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George Segall, M.D. Stanford University PET Myocardial Perfusion Imaging: Protocols and Procedures.

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Presentation on theme: "George Segall, M.D. Stanford University PET Myocardial Perfusion Imaging: Protocols and Procedures."— Presentation transcript:

1 George Segall, M.D. Stanford University PET Myocardial Perfusion Imaging: Protocols and Procedures

2 PET Perfusion Agents Rubidium-82 ( 82 Rb)Chloride75 sec3.15 Nitrogen-13 ( 13 N)Ammonia10 min1.19 O-15 ( 15 O)Water 110 sec1.72 Copper-62 ( 62 Cu)PTSM 9.8 min2.94 Potassium-38 ( 38 K)Chloride 7.6 min2.70 Carbon-11 ( 11 C)Butanol20 min0.96 RadioisotopeFormHalf-life MeV Diffusible tracers PTSM, pyruvaldehyde methylthiosemicarbazone

3 Medicare Coverage Policy 1995Rb-82 PET for myocardial perfusion 1998F-18 deoxyglucose PET and SPECT for myocardial viability 2003N-13 ammonia for myocardial perfusion

4 Medicare Coverage Policy for Rb-82 and N-13 ammonia PET whether at rest alone, or rest with stress, is approved when PET is performed in place of SPECT, or used following SPECT when results are equivocal, technically uninterpretable, or discordant with clinical care SPECT may not be used following an inconclusive PET

5 RAM License Strontium mCi Rubidium mCi Strontium mCi

6 Rb-82 Infusion System

7 Relative Advantages Rb-82 N-13 ammonia AvailabilityExcellent Limited LogisticsEasy Difficult CostFixed Variable

8 Decision Analysis Occasional Imaging and On-site cyclotron N-13 ammonia Daily Imaging and PET/CT capacity Rb-82 chloride

9 Decision Analysis Flexibility Exercise N-13 ammonia Adenosine Dipyridamole Dobutamine Convenience Adenosine Rb-82 chloride Dipyridamole Regadenoson

10 Scheduling N-13 ammonia scheduled > 1D in advance problematic cases inconclusive SPECT high BMI Rb-82 chloride scheduled day of exam ED and inpatients √ √ √

11 Emission protocol N-13 ammonia Rb-82 chloride mCi 2D gated emission start 10 min p injection mCi 2D gated emission start 90 sec p injection

12 2D vs 3D Gated Rb-82 PET Knesaurek. BMC Nucl Med 2007;7:4 16 normal volunteers had resting Rb-82 on a BGO PET camera Low dose (20 mCi) 3D acquisition compared to high dose (60 mCi) 2D acquisition

13 Emission Reconstruction Rb-82 chloride N-13 ammonia reconstruction filter: Butterworth 0.4 roll-off / power 10 post reconstruction: axial smoothing reconstruction filter: Butterworth 0.40 roll-off / power 10 no post reconstruction smoothing

14 CT protocol 140 keV mAs (noise index 25.0) pitch 0.5 ungated

15 PET Perfusion Agents Rb-82 Chloride and N-13 ammonia are both extractable agents which passively diffuse across cell membranes Both tracers have high first-pass myocardial extraction fractions, which are inversely related to flow is a non-linear manner.

16 Rb-82 chloride Rb-82 is rapidly cleared from the circulation Tang. Phys Med Biol 2009;54:

17 N-13 ammonia N13 is rapidly cleared from the circulation

18 N-13 ammonia N-13 ammonia is trapped in the myocardium from the action of glutamate dehydrogenase 1 and glutamine synthetase 2 13 NH 3 13 NH 4 + glutamine urea  - ketoglutarate glutamate NH 3 glutamine NH 3

19 PET Perfusion Agents Rb-82 Chloride N-13 ammonia Relationship to CBF Schelbert Hr, Schwaiger M. In: PET and Autoradiography. Eds: Phelps ME, Mazziotta JC, Schelbert H 1986 Bergman SR. In: PET of the Heart. Eds: Bergmann SR, Sobel BE. 1992

20 Work Flow inject scan Pers inject scan inject scan Pers inject scan N-13 ammonia mCi Rb mCi min CT

21 Rb-82 chloride inject scan Pers inject scan inject min CT Aden inject scan CT

22 Rb-82 chloride inject scan Pers inject scan inject min CT Reg inject scan CT

23 N-13 ammonia inject scan Pers min CT inject scan CT Ex scanCT inject min

24 Cyclotron starts production 23 minutes prior to calibration time Injection times Ex Reg Ad Per Dob = inject

25 Normal Rb-82 perfusion study

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29 Abnormal Rb-82 perfusion study

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31 Normal N-13 perfusion study

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33 Abnormal N-13 perfusion study 72 year old man with peripheral vascular disease. Coronary arteriography: LAD: 60% ostial and 80% mid vessel stenoses LCX: 90% proximal stenosis and occluded OM RCA: 90% ostial stenosis

34 Summary PET myocardial perfusion protocols are simple and easy to incorporate in most practices Rb-82 and N-13 ammonia are qualitatively equivalent

35 Summary High throughput, and low cost per patient makes Rb-82 PET practical in a high volume practice NH3-ammonia PET is better suited for occasional use in patients with inconclusive SPECT, or as the test of choice in problematic patients

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