ΕΞΕΛΙΞΕΙΣ ΣΤΙΣ ΑΝΑΙΜΑΚΤΕΣ ΑΠΕΙΚΟΝΙΣΤΙΚΕΣ ΔΙΑΓΝΩΣΤΙΚΕΣ ΤΕΧΝΙΚΕΣ UPDATE 2012

ΕΞΕΛΙΞΕΙΣ ΣΤΙΣ ΑΝΑΙΜΑΚΤΕΣ ΑΠΕΙΚΟΝΙΣΤΙΚΕΣ ΔΙΑΓΝΩΣΤΙΚΕΣ ΤΕΧΝΙΚΕΣ UPDATE 2012 Δρ. Ιωάννης Β. Βασιλειάδης, FACC,FESC,FAHA,FASNC Διευθυντής -Καρδιολόγος, Ευρωκλινική Αθηνών Disclosure: No conflict of interest to declare

New Developments in Echocardiography 3-4D Echo Myocardial deformation Imaging(Tissue Doppler-speckle Tracking )

3-4 Dimensional Speckle Tracking MITRALCLIP MVR EVEREST registry- these techniques should probably not be used for patients with a very limited life expectancy or those with extreme values of left/right ventricular remodelling who would only derive a very limited benefit. We are currently at the stage of evaluation where results should be carefully compared with those of surgery and contemporary medical treatment. Thus we must work hard as the greatest challenges are still to come. Feldman and Cilingiroglu J Am Coll Cardiol 2011; SAPIENS AV DEPLOIT TAVI Imaging, particularly echocardiography, will be used to evaluate patients, plan procedures, guide deployment, and evaluate outcomes. Accurate registries and the reporting of outcomes and complications in a systematic way, as well as institutional participation in multicenter trials, will be integral to ensuring a bright future for this new technology and ultimatelyfor improving outcomes in patients with valvular heart disease Jayasuriya et al. J Am Soc Echocardiogr 2011 4DSTE Algorithms to generate metric strain or strain rate (4DST) Weymann EA. JACC 2010

SpeckleTracking Echocardiography Incremental Prognostic Value of Novel Left Ventricular Diastolic Indexes for Prediction of Clinical Outcome in Patients With ST-Elevation Myocardial Infarction Novel diastolic indexes in ST-elevation AMI derived from strain and strain rate analysis using 2-dimensional speckle tracking imaging.sr IsoVolRelax was incremental to left ventricular ejection fraction, TIMI flow grade 0 to 1 PCI, and multivessel disease and superior to other diastolic indexes in predicting future cardiovascular events after AMI. SRIVR may be useful in identifying high-risk patients soon after AMI Miriam Shanks, Am J Cardiol 2010 Longitudinal and Circumferential Strain Rate, Left Ventricular Remodeling, and Prognosis After MI longitudinal and circumferential SRs were independent predictors of outcomes after MI, whereas only circumferential SRs was predictive of remodeling, suggesting that preserved circumferential function might serve to restrain ventricular enlargement after MI. Hung et al. J Am Coll Cardiol 2010

2D STE and CRT In particular, the absence of radial or transverse dysynchrony was shown to be associated with a high rate of unfavourable clinical events following CRT in patients with routine indications. STAR study. H. Tanaka et al. European Heart Journal 2010

Ma tthias E g g er, J une 2003 2 Nuclear Cardiology Sustained innovation GE MINI combined P E T/CT tomog ra ph D-SPECT CZT Technology Hybrid SPECT-PET/CT Hybrid 3T MRI/PET PET Multi-headed Tomography g-spect Vest Nuclear Holter Mobile Camera Supine RNA Plannar γ-camera 13 N-NH 3! 18 F-FDG! Scintillation 1973 1980 1990 2000 2005 2010 2020

