial flow reserve (MFR) were obtained and correlated with CAVi, and semi-quantitative perfusion images were analyzed for the presence of ischemia. Harrell's c-statistic and net reclassification improvement (NRI) analysis were performed to evaluate the incremental value of CAVi over the CCTA model (i.e., stenosis > 50% and > 70%). RESULTS CAVi correlated moderately with stress MBF and MFR (R = 0.50, p < 0.001, and R = 0.39, p = 0.002). Mean stress MBF and MFR were lower in patients with low (i.e., ≤ 20.2 mm3/g, n = 24) versus high (i.e., > 20.2 mm3/g, n = 36) CAVi (p < 0.001 for both comparisons). CAVi was independently associated with abnormal stress MBF (OR 0.90, 95% CI 0.82-0.998, p = 0.045). CAVi increased the predictive ability of the CCTA model for abnormal stress MBF and ischemia (c-statistic 0.763 versus 0.596, pdiff < 0.05 and 0.770 versus 0.645, pdiff < 0.05, NRI 0.84, p = 0.001 and 0.96, p < 0.001, respectively). CONCLUSIONS CAVi exhibits incremental value to predict both abnormal stress MBF and ischemia over CCTA alone. KEY POINTS • Coronary artery volume indexed to left myocardial mass (CAVi), derived from coronary computed tomography angiography (CCTA), is correlated with myocardial blood flow indices derived from 13N-ammonia positron emission tomography myocardial perfusion imaging. • CAVi is independently associated with abnormal stress myocardial blood flow. • CAVi provides incremental diagnostic value over CCTA for both abnormal stress MBF and ischemia.
Collapse
Affiliation(s)
- Georgios Benetos
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Georgios P Rampidis
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Elia von Felten
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Adam Bakula
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Aleksandra Sustar
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
32
|
Patriki D, von Felten E, Bakula A, Giannopoulos AA, Kamani CH, Schwyzer M, Messerli M, Benz DC, Gebhard C, Gräni C, Pazhenkottil AP, Kaufmann PA, Fuchs TA, Buechel RR. Splenic switch-off as a predictor for coronary adenosine response: validation against 13N-ammonia during co-injection myocardial perfusion imaging on a hybrid PET/CMR scanner. J Cardiovasc Magn Reson 2021; 23:3. [PMID: 33407586 PMCID: PMC7789581 DOI: 10.1186/s12968-020-00696-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 12/09/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Inadequate coronary adenosine response is a potential cause for false negative ischemia testing. Recently, the splenic switch-off (SSO) sign has been identified as a promising tool to ascertain the efficacy of adenosine during vasodilator stress cardiovascular magnetic resonance imaging (CMR). We assessed the value of SSO to predict adenosine response, defined as an increase in myocardial blood flow (MBF) during quantitative stress myocardial perfusion 13 N-ammonia positron emission tomography (PET). METHODS We prospectively enrolled 64 patients who underwent simultaneous CMR and PET myocardial perfusion imaging on a hybrid PET/CMR scanner with co-injection of gadolinium based contrast agent (GBCA) and 13N-ammonia during rest and adenosine-induced stress. A myocardial flow reserve (MFR) of > 1.5 or ischemia as assessed by PET were defined as markers for adequate coronary adenosine response. The presence or absence of SSO was visually assessed. The stress-to-rest intensity ratio (SIR) was calculated as the ratio of stress over rest peak signal intensity for splenic tissue. Additionally, the spleen-to-myocardium ratio, defined as the relative change of spleen to myocardial signal, was calculated for stress (SMRstress) and rest. RESULTS Sixty-one (95%) patients were coronary adenosine responders, but SSO was absent in 18 (28%) patients. SIR and SMRstress were significantly lower in patients with SSO (SIR: 0.56 ± 0.13 vs. 0.93 ± 0.23; p < 0.001 and SMRstress: 1.09 ± 0.47 vs. 1.68 ± 0.62; p < 0.001). Mean hyperemic and rest MBF were 2.12 ± 0.68 ml/min/g and 0.78 ± 0.26 ml/min/g, respectively. MFR was significantly higher in patients with vs. patients without presence of SSO (3.07 ± 1.03 vs. 2.48 ± 0.96; p = 0.038), but there was only a weak inverse correlation between SMRstress and MFR (R = -0.378; p = 0.02) as well as between SIR and MFR (R = -0.356; p = 0.004). CONCLUSIONS The presence of SSO implies adequate coronary adenosine-induced MBF response. Its absence, however, is not a reliable indicator for failed adenosine-induced coronary vasodilatation.
