1. Nuclear Cardiology FAN Chengzhong M.D. Professor
Department of Nuclear Medicine
Sichuan University
2018/7/3

2. Cardio-vascular System
2018/7/3

3. Nuclear Cardiology: status of myocardium and coronary perfusion.
Myocardial perfusion imaging (MPI):
status of myocardium and coronary perfusion.
Radionuclide ventriculography:
status of heart function.
Cardiac positron emission tomography.
status of myocardium viability
 Infarct-avid imaging:
detection of acute myocardial infarction (MI).
2018/7/3

4.  Quantification: wide range of functional and metabolic parameters.
Advantages:
noninvasiveness,
 Quantification: wide range of functional and metabolic parameters.
Must be always considered in the context of other cardiac diagnostic procedures:
Echocardiography, Contrast angiography
Electrocardiography (ECG),
Serum enzymes
2018/7/3

5. MYOCARDIAL PERFUSION IMAGING
The single most frequent application of nuclear cardiology is the assessment of myocardial perfusion.
2018/7/3

6. Application: Diagnosis of CAD. Diagnosis of acute MI.
Risk stratification after infarction.
Assessment of viable myocardium versus scar.
2018/7/3

7. Integrative concept about MPI:
MPI scintigram depicts two sequential events:
First, tracer must be delivered to the myocardium.
Second, a viable, metabolically active myocardial cell must be present to localize the tracer.
2018/7/3

8. The scintigram may be thought of as a map of regional myocardial perfusion to viable myocardial tissue.
If a patient has a decrease in regional perfusion, or a loss of cell viability, a photon-deficient or a photon-defect lesion is depicted scintigraphically.
2018/7/3

9. Pharmaceuticals for Perfusion Imaging
Thallium 201-chloride
(2) Technetium-99m sestamibi (Tc-99m MIBI)
(3) Technetium-99m Tetrofosmin
(4) Technetium-99m Teberoxin
2018/7/3

10. PHYSICAL PROPERTIES: Tl-201
（1）Thallium 201-chloride
PHYSICAL PROPERTIES: Tl-201
■ Low energy (71-80 keV X-rays from Hg-201 daughter) ■ Potassium analog ■ Perfusion marker under most conditions ■ Redistributes ■ Chemical form: Thallous Chloride (Tl-201) ■ Tl-201 is a cyclotron produced nuclide with t1/2 = 73 hours. ■ Limitation: photons easily attenuated by body tissues (71 keV Hg x-rays) ■ Long physical and biological half lives increase radiation dose, limiting patient injectable doses to 5 mCi ■ Imaging procedure involves a stress exam followed by a second exam after redistribution which can take anywhere from 4-24 hours
2018/7/3

11. Thallium 201-chloride Mechanism of localization and pharmacokinetics:
high extraction fraction during transit through myocardial capillary bed. The extraction is proportional to regional perfusion.
peak uptake in the myocardium occurs 10 to 20 minutes after IV. In normal subjects approximately 5% of the administered dose localize in the myocardium.
2018/7/3

12.  after initial uptake has occurred, thallium undergoes “redistribution” in the body.
 “redistribution”: a dynamic equilibrium of Tl-201 exists between the myocardium and vascular pool. Several hours after initial tracer administration the scintigraphic images depict an equilibrated pattern. This is the basis of the “stress-redistribution” imaging strategy.
2018/7/3

13. Defects on delayed images depict scar.
Cold defects seen on early images may represent areas of decreased flow or areas of myocardial scar without viable cells.
Defects on delayed images depict scar.
Areas demonstrating equilibration or “fill-in” of activity on delayed images represent viable myocardium rendered ischemic during exercise.
2018/7/3

14. (2) Technetium-99m sestamibi (Tc-99m MIBI) PHYSICAL PROPERTIES: Tc-99m
■ Low energy ■ Tc-99m is a generator-produced nuclide with t1/2 = 6 hours. ■ Photons easily penetrate body tissues (140 keV r-rays) ■ Relatively low radiation dose per mCi, so patient could receive a maximum of mCi for a stress/rest study
2018/7/3

15. (2) Technetium-99m sestamibi (Tc-99m MIBI)
A member of a chemical family referred as isonitriles;
Chemical name is hexakis 2-methoxyisobutyl isonitrile.
A monovalent cation.
Prepared from a kit and requires boiling to effect labeling.
Diffuse passively out of blood and localizes in mitochondria on the basis of their negative potentials.
2018/7/3

16. Pharmacokinetics
Tc-99m sestamibi is cleared from the blood and uptake in myocardium rapidly.
Progressive clearance of liver and lung activity with excretion of the tracer through the kidneys and biliary system results in better myocardium-to-background ratios at 60 to 120 minutes.
The clearance half-time from the myocardium is long (>5 hrs).
Minimal recirculation or redistribution occurs after initial uptake.
2018/7/3