Instrumentation Technical Developments Limitation of aquisition time (2-4 min stress, 2 rest Better Spatial resolution: SPECT: (4mm), PET(2-4MM) Auto correction for photon scatter,attenuation,noise Less radiation exposure SPECT: Tetro r/s 6mS, s/ 4mSv) - PET: FDG 4,5mSv, Rb82 2.5mSv New Agents This agent offers the advantages of having a 90% first pass myocardial extraction fraction, thereby reducing the roll-off phenomenon and a longer halflife than other PET perfusion agent,capable for treadmill exercise ADVANCE-MPI Trial :Regadenoson was equivalent to adenosine in diagnostic efficacy, and better tolerated from a symptomatic standpoint. Combination of Regadenoson (Rapiscan-Lexiscan Lantheus ) and ETT for those failed to reach 85% of age-predicted maximal heart rate at maximal exercise, they received a standard bolus of regadenoson followed 30 seconds later with injection of radiotracer

SPECT-Viability (PET and Recovery Following revascularization study, the first large randomized trial using an FDG-PET guided approach to management of patients with coronary disease and severe left ventricular dysfunction.pet viability failed to demonstrate improved survival after CABG compared to standard care PARR-2 Beanlands JACC 2009 OAT: (Occluded Artery Trial),which randomized stable patients with an occluded infarct related artery to PCI or optimal medical treatment alone. Pts with viable myocardium after acute MI had similar degrees of improvement in LV function whether teated with medical therapy or revascularization Cantor WJAm Heart J 2009

SPECT Prognosis-Appropriateness Cardiac Sympathetic Denervation Assessed With 123-Iodine Metaiodobenzylguanidine SPECT Imaging Predicts Ventricular Arrhythmias in Implantable Cardioverter-Defibrillator Patients Boogers et al. JACC 2010 The 5 most frequent inappropriate indications accounted for the vast majority (92%) of the inappropriate studies A multicenter assessment of the use of single-photon emission computed tomography myocardial perfusion imaging with appropriateness criteria. Hendel RC J Am Coll Cardiol 2010.

ADVANCES IN CTA High temporal resolution (83 ms) Equal spatial resolution (0.4x3mm3) Potentially lower dose 1)prospective ECG triggering; 2) high-pitch scanning; 3)tube voltage reduction. Coronary computed tomography angiography with a consistent dose below 1 msv using prospectively electrocardiogram-triggered highpitch spiral acquisition. Achenbach S, et al. Eur Heart J 2010;31:340 6. GE : CT750 HD Gemstone detectors, eliminating blooming artefacts, 1mSv Philips: Brillance ICT SP 250 slices in two cardiac cycles Toshiba: AquillonOne 320 slices in one cardiac cycle Siemens: Somatron Definition Flash Dual source in 0.25 sec, 1mSv

CTA Prognosis MESA Trial The presence of coronary calcium predicts cardiac events.a systematic review of 49 studies of coronary calcium CT exams on 71,595 asymptomatic patients and 3,924 symptomatic patients. Over a mean follow-up period of 50 months, asymptomatic patients with no coronary calcium had cardiovascular events (0.47%), compared with 4.14%; p 0.001 Among symptomatic patients, (1.8%) without calcium had events over the ensuing months, compared with (8.99%) with coronary calcium. Calcium scoring in very low-risk Framingham score patients may not yield reclassification value, higher CACS low-interm Framingham risk pts (<5-20%) Okwuosa al.. J Am Coll Cardiol 2011. CONFIRM Trial Prognostic Value of Multidetector Coronary Computed Tomographic Angiography for Prediction of All-Cause Mortality FREE suggest that CCTA coronary angiography may be a prognostically useful noninvasive imaging modality for the evaluation of patients with chest symptoms. The present results reveal the prognostic value of CCTA findings and provide the first mortality data which may be used to guide clinical application of this new technology.