Collapse
Affiliation(s)
- Dimitri Patriki
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Elia von Felten
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Adam Bakula
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Christel H Kamani
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Moritz Schwyzer
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich and University Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
33
|
Benz DC, Buechel RR. The winding road towards respiratory motion correction: is this just another dead-end or do we finally get breathing under control? J Nucl Cardiol 2020; 27:2231-2233. [PMID: 30843146 DOI: 10.1007/s12350-019-01679-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
34
|
Pazhenkottil AP, Benz DC. New insights in the assessment of left ventricular dyssynchrony: Laying the foundations for phase analysis by cardiac SPECT. J Nucl Cardiol 2020; 27:2280-2282. [PMID: 30734218 DOI: 10.1007/s12350-019-01622-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Aju P Pazhenkottil
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland.
| | - Dominik C Benz
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| |
Collapse
|
35
|
Bengs S, Haider A, Warnock GI, Fiechter M, Pargaetzi Y, Rampidis G, Etter D, Wijnen WJ, Portmann A, Osto E, Treyer V, Benz DC, Meisel A, Fuchs TA, Gräni C, Buechel RR, Kaufmann PA, Pazhenkottil AP, Gebhard C. Quantification of perivascular inflammation does not provide incremental prognostic value over myocardial perfusion imaging and calcium scoring. Eur J Nucl Med Mol Imaging 2020; 48:1806-1812. [PMID: 33200300 PMCID: PMC8113311 DOI: 10.1007/s00259-020-05106-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/01/2020] [Indexed: 01/07/2023]
Abstract
Aims Perivascular fat attenuation index (FAI) has emerged as a novel coronary computed tomography angiography (CCTA)–based biomarker predicting cardiovascular outcomes by capturing early coronary inflammation. It is currently unknown whether FAI adds prognostic value beyond that provided by single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) and CCTA findings including coronary artery calcium scoring (CACS). Methods and results A total of 492 patients (mean age 62.5 ± 10.8 years) underwent clinically indicated multimodality CCTA and electrocardiography (ECG)-gated 99mTc-tetrofosmin SPECT-MPI between May 2005 and December 2008 at our institution, and follow-up data on major adverse cardiovascular events (MACE) was obtained for 314 patients. FAI was obtained from CCTA images and was measured around the right coronary artery (FAI[RCA]), the left anterior descending artery (FAI[LAD]), and the left main coronary artery (FAI[LMCA]). During a median follow-up of 2.7 years, FAI[RCA] > − 70.1 was associated with an increased rate of MACE (log rank p = 0.049), while no such association was seen for FAI[LAD] or FAI[LMCA] (p = NS). A multivariate Cox regression model accounting for cardiovascular risk factors, CCTA and SPECT-MPI findings identified FAI[RCA] as an independent predictor of MACE (HR 2.733, 95% CI: 1.220–6.123, p = 0.015). However, FAI[RCA] was no longer a significant predictor of MACE after adding CACS (p = 0.279). A first-order interaction term consisting of sex and FAI[RCA] was significant in both models (HR 2.119, 95% CI: 1.218–3.686, p = 0.008; and HR 2.071, 95% CI: 1.111–3.861, p = 0.022). Conclusion FAI does not add incremental prognostic value beyond multimodality MPI/CCTA findings including CACS. The diagnostic value of FAI[RCA] is significantly biased by sex.