17. Imaging is initiated from 30 to 90 minutes after IV for resting studies.
Imaging may be started at 15 minutes for exercise stress studies because the heart/lung and heart/liver ratios are higher than when tracer is given at rest.
2018/7/3

18. Comparison of Image Quality of Thallium 201 and Tc-99m Cardiac Agents
■ Tc-99m has more optimal energy ■ Higher injected dose means more photons and better counting statistics ■ Higher target to background ratio ■ More rapid acquisition ■ Improved resolution ■ Fixed Distribution provides flexibility and permits gating
2018/7/3

19. Imaging Protocols Thallium-201 chloride see page 68-69.
patient preparation and follow-up
dosage and route of administration
time of imaging
planar imaging
SPECT imaging acquisition parameters
SPECT reconstruction parameters
2018/7/3

20. (2) Technetium-99m sestamibi see page 69-70.
(3) SPECT imaging
 general all-purpose collimator: Tl-201
high resolution collimator: Tc-99m-sestamibi
180 arc length: 45o RAO to 135o LPO
 noncircular (body contoured) versus circular
orbits
2018/7/3

21. ECG-synchronized SPECT (gated SPECT, GSPECT) with Tc-99m-sestamibi.
Cont.
ECG-synchronized SPECT (gated SPECT,
GSPECT) with Tc-99m-sestamibi.
Advantages:
Replay sequential gated images in cinematic display to assess regional wall motion.
Possibility of calculating LVEF.
Measuring wall motion and thickening.
More accurately analyzing tracer distribution.
2018/7/3

22. ECG-synchronized SPECT (gated SPECT, GSPECT) with Tc-99m-sestamibi
Principle of ECG-gated acquisition：
(A). R–R interval on ECG：1 cardiac cycle；8 frames of equal duration
(B).Image data from each frame are acquired over multiple cardiac cycles and stored separately in specific locations (“bin”) of computer memory
(C).When all data in a bin are added together, image represents a specific phase of cardiac cycle. Typically, a volume curve is obtained, which represents endocardial volume for each of 8 frames.
ED end-diastole; ES end-systole.
Principle of ECG-gated acquisition. R–R interval on ECG, representing 1 cardiac cycle, is typically divided into 8 frames of equal duration (A). Image data from each frame are acquired over multiple cardiac cycles and stored separately in specific locations (“bin”) of computer memory (B). When all data in a bin are added together, image represents a specific phase of cardiac cycle. Typically, a volume curve is obtained, which represents endocardial volume for each of 8 frames (C). ED end-diastole; ES end-systole.
GSPECT is a simple method to evaluate the LV perfusion and function within a single study.
GSPECT is a simple method to evaluate the LV perfusion and function within a single study
2018/7/3

23. 2018/7/3

24. Appearance of the Normal Myocardial Perfusion Scintigram
Uniform uptake of tracer throughout the left ventricular myocardium.
(The myocardium may appear thinner at the apex. The valve planes demonstrate absence of uptake, giving the heart a horseshoe or U-shaped appearance on long-axis SPECT views).
The right ventricle is typically not seen on rest studies. (Visualization is significant in cases of right ventricular hypertrophy).
2018/7/3

25. Cont.
The heart has a ring or doughnut appearance on short-axis SPECT views. Decreased uptake in the septum on more posterior short-axis SPECT views near the base is due to the membranous septum and should not be mistaken for an abnormality.
Some lung uptake is usually noted. Significant lung uptake may be seen in heavy smokers, patients with underlying lung disease, and patients in congestive heart failure.
2018/7/3

26. 2018/7/3

27. 2018/7/3

28. Short Axis Slices
2018/7/3

29. Short axial slices
2018/7/3

30. Vertical Long Slices
2018/7/3

31. Vertical axial slices
2018/7/3

32. Horizontal Long Slices
2018/7/3

33. Horizontal axial slice
2018/7/3

34. Horizontal Long Slices Normal Scintigram
Short Axis Slices
Vertical Long Slices
Horizontal Long Slices
Normal Scintigram
2018/7/3

35. Normal myocardial perfusion scintigram
2018/7/3

36. back
Normal myocardial perfusion scintigram
2018/7/3

37. Cont.
In some women the breast causes attenuation of activity from the heart, resulting in spurious defects along the lateral wall.
The second artifact is interposition of the diaphragm and subdiaphramatic viscera between the gamma camera and the heart. Activity from the inferior and posterior lateral walls of the left ventricle can be attenuated.
Attenuation artifacts are more significant problems for Tl-201 because of the lower energy of the photons.
2018/7/3

38. Applications of Myocardial Perfusion Imaging
Diagnosis of Coronary Artery Disease
Coronary stenoses of up to 90% may not be associated with any observable perfusion abnormality or symptoms under resting conditions, and what percentage of stenosis actually constitutes a hypodynamically critical lesion has been the subject of much study and debate. Factors such as the length, irregularity of a stenosis and circumferential narrowing are clearly important. Most angiographic laboratories consider a coronary stenosis of 70% or greater to be significant.
2018/7/3