hemodynamically significant coronary stenosis CAC out performs SCORE risk factor analysis as a first step screening for the detection of subclinical coronary atherosclerosis I.Vassiliadis et al. Eur.Heart J 2011 (Suppl) t The prevalence of significant stenosis ( 50%), atherosclerotic plaques and moderate to severe coronary calcium score increased with pericardial fat amount. Ο.Καιτοζιης, Ε Δασποτοπουλοσ, Ι Βασιλειαδης 33 Συν ΕΚΕ 2012 Best abstract session

CTA Perfusion CTA-MYOCARDIAL PERFUSION IMAGING. CORE 320 Study: Angiography to assess the diagnostic Performance of combined 320-row CTA and myocardial CT perfusion. myocardial imaging (CTP)compared with (1) the combination of conventional coronary angiography and SPECT-MPI and (2) conventional coronary alone. Vavere et al. J. of Cardiovascular Computed Tomography (2011) Adenosine stress CT MPI with 128-slice dualsource CT in patients with known SPECT perfusion defects the sensitivity of CT to identify SPECT perfusion defects was 83% with a specificity of 78% Compared with invasive coronary angiography, the sensitivity to detect significant stenoses in territories with perfusion defects was 95%, with a specificity of 65%. The combined effective dose from the stress and rest CT myocardial perfusion scans was reported as 18 msv.. Ho KT, JACC Img 2010

A 7-center Japanese trial in 138 patients, coronary MRA was compared with conventional angiography for the detection of a 50% stenosis. The MRA examination was completed in 127 of 138 patients (92%), with a sensitivity of 88% and a specificity of 71% on a per-patient basis. Kato S, et al. J Am Coll Cardiol 2010 ;

MRI Diagnosis-Prognosis Myocardial perfusion imaging Risk of SCD in LV dysfx : 29% ICD discharge rate in pts with fibrosis vs 14% in those with no. Iles JACC 2011 Myocardial fibrosis Mid-wall pattern of myocardial fibrosis defined by MRI delayed enhancement (n 54) was the strongest independent predictor of all-cause mortality by multivariate analysis (HR: 5.35; p 0.03) among 143 nonischemic cardiomyopathy patients followed for 2.0 years. Dweck MR, Am Coll Cardiol 2011.

BUT: The X-ray angiography, the reference standard for the trial, confirmed significant coronary disease in 39% of the study

Coronary angiography is a widely accepted invasive technique but Pool data in the subset of patients with suspected, coronary artery disease undergoing diagnostic CA, demonstrate that 20-40% of them are inconclusive to document hemodynamically severe atherosclerotic disease Another important issue is that despite many technical advances in invasive CA, the definition of functionally relevant coronary stenoses by purely morpho-anatomical criteria remains controversial. Finally CA is limited by its invasive nature and carries small, nevertheless not negligible, procedure-related mortality (0.15%) and morbidity (1.5%) rates and relatively high cost.

Waranty period 4 yrs In addition to assessing luminal obstruction, it will be important to evaluate the hemodynamic significance of these stenoses for proper patient management. De Bruyne B, Edt:. J Am Coll Cardiol 2011

35% 80% 96%

Diagnostic value of hybrid imaging ENVINCI CTA +SPECT-PET/CT in intermediate IHD risk with characteristics generic/biomarkrs Prevalence of CAD 22% - The probability of disease predicted by current clinical models, largely overestimated the actual prevalence suggesting the need to better stratify the risk of pts by more accurate diagnostic tools - Incremental predictive models including clinical, bio-humoral and imaging data, showed a progressive increase of diagnostic performance

MR-PET FUSION MOLLECULAR IMAGING IF ATHEROSCLEROSIS Molecular Imaging of atherosclerosis Co-registration with high-resolution MRI and 18F-FD PET Imaging with Hybrid Device A) PET-CT B) MR-PET: Απεικόνιση καρωτίδων ασθνόυς µε αθηροσκληρυντικη νόσο µε χρήση FDG. Η διαγραφή του τοιχώµατος των αγγείων και η ενδογενής αντίθεση των µαλακών ιστών είναι βελτιωµένες µε τη χρήση του MR σαν συνδυασµένη απεικόνιση µε το PET όπως καταδεικνύεται µε το ενθετο. Με λευκα βέλη οι καρωτίδες Fayad ZA. 2010