Collapse
Affiliation(s)
- Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, 8952, Schlieren, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, 8952, Schlieren, Switzerland
| | - Geoffrey I Warnock
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, 8952, Schlieren, Switzerland
| | - Michael Fiechter
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, 8952, Schlieren, Switzerland
- Swiss Paraplegic Center, 6207, Nottwil, Switzerland
| | - Yves Pargaetzi
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, 8952, Schlieren, Switzerland
| | - Georgios Rampidis
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Dominik Etter
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, 8952, Schlieren, Switzerland
| | - Winandus J Wijnen
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, 8952, Schlieren, Switzerland
| | - Angela Portmann
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, 8952, Schlieren, Switzerland
| | - Elena Osto
- Institute of Clinical Chemistry, University of Zurich, 8091, Zurich, Switzerland
- University Heart Center, University Hospital Zurich, 8006, Zurich, Switzerland
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
- Institute for Regenerative Medicine, University of Zurich, 8952, Schlieren, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Alexander Meisel
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, 8952, Schlieren, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
- University Heart Center, University Hospital Zurich, 8006, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, 8091, Zurich, Switzerland.
- Center for Molecular Cardiology, University of Zurich, 8952, Schlieren, Switzerland.
| |
Collapse
|
36
|
Fiechter M, Roggo A, Burger IA, Bengs S, Treyer V, Becker A, Marȩdziak M, Haider A, Portmann A, Messerli M, Patriki D, Mühlematter UJ, von Felten E, Benz DC, Fuchs TA, Gräni C, Pazhenkottil AP, Buechel RR, Kaufmann PA, Gebhard C. Association between resting amygdalar activity and abnormal cardiac function in women and men: a retrospective cohort study. Eur Heart J Cardiovasc Imaging 2020; 20:625-632. [PMID: 31083711 DOI: 10.1093/ehjci/jez047] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/04/2019] [Indexed: 12/17/2022] Open
Abstract
AIMS Cardiovascular outcomes of women with coronary artery disease (CAD) are perceived as relatively worse when compared to men. Amygdalar metabolic activity has recently been shown to independently predict cardiovascular events in patients without known cardiovascular disease. Given that traditional algorithms for risk prediction perform worse in women than in men, we sought to assess sex-specific associations between amygdalar metabolic activity and cardiac dysfunction with suspected or known CAD. METHODS AND RESULTS This retrospective study included 302 patients (mean age 66.8 ± 10.2 years, 29.1% women) selected for evaluation of CAD, malignant, or inflammatory disease. All patients had undergone both, myocardial perfusion imaging by single photon emission computed tomography (MPI-SPECT) and whole-body fluoro-18-deoxyglucose (18F-FDG) positron emission tomography (PET), within 6 months. 18F-FDG resting amygdalar uptake was significantly increased in women with abnormal MPI scans (standardized uptake value 33.4 ± 6.5 vs. 30.4 ± 4.7, P = 0.043), while no such difference was observed in men (P = 0.808). In women, but not in men, a negative association between 18F-FDG resting amygdalar activity and left ventricular ejection fraction (LVEF) was observed (Pearson r = -0.308, P = 0.004). Accordingly, either LVEF [B-coefficient (standard error, SE) = -0.232 (0.109), P = 0.045] or abnormal MPI [B-coefficient (SE) = 8.264 (2.449), P = 0.003] were selected as significant predictors of high amygdalar 18F-FDG uptake in a fully adjusted linear regression model in women, and a first order interaction term consisting of sex and LVEF or sex and abnormal MPI was significant (P = 0.035 and P = 0.001, respectively). CONCLUSION Resting amygdalar metabolic activity is associated with abnormal cardiac function and perfusion in women, suggesting a link between emotional stress and cardiovascular disease in women.
Collapse
Affiliation(s)
- Michael Fiechter
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Switzerland.,Swiss Paraplegic Center, Nottwil, Switzerland
| | - Andrea Roggo
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Irene A Burger
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Switzerland
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Anton Becker
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Switzerland
| | - Monika Marȩdziak
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Switzerland
| | - Angela Portmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Dimitri Patriki
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Urs J Mühlematter
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Switzerland
| | - Elia von Felten
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Switzerland
| |
Collapse
|
37
|
Gräni C, Benz DC, Gupta S, Windecker S, Kwong RY. Sudden Cardiac Death in Ischemic Heart Disease. JACC Cardiovasc Imaging 2020; 13:2223-2238. [DOI: 10.1016/j.jcmg.2019.10.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 12/16/2022]
|
38
|
Benz DC, Benetos G, Rampidis G, von Felten E, Bakula A, Sustar A, Kudura K, Messerli M, Fuchs TA, Gebhard C, Pazhenkottil AP, Kaufmann PA, Buechel RR. Validation of deep-learning image reconstruction for coronary computed tomography angiography: Impact on noise, image quality and diagnostic accuracy. J Cardiovasc Comput Tomogr 2020; 14:444-451. [DOI: 10.1016/j.jcct.2020.01.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/29/2019] [Accepted: 01/08/2020] [Indexed: 02/06/2023]
|
39
|
Benz DC, Kaufmann PA, von Felten E, Benetos G, Rampidis G, Messerli M, Giannopoulos AA, Fuchs TA, Gräni C, Gebhard C, Pazhenkottil AP, Flammer AJ, Kaufmann PA, Buechel RR. Prognostic Value of Quantitative Metrics From Positron Emission Tomography in Ischemic Heart Failure. JACC Cardiovasc Imaging 2020; 14:454-464. [PMID: 32771569 DOI: 10.1016/j.jcmg.2020.05.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the prognostic and clinical value of quantitative positron emission tomographic (PET) metrics in patients with ischemic heart failure. BACKGROUND Although myocardial flow reserve (MFR) is a strong predictor of cardiac risk in patients without heart failure, it is unknown whether quantitative PET metrics improve risk stratification in patients with ischemic heart failure. METHODS The study included 254 patients referred for stress and rest myocardial perfusion imaging and viability testing using PET. Major adverse cardiac event(s) (MACE) consisted of death, resuscitated sudden cardiac death, heart transplantation, acute coronary syndrome, hospitalization for heart failure, and late revascularization. RESULTS MACE occurred in 170 patients (67%) during a median follow-up of 3.3 years. In a multivariate Cox proportional hazards model including multiple quantitative PET metrics, only MFR predicted MACE significantly (p = 0.013). Beyond age, symptom severity, diabetes mellitus, previous myocardial infarction or revascularization, 3-vessel disease, renal insufficiency, ejection fraction, as well as presence and burden of ischemia, scar, and hibernating myocardium, MFR was strongly associated with MACE (adjusted hazard ratio per increase in MFR by 1: 0.63; 95% confidence interval: 0.45 to 0.91). Incorporation of MFR into a risk assessment model incrementally improved the prediction of MACE (likelihood ratio chi-square test [16] = 48.61 vs. chi-square test [15] = 39.20; p = 0.002). CONCLUSIONS In this retrospective analysis of a single-center cohort, quantitative PET metrics of myocardial blood flow all improved risk stratification in patients with ischemic heart failure. However, in a hypothesis-generating analysis, MFR appears modestly superior to the other metrics as a prognostic index.