3-dimensional dynamic stress MRI at 3-T to quantify the volume of perfusion defects before and after coronary intervention in 48 patients. Percentage of LV volume subtended by the hypoenhanced defect during adenosine stress was reduced from 14.2 to 3.2 by coronary stenting. Manka R, J Am Coll Cardiol 2011

Knuuti et al EHJ 2012

Συµπεράσµατα Οι εν χρήση αναίµακτες απεικονιστικές τεχνικές ECHO-NUCLEAR-CTA-MRI µεµονωµένα η σε συνδυασµό, εξασφαλίζουν σε υψηλό ποσοστό της διάγνωση εκτίµηση και πρόγνωση κλινικών µορφών στεφανιαίας νόσου.λόγω της αυξανόµενης διαθεσιµότητα πολλών εναλλακτικών µορφών απεικόνισης,προσδοκάται ότι η έµφαση θα δοθεί περισσότερο από ποτέ στη σχέση κόστους/οφέλους επί πληθυσµιακής βάσης Η ευάλωτη αθηρωµατική πλάκα που ευθύνεται για τη πρόκληση οξέων στεφανιαίων συνδρόµων σε ασυµπτωµατικούς ασθενείς µε προκλινικη µορφή ΣΝ, αποτελεί τον µελλοντικό στόχο αναίµακτων και επεµβατικών απεικονιστικών τεχνικών. Oι αναίµακτες τεχνικές ως µέσο πρωτοπαθούς πρόληψης, απαιτούν συνδυασµό λειτουργικής και µε ανατοµικής απεικόνισης (υβριδική τεχνική PET/CT, PET/MRI) ώστε να πετύχουν το µέγιστο της διακριτικής ικανότητας Η επιλογή των ευάλωτων ασθενών θα στηριχτεί στην κλινική κρίση σε συνεκτίµηση προς τους παράγοντες κινδύνου, βιολογικούς δείκτες και απλές εργαστηριακές τεχνικές (CIMT-ABI-CAC) και θα επικυρωθεί από τις εξειδικευµένες απεικονιστικές τεχνικές Η καρδιακή απεικόνιση αποτελεί ενότητα πλέον από 4 συνιστάµενες (Υπερηχογραφία, Πυρηνική Καρδιολογία, Αξονική τοµογραφία καρδιάς και Μαγνητικός συντονισµός), που θα αποτελέσει αντικείµενο εξειδίκευσης νέων καρδιολόγων στο µέλλον.

MULTIMODALITY IMAGER

Αλήθειες,µύθοι και λαϊκές δοξασίες για τους κίνδυνους από την ακτινοβολία

1 2 Melikian et al.j Am Coll Cardiol Interv 2010

IMAGING THE FUTURE OF CARDIOLOGY A.H Geschlick et al. Heart 2007

ΚΑΡΔΙΑΓΓΕΙΑΚΗ ΑΠΕΙΚΟΝΙΣΗ Πως θα επηρεάσει την άσκηση της σύγχρονης Καρδιολογίας? Αναπάντητα ερωτήµατα: Ποιος είναι ο ιδανικός εξεταζόµενος? Ποιος πρέπει να ερµηνεύει τα αποτελέσµατα? Ποιος πρέπει να πληρώνει την µελέτη? Ποιος θα εκπαιδεύει ποιόν? Πώς θα επηρεαστούν οι κατευθυντήριες οδηγίες?