Collapse
Affiliation(s)
- Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland; Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Philippe A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Elia von Felten
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Georgios Benetos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Georgios Rampidis
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland; Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland; Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland; Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Andreas J Flammer
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland.
| |
Collapse
|
40
|
Benz DC, Giannopoulos AA. Fractional flow reserve as the standard of reference: All that glistens is not gold. J Nucl Cardiol 2020; 27:1314-1316. [PMID: 31175624 DOI: 10.1007/s12350-019-01771-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 05/20/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Dominik C Benz
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
- Cardiology Department, University Hospital Zurich, Zurich, Switzerland.
| |
Collapse
|
41
|
Fiechter M, Bengs S, Roggo A, Haider A, Marędziak M, Portmann A, Treyer V, Burger IA, Messerli M, Patriki D, von Felten E, Benz DC, Fuchs TA, Gräni C, Pazhenkottil AP, Buechel RR, Kaufmann PA, Gebhard C. Association between vertebral bone mineral density, myocardial perfusion, and long-term cardiovascular outcomes: A sex-specific analysis. J Nucl Cardiol 2020; 27:726-736. [PMID: 31286420 DOI: 10.1007/s12350-019-01802-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/22/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Sexual dimorphism in the manifestation of coronary artery disease (CAD) has unleashed a call to reconsider cardiovascular risk assessment. Alterations of bone mineral density (BMD) have been associated with congestive heart failure and appear to be modified by sex. However, the sex-specific association between BMD, myocardial perfusion, and cardiovascular outcomes is currently unknown. METHODS A total number of 491 patients (65.9 ± 10.7 years, 32.4% women) underwent 13N-ammonia positron emission tomography/computed tomography for evaluation of CAD, and were tracked for major adverse cardiac events (MACEs). RESULTS Event-free survival (median follow-up time of 4.3 ± 2.0 years) was significantly reduced in patients with low (≤ 100 Hounsfield units) compared to those with higher BMD (log-rank P = .037). Accordingly, reduced BMD was chosen as significant predictor of MACE in a fully adjusted proportional hazards regression model (P = .015). Further, a first-order interaction term consisting of sex and BMD was statistically significant (P = .007). BMD was significantly lower in patients with abnormal myocardial perfusion or impaired left ventricular ejection fraction (P < .05). This difference, however, was noticed in men, but not in women. CONCLUSIONS The association between low BMD and cardiovascular disease is sex dependent. Our data suggest that quantification of BMD during myocardial perfusion imaging for evaluation of CAD may be particularly useful in men.
Collapse
Affiliation(s)
- Michael Fiechter
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland.
- Swiss Paraplegic Center, Nottwil, Switzerland.
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Andrea Roggo
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Monika Marędziak
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Angela Portmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Irene A Burger
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Dimitri Patriki
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Elia von Felten
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| |
Collapse
|
42
|
Gebhard C, Messerli M, Lohmann C, Treyer V, Bengs S, Benz DC, Giannopoulos AA, Kudura K, von Felten E, Schwyzer M, Gaemperli O, Gräni C, Pazhenkottil AP, Buechel RR, Kaufmann PA. Sex and age differences in the association of heart rate responses to adenosine and myocardial ischemia in patients undergoing myocardial perfusion imaging. J Nucl Cardiol 2020; 27:159-170. [PMID: 29687292 DOI: 10.1007/s12350-018-1276-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND In light of growing cardiovascular mortality rates observed in young women, sexual dimorphism in cardiac autonomic nervous control is gaining increasing attention. Heart rate responses to adenosine mirror autonomic activity and may carry important prognostic information. METHODS AND RESULTS Hemodynamic changes during adenosine stress were retrospectively analysed in a propensity-matched cohort of 1932 consecutive patients undergoing myocardial perfusion single-photon-emission computed tomography (MPI-SPECT). Heart rate (HR) and systolic blood pressure (SBP) increased during adenosine infusion (P < 0.001). The increase in SBP and HR (heart rate reserve, HRR), was significantly more pronounced in women compared with men (P < 0.05). Patients ≤ 55 years had a higher HRR compared with patients > 55 years (46.8% vs 37.5%, P = 0.015). Women ≤ 55 years with a reversible perfusion defect on MPI-SPECT exhibited the highest HRR (89.2%), while age-matched men showed a blunted HR response to adenosine (26.4%, P = 0.01). Accordingly, age and an interaction term of female sex and increased HRR were identified as significant predictors of myocardial ischemia in a multiple regression analysis (OR 1.4, 95% CI 1.02-1.9, P = 0.038). CONCLUSION HRR during adenosine infusion is influenced by age and sex. Our data suggest a stronger, sympathetic-driven, hemodynamic response to adenosine in younger women with myocardial ischemia.