Το µέλλον της αναίµακτης απεικόνισης Επαναπρογραµµατισµός λειτουργίας των διαθεσίµων µεθόδων η εξέλιξη των πρωτοεµφανιζόµενων τεχνολογιών που παρέχουν µια συνδυασµένη εκτίµηση της ανατοµίας και λειτουργικότητας Λόγω της αυξανόµενης διαθεσιµότητα πολλών εναλλακτικών µορφών απεικόνισης,προσδοκαται ότι η έµφαση θα δοθεί περισσότερο από ποτέ στη σχέση κόστους/ οφέλους επί πληθυσµιακής βάσης Σε εξατοµικευµένο επίπεδο η προσοχή στρέφεται στην επί µέρους προγνωστική ακρίβεια

We believe that an integrated, multimodality imaging approach is optimal for the solution of clinical problems Κλινικές εφαρµογές σε εξέλιξη Μελέτη αιµάτωσης του µυοκαρδίου στην κόπωση και ηρεµία µε δυνατότητα ποσοτικής µέτρησης της στεφανιάιας ροής και εφεδρείας µε αντιστoιχηση προς την ανατοµία του στεφανιαίου δικτύου PET/CT- SPECT/CT Μελέτη βιωσιµότητας µε αντιστοίχηση προς το υπευθυνο αγγείο PET/CTA PET/MRI Εντόπιση και αναγνώριση σύστασης αθηρωµατικής πλάκας PET/MRI, PET/CT

Υβριδική απεικονιση Σύγχρονη διάσταση της καρδιακής απεικόνισης µε σύµµειξη εικόνων PET/CT- SPECT/CT Μελέτη αιµάτωσης του µυοκαρδίου στην κόπωση και ηρεµία µε δυνατότητα ποσοτικής µέτρησης της στεφανιαίας ροής και εφεδρείας µε αντιστoιχηση προς την ανατοµία του στεφανιαίου δικτύου PET/CTA PET/MRI Μελέτη βιωσιµότητας µε αντιστοίχηση προς το υπευθυνο αγγείο PET/MRI, PET/CT Εντόπιση και αναγνώριση σύστασης αθηρωµατικής πλάκας

R.Bonow Edt. Lancet 2011 states that the future of CMR will depend on its availability, costeffectiveness, and ability to improve patient outcomes. "Diagnosis of coronary artery disease alone is not sufficient to determine the need for revascularization," Bonow writes. "To show value, advances in imaging must be coupled with enhanced patient well-being or a reduction in unnecessary downstream testing and procedures." Bonow looks forward to comparativeeffectiveness trials, such as RESCUE andpromise, to show whether CMR provides an incremental increase in clinical value compared with SPECT and echocardiography.

Radiation Safety Η έκφραση της έκθεσης στην ακτινοβολία σε µονάδες κινδύνου εµφάνισης καρκίνου είναι παρελκυστική διότι: 1. Οι τιµές της δόσης ακτινοβολίας εµπεριέχουν σηµαντική ασάφεια διότι βασίζονται σε περιορισµένα βιοκινητικά δεδοµένα (ανθρώπων η ζώων) και εξάγονται για τον µέσο όρο και όχι για το συγκεκριµένο άτοµο. 2. Ενώ η µέση έκθεση στην ακτινοβολία η οι τιµές καρκινικού κινδύνου µπορούν να εκφραστούν για τον γενικό πληθυσµού, η προστιθέµενη επιβάρυνση (τιµές καρκινικού κινδύνου ) από συγκεκριµένη εξέταση για τον συγκεκριµένο άρρωστο δεν µπορεί να εξαχθεί από µοντέλο γενικού πληθυσµού 3. Η µετατροπή της δόσης ακτινοβολίας σε καρκινικό κίνδυνο στηρίζεται σε γραµµική και όχι εξαρτώµενη από τον ουδό υπόθεση (LNT Hypothesis). Δηλ. τα δεδοµένα της έκθεσης στην ακτινοβολία από ιατρικές απεικονιστικές πράξεις αποτελούν προέκταση παρατηρήσεων εµφάνισης καρκίνου σε επιζήσαντες από το Nagasaki η από Πυρ. Ατυχήµατα που εξετέθησαν σε µεγάλες δόσεις ακτινοβολίας. Εποµένως δεν µπορεί ως µοντέλο πρόβλεψης να δουλέψει για χαµηλές δόσεις American Society Nuclear Cardiology Statement Oct. 2008

Radiation Safety Effective dose equivalent (He) Chest x-ray 0.002 rem (0.02 msv) Nucl Med Science Safety Coro angiogram 0.5-1.2 rem (5.6-12 msv) 1996 PCI 1.8-2.2 rem (18-22mSv) MPI (Tl-201) 1.0-1.7 rem (10-17mSv) Eur J Nucl Med 2005:32 (Tc-99m) 0.5-0.7 rem (5-7 msv) GBPI 1.0 rem (10 msv) EPS 1.2 rem (12 msv) MSCT (16 slices)1.4 rem (14mSv) JACC 2006:47 Natural exposure (yr) 0.36 rem (3.6 msv) Maximum Allowable Radiation Limits/yr Cummulative exposure(yr) 5 rem 50mSv 10mSv x age JACC1998:31 Life time attributable risk (LAR) for solid cancer A dose equivalent of 50mSv/yr should be associated with an incremental increase in risk of 0.2%/yr to the 20% of risk in general population

Stress Echocardiography Prognostic value in patients with normal exercise ECGs. Patients with a normal electrocardiogram (ECG) and absence of symptoms during routine nonimaging stress testing are often considered to be of low risk for cardiac events; however, the reduced sensitivity of this approach may result in failure to identify some patients at risk 16.7%) developed ischemia with exercise (new or worsening wall motion abnormalities) The 5-year mortality and MCE rates were 6.4% and 4.2%, respectively, in patients without ischemia versus 12.1% and 10.1% in those with ischemia (p 0.001). Bouzas-Mosquera A. JACC 2009 Exercise-Induced Delayed LV Relaxation The observation that diastolic abnormalities persist well after recovery of systolic function may have important diagnostic implications in the diagnosis of transient ischemia.was tested using ST strain imaging. Ten minutes after treadmill exercise testing,regional delayed relaxation was still observed in 85% of territories perfused by stenotic vessels. Ishi K. JACC 2009

Tissue Doppler Imaging Diastolic Function Several recent papers have raised questions about the reliability of tissue Doppler imaging (TDI) measures of LV relaxation as markers of LA pressure or diastolic fx Role in predicting survival Geske JB JASE 2009 Mullens W. Circulation 2009 Masutani Circulation 2008 Longitudinal TDI velocities from 6 basal segments were averaged and ratios E/e=, e=/ a=, and e=/a= s= (eas index) taken as measures of LV filling pressure, diastolic performance, and combined systolic and diastolic performance, respectively. Among all TDI parameters, the eas index was the best predictor of death, even in patients with normal conventional echocardiograms Mogelvang R, Circulation 2009

Advances in Nuclear Cardiology New SPECT cameras to perform dynamic acquisitions for the purpose of absolute blood flow alculations. Furthermore, software to compute absolute blood flow and CFR from dynamic Rb-82 PET is now commercially available I-123-MIBG imaging of cardiac sympathetic innervation and phase analysis of gated SPECT to quantify dysynchrony; to help guide the use of devices for cardiac resynchronization or arrhythmia management in patients with congestive heart failure. Pharmacological stress testing with the selective adenosine receptor A2a agonist, regadenoson Quantitative myocardial blood flow assessment with Rb-82 PET evaluating patients with heart failure. Metabolic imaging Absolute flow quantification with the currently approved PET myocardial flow tracers Promise of molecular imaging utilizing