Collapse
Affiliation(s)
- Catherine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland.
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Christine Lohmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Ken Kudura
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Elia von Felten
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Moritz Schwyzer
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Oliver Gaemperli
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland
| |
Collapse
|
43
|
Grossmann M, Giannopoulos AA, Bechtiger FA, Messerli M, Schwyzer M, Benz DC, Kudura K, Gebhard C, Gräni C, Pazhenkottil AP, Kaufmann PA, Buechel RR. Ultra-low-dose computed tomography for attenuation correction of cadmium-zinc-telluride single photon emission computed tomography myocardial perfusion imaging. J Nucl Cardiol 2020; 27:228-237. [PMID: 29923103 DOI: 10.1007/s12350-018-1303-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 04/30/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The applicability of ultra-low-dose computed tomography (CT) for attenuation correction (AC) of single-photon-emission computed tomography myocardial perfusion imaging (SPECT-MPI) remains elusive. METHODS AND RESULTS One-hundred patients underwent one-day 99mTc-tetrofosmin stress-rest MPI and non-contrast enhanced cardiac CT with 120, 80, and 70 kilovolt peak (kVp) tube voltage and tube current of 200 milliamperes for creation of AC maps. Normalized percent myocardial uptake from SPECT-MPI using 80 kVp scans for AC showed excellent correlation vs AC from 120 kVp scans for stress [intraclass correlation (ICC) = 0.988, 95% CI = 0.986-0.989, P < .001] and rest (ICC = 0.985, 95% CI = 0.983-0.987, P < .001) with narrow Bland-Altman limits of agreement (BA-LA) (- 5.3% to 4.5% and - 5.4% to 4.4%, respectively) and minimal bias (- 0.4% and - 0.5%, respectively). Correlation of AC SPECT-MPI based on 70 vs 120 kVp scans was excellent for stress (ICC = 0.988, 95% CI = 0.986-0.989, P < .001) and rest (ICC = 0.986, 95% CI = 0.984-0.987, P < .001) with narrow BA-LA (- 5.3% to 4.4% and - 5.2% to 4.5%, respectively) and small bias (- 0.4% and - 0.3%, respectively). Mean effective radiation dose for the 120, 80 and 70 kVp scans were 0.58 ± 0.07, 0.19 ± 0.02, and 0.12 ± 0.01 mSv, respectively. CONCLUSIONS Attenuation maps for MPI obtained from ultra-low radiation dose CT scans are interchangeable with attenuation maps from standard-dose CT while offering a substantial reduction in radiation dose exposure.