Technical Developments Nuclear SPECT-PET Limitation of aquisition time (2-4 min stress, 2 rest Better Spatial resolution: SPECT: (4mm), PET(2-4MM) Auto correction for photon scatter,attenuation,noise Less radiation exposure SPECT: Tetro r/s 6mS, s/msv) - PET: FDG 4,5mSv, Rb822.5mSv CTA a 320-detector row scannerwas introduced, which has a wide enough detector array that the entire heart can be covered in 1 gantry rotation with no table movement. Flash CT MRI Higher field strength(3.0-t) MRI scanners (3.0-T) In cardiac imaging, higher field strengths have been associated with a variety of challenges and limitations, including electrocardiographic (ECG) gating. The scanner s magnetic field causes interference with the ECG signal Frauenrath T, Hezel F, Heinrichs U, Kozerke S. Feasibility of cardiac gating free of interference with electro-magnetic fields at 1.5 Tesla, 3.0 Tesla and 7.0 Tesla using an MR-stethoscope. Invest Radiol 2009;44: 539 47.

TISSUE DOPPLER IMAGING-TISSUE SYNCHRONIZATION IMAGING-SPECKLE TRACKING HFNEF. 1/3 of pts s presenting with symptoms and signs of HF will have a normal LVEF. Invasive studies have suggested that this is due to decreased relaxation and increased LV stiffness.longitudinal radial ST, apical rotation ST and Diastolic mitral annular TDI at rest and during ecercise were lower and failed to increase with exercise suggesting LV dysfx. Tan YT JACC2009 Predicting response to CRT (PRORPECT Trial) PRO PROSPECT study has limitations including: patient selection (20.2% of patients had LVEF 35% and 37.8% had an LV internal dimension 65 mm), high interobserver variability suggesting nwer techniques ST-3D Bax JJ. JACC 2009 CONS A critical weakness of echocardiographic criteria for response to CRT is the general absence of hard clinical end points They suggest that future studies should include magnetic resonance imaging evaluation of the location and extent of myocardial scar and CT assessment of venous anatomy and lead placement in addition to echocardiographic measures of dyssynchrony (e.g., strain 3D imaging) in assessing the response to therapy. Hawkins NM. JACC 2009 Reverse remodeling in patients with NYHA functional class I/II heart failure( REVERSE Trial) The LV end-diastolic volume and ESV indexes decreased in the treatment group (CRT on) compared with controls (CRT off), both p 0.001; whereas LVEF increased in the CRT-on patients compared with controls (p 0.0001) from baseline through 12 months. St. John Sutton M. Circulation 2009

Anatomy meets function: modeling coronary flow reserve on the basis of coronary computed tomography We believe angiography. that an integrated, multimodality J Am Coll Cardiol 2011;58:1998 2000. imaging approach is optimal for the solution of clinical problems Κλινικές εφαρµογές σε εξέλιξη Μελέτη αιµάτωσης του µυοκαρδίου στην κόπωση και ηρεµία µε δυνατότητα ποσοτικής µέτρησης της στεφανιάιας ροής και εφεδρείας µε αντιστoιχηση προς την ανατοµία του στεφανιαίου δικτύου PET/CT- SPECT/CT Μελέτη βιωσιµότητας µε αντιστοίχηση προς το υπευθυνο αγγείο PET/CTA PET/MRI Εντόπιση και αναγνώριση σύστασης αθηρωµατικής πλάκας PET/MRI, PET/CT

Kaplan-Meier analysis for hard cardiac event-free survival in patients with abnormal Agatston score values (A), nonobstructive versus obstructive CAD (B), normal coronary arteries versus nonsignificant coronary lesions and significant CAD (C), and no corona... Russo V et al. Circ Cardiovasc Imaging 2010;3:351-359 Copyright American Heart Association

Progress in Scanners High temporal resolution (83 ms) Equal spatial resolution (0.4 x 0.4 x 0.4 mm 3 ) Potentially lower dose GE : CT750 HD Gemstone detectors, eliminating blooming artefacts, 1mSv Philips: Brillance ICT SP 250 slices in two cardiac cycles Toshiba: AquillonOne 320 slices in one cardiac cycle Siemens: Somatron Definition Flash Dual source in 0.25 sec, 1mSv