Collapse
Affiliation(s)
- Marvin Grossmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Fabiola A Bechtiger
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Moritz Schwyzer
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Ken Kudura
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
44
|
Benetos G, Buechel RR, Gonçalves M, Benz DC, von Felten E, Rampidis GP, Clerc OF, Messerli M, Giannopoulos AA, Gebhard C, Fuchs TA, Pazhenkottil AP, Kaufmann PA, Gräni C. Coronary artery volume index: a novel CCTA-derived predictor for cardiovascular events. Int J Cardiovasc Imaging 2020; 36:713-722. [PMID: 31894527 DOI: 10.1007/s10554-019-01750-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/13/2019] [Indexed: 10/25/2022]
Abstract
Coronary computed tomography angiography (CCTA) provides critical prognostic information on plaque burden and stenosis severity of coronary arteries. We aimed to investigate the long-term prognostic value of coronary artery volume per myocardial mass as a potential new imaging parameter. Consecutive patients with suspected coronary artery disease (CAD) were included. Coronary artery volume index (CAVi) was defined as volume over myocardial mass. Additionally, obstructive CAD (≥ 70% stenosis) and segment severity score (SSS: sum of all segments scored according to lesion severity with 0 = no lesion, 1 = narrowing < 50%, 2 = stenosis 50-69% and 3 = stenosis ≥ 70%) were evaluated. Major adverse cardiovascular events (MACE) were defined as cardiac death, non-fatal myocardial infarction or revascularization. The association of CAVi with MACE was evaluated using Cox regression hazards ratios (HR) and Kaplan Meier curves. In a total of 325 patients, 36 (11.1%) patients experienced MACE during the mean follow-up of 5.4 ± 1.7 years. Patients with low-CAVi (< 27.9 mm3/g) experienced more MACE than patients with high-CAVI (17.2% versus 4.5%, p < 0.001, Kaplan Meier curve p = 0.001). SSS, obstructive CAD and low-CAVi were all significant predictors of MACE in univariable analysis (HR 1.14, 95% CI 1.09-1.19, p < 0.001; HR 5.51, 95% CI 2.86-10.60, p < 0.001; and HR 3.79, 95% CI 1.66-8.65, p = 0.002, respectively). CAVi maintained significant association with MACE when adjusted to SSS (CAVi HR 2.43, 95% CI 1.02-5.75, p = 0.04) or obstructive CAD (CAVi HR 2.4, 95% CI 1.002-5.75, p = 0.049). CAVi could further risk stratify patients without obstructive CAD when stratifying patients according to obstructive CAD (Kaplan-Meier curve p = 0.049). CAVi is a novel CCTA-derived imaging parameter, yielding independent prognostic value over stenosis and plaque burden.
Collapse
Affiliation(s)
- Georgios Benetos
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Marisa Gonçalves
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Elia von Felten
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Georgios P Rampidis
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Olivier F Clerc
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Cathérine Gebhard
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Tobias A Fuchs
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Christoph Gräni
- Department of Nuclear Medicine, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. .,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| |
Collapse
|
45
|
Grani C, Benetos G, Goncalves M, Benz DC, Messerli M, Gebhard C, Kaufmann PA, Buechel RR. Coronary Artery Volume Index - A Novel CCTA-derived Predictor For Cardiovascular Events. J Cardiovasc Comput Tomogr 2020. [DOI: 10.1016/j.jcct.2019.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
46
|
Boscolo Berto M, Benz DC, Gräni C. Noninvasive Assessment of Coronary Artery Disease - Anatomical versus Functional Imaging and the Marginal Role of Exercise Electrocardiograms. Praxis (Bern 1994) 2020; 109:1141-1149. [PMID: 33108995 DOI: 10.1024/1661-8157/a003531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Coronary artery disease (CAD) is the leading cause of morbidity and mortality in the industrialized countries. Assessment of symptomatic patients with suspected obstructive CAD is a common reason for a clinical visit. Noninvasive anatomical and functional imaging are established tools to rule-in and rule-out CAD, to assess the severity of disease and to determine the potential risk of future cardiovascular events. In this review, we discuss the updated Guidelines from the European Society of Cardiology on Chronic Coronary Syndromes and explore the different imaging modalities used in current clinical practice for the noninvasive assessment of CAD. The pros and cons of each method, especially comparing anatomical and functional testing, are presented. Furthermore we we address the practical clinical aspects in the selection of the optimal noninvasive tests according to clinical need.
Collapse
Affiliation(s)
| | - Dominik C Benz
- Department of Nuclear Medicine and Department of Cardiology, University Hospital Zurich
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern
| |
Collapse
|
47
|
Benz DC, Benetos G, Rampidis G, Kaufmann P, Buechel R. Validation Of Deep-learning Image Reconstruction For Coronary Computed Tomography Angiography: Impact On Noise, Image Quality And Diagnostic Accuracy. J Cardiovasc Comput Tomogr 2020. [DOI: 10.1016/j.jcct.2019.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
48
|
Possner M, Buechel RR, Vontobel J, Mikulicic F, Gräni C, Benz DC, Clerc OF, Fuchs TA, Tobler D, Stambach D, Greutmann M, Kaufmann PA. Myocardial blood flow and cardiac sympathetic innervation in young adults late after arterial switch operation for transposition of the great arteries. Int J Cardiol 2020; 299:110-115. [DOI: 10.1016/j.ijcard.2019.07.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/03/2019] [Accepted: 07/11/2019] [Indexed: 11/24/2022]
|
49
|
Schwyzer M, Martini K, Benz DC, Burger IA, Ferraro DA, Kudura K, Treyer V, von Schulthess GK, Kaufmann PA, Huellner MW, Messerli M. Artificial intelligence for detecting small FDG-positive lung nodules in digital PET/CT: impact of image reconstructions on diagnostic performance. Eur Radiol 2019; 30:2031-2040. [PMID: 31822970 DOI: 10.1007/s00330-019-06498-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/21/2019] [Accepted: 10/07/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To evaluate the diagnostic performance of a deep learning algorithm for automated detection of small 18F-FDG-avid pulmonary nodules in PET scans, and to assess whether novel block sequential regularized expectation maximization (BSREM) reconstruction affects detection accuracy as compared to ordered subset expectation maximization (OSEM) reconstruction. METHODS Fifty-seven patients with 92 18F-FDG-avid pulmonary nodules (all ≤ 2 cm) undergoing PET/CT for oncological (re-)staging were retrospectively included and a total of 8824 PET images of the lungs were extracted using OSEM and BSREM reconstruction. Per-slice and per-nodule sensitivity of a deep learning algorithm was assessed, with an expert readout by a radiologist/nuclear medicine physician serving as standard of reference. Receiver-operator characteristic (ROC) curve of OSEM and BSREM were assessed and the areas under the ROC curve (AUC) were compared. A maximum standardized uptake value (SUVmax)-based sensitivity analysis and a size-based sensitivity analysis with subgroups defined by nodule size was performed. RESULTS The AUC of the deep learning algorithm for nodule detection using OSEM reconstruction was 0.796 (CI 95%; 0.772-0.869), and 0.848 (CI 95%; 0.828-0.869) using BSREM reconstruction. The AUC was significantly higher for BSREM compared to OSEM (p = 0.001). On a per-slice analysis, sensitivity and specificity were 66.7% and 79.0% for OSEM, and 69.2% and 84.5% for BSREM. On a per-nodule analysis, the overall sensitivity of OSEM was 81.5% compared to 87.0% for BSREM. CONCLUSIONS Our results suggest that machine learning algorithms may aid detection of small 18F-FDG-avid pulmonary nodules in clinical PET/CT. AI performed significantly better on images with BSREM than OSEM. KEY POINTS • The diagnostic value of deep learning for detecting small lung nodules (≤ 2 cm) in PET images using BSREM and OSEM reconstruction was assessed. • BSREM yields higher SUVmaxof small pulmonary nodules as compared to OSEM reconstruction. • The use of BSREM translates into a higher detectability of small pulmonary nodules in PET images as assessed with artificial intelligence.
Collapse
Affiliation(s)
- Moritz Schwyzer
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.,Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Katharina Martini
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Irene A Burger
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Daniela A Ferraro
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Ken Kudura
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Gustav K von Schulthess
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Martin W Huellner
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland. .,University of Zurich, Zurich, Switzerland.
| |
Collapse
|
50
|
Benz DC, Giannopoulos AA. Do we really need to look at volumetric measurements with 99mTc single photon emission computed tomography (SPECT) myocardial perfusion imaging? J Nucl Cardiol 2019; 26:1717-1719. [PMID: 29589207 DOI: 10.1007/s12350-018-1263-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Dominik C Benz
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Andreas A Giannopoulos
- Cardiac Imaging, Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|