A 7-center Japanese trial in 138 patients, coronary MRA was compared with onventional angiography for the detection of a 50% stenosis. The MRA examination was completed in 127 of 138 patients (92%), with a sensitivity of 88% and a specificity of 71% on a per-patient basis. Kato S, et al. J Am Coll Cardiol 2010 ;

EAE recommendations about pocket size imaging devices can be summarized in: 1. Pocket size imaging devices do not provide a complete diagnostic echocardiographic examination. The range of indications for their use is therefore limited 2. Imaging assessment with pocket size imaging devices should be reported as part of the physical examination of the patient 3.Image data should be stored according to the applicable national rules for technical examinations with the exception of cardiologists who are certified for transthoracic echocardiography according to national legislation, specific training and certification is recommended for all users. The certification should be limited to the clinical questions that can potentially be answered by pocket size devices The patient has to be informed that an examination with the current generation of pocket size imaging devices does not replace a complete echocardiogram

European Association of Cardiovascular Imaging (EACVI) Statutes of the European Association of Cardiovascular Imaging (EACVI) draft 15 May 2011 Panos Vardas (P-E), Adam Torbicki (V-P), Luc Pierard (ESC Board), Sophie Squarta (SC) The potential components of the future Association (EAE, WGs on CMR, WG on Nuclear Cardiology and cardiac CT), as well as its potential close collaborators (EAPCI, WG on Computers in Cardiology), updated during a meeting at the Heart House, March 9th 2011 a following road map to the EACVI is suggested

Contrast Echocardiography (CE) Clinical impact of CE in patients with technically difficult studies in the routine clinical setting. Contrast echocardiography led to avoidance of further diagnostic tests (e.g., transesophageal echocardiography [TEE] or nuclear imaging) in 32.8% of patients because of improved assessment of LV function. Additional procedures were avoided most often in patients in the SICU (55%).Overall, CE had some impact in 35.6% of suboptimal studies with the greatest impact seen in patients in the SICU, followed by the medical ICU, impatient wards, and least in the outpatient setting. Kurt M. JACC 2009

Hybrid SPECT/CT AND PET CT imaging ort their initial experience with low-dose, prospectively gated coronary CTA, which reduced radiation exposure by 70% without compromising

A Multi Disciplinary Approach. Nuclear imaging of plaque biology 18FDG PET CT VCAM-1 targeted tracer 18F-4V before statins SPECT imaging of apoptosis VCAM-1 targeted tracer 18F-4V after statins MMP-targeted microspect-ct Nahrendorf M et al Circulation2008

Risk of SCD in LV dysfx : 29% ICD discharge rate in pts with fibrosis vs 14% in those with no. Iles JACC 2011)

A Multi Disciplinary Approach

MRI Fusion MRI/PET, MRI/CT MR-PET FUSION MOLLECULAR IMAGING IF ATHEROSCLEROSIS Plaque MESA : (Multi- Ethnic Study of Atherosclerosis). They imaged the proximal coronary artery in cross-section and compared the total coronary wall thickness with the outer contour area and the luminal area, before and after adjustment for body mass index and LV mass. The predominant change in vessel size was due to a larger increase in outer wall area than in the luminal area, which the authors interpreted as positive remodeling Miao C. JACC 2009 A) PET-CT B) MR-PET: Απεικόνιση καρωτίδων ασθνόυς µε αθηροσκληρυντικη νόσο µε χρήση FDG. Η διαγραφή του τοιχώµατος των αγγείων και η ενδογενής αντίθεση των µαλακών ιστών είναι βελτιωµένες µε τη χρήση του MR σαν συνδυασµένη απεικόνιση µε το PET όπως καταδεικνύεται µε το ενθετο. Με λευκα βέλη οι καρωτίδες Fayad ZA. 2010 PET-CT PET-MRI: Carotid artery imaging of a pt with atherosclerotic disease using FDG. The delineation of the vessel wall and the endogenous contrast of the soft tissyews is improved with MRI compared to CTA Fayad ZA 18. Arterioscler Thromb Vasc Biol 2009;