39. Interventional maneuver  alter organ function  functional reserve.
Exercise stress testing
Pharmacological stress testing
2018/7/3

40. EXERCISE STRESS TESTING
Rationale: physical exercise increases cardiac workload  increased work increases myocardial oxygen demand  normal coronary arteries dilated and flow increases
Healthy subjects have tremendous coronary flow reserve, blood flow may be 3-5 times greater
Stenotic vessels do not dilate, flow reserve is limited, myocardial ischemia is induced
Coronary artery stenosis greater than 85% to 90% is required before flow is diminished at rest.
2018/7/3

41. Treadmill exercise testing
2018/7/3

42. Leg exercise
Back
2018/7/3

43. Manifestation of Myocardial Ischemia
Electrocardiogram: ion flux across cell membrane is impaired by ischemia; electrical activity also changes and is manifest as ST segment depression on ECG.
Myocardial perfusion imaging: relative decrease in regional flow is manifest as relative photon-deficient area.
Radionuclide ventriculography: contraction of ischemic myocardium is decreased and manifest as either segmental wall motion abnormalities or a fall in global parameters, such as EF.
2018/7/3

44. >85% of the age-predicted maximum heart rate (220-age);
One of the important principles of all interventions is that the degree of stress must be sufficient to unmask underlying abnormalities. The adequacy of exercise is judged by
>85% of the age-predicted maximum heart rate (220-age);
 “double product”: heart rate  systolic blood pressure>25,000.
2018/7/3

45.  Infarction: defects that remain “fixed” between the image sets.
Diagnostic Patterns in Coronary Artery Disease
See page 76, table 5-3.
 Normal: no defects noted on either image.
 Transient ischemia: cold defects on poststress images that fill in on delayed images.
 Infarction: defects that remain “fixed” between the image sets.
2018/7/3

46. LCx (left circumflex branch): serves the lateral and posterior walls.
Anatomy of Coronary Circulation (distribution of major vessels): See page 78-79, Fig to 5-16
LAD (left anterior descending artery): serves most of the septum and the anterior wall of the left ventricle.
LCx (left circumflex branch): serves the lateral and posterior walls.
RCA (right coronary artery): serves the right ventricle, the inferior portion of the septum, and portions of the inferior wall of the left ventricle.
The apex may be perfused by branches from any of the three main vessels.
Schematic
2018/7/3

47. 2018/7/3

48. Myocardial infarction
Stress induced dilatation (transient ischemic dilatation): a secondary indicator of ventricular dysfunction and indicates significant CAD.
“Reverse distributin”: relatively uncommon but vexing scintigraphic pattern. A pattern of worsening of a perfusion defect or the development of a new defect on redistribution (Tl-201) or rest (Tc-99m-MIBI) images compared with immediate poststress images.
Myocardial infarction
Coronary artery surgery and transplantation
Should be viewed with caution, the sign is neither sensitive nor specific.
dilatation [,dɪlə'teʃən]
2018/7/3

49. Quantitative Analysis
Circumferential profile histogram: created from
the patients’ regional uptake and rate of
washout and compared with a reference
standard
Polar map: created from the short-axis SPECT tomograms.
circumferential [sɚ,kʌmfə'rɛnʃəl]
2018/7/3

50. Decision Support Systems : ANN (artificial neural network)
A number of new approaches to quantitative analysis are being applied to gated SPECT studies obtained with Tc-99m agents.
Decision Support Systems :
ANN (artificial neural network)
Expert systems
CBR (case-based reasoning)
2018/7/3

51. Quantitative analysis may increase observers’ confidence but have not been shown convincingly to improve overall study accuracy.
confidence ['kɑnfədəns]
2018/7/3

52. Dipyridamole (Persatine) and adenosine pharmacological stress testing
For those patients who are unable to achieve adequate exercise stress test.
2018/7/3

53. Persatine and adenosine are potent coronary vasodilators capable of causing a threefold to fourfold increase in flow in normal coronary arteries.
Persatine is an inhibitor of adenosine deaminase and thus acts by augmenting the effect of endogenous adenosine.
adenosine英音：[ə'denəsi:n]美音：[ə'dɛnəsɪn]
2018/7/3

54. Adenosine activates the A2 receptors on the cell membrane of smooth muscle and create the vasodilation of coronary arteries.
Adenosine has the advantage of a very short plasma half-life (<10 sec).
If symptoms develop, no antidote to the adenosine is necessary. Infusion is simply terminated.
2018/7/3

55. The action of Persatine is more prolonged (plasma half-life is 20-30 min).
Side effects include chest pain, nausea and vomiting, dizziness, headache, shortness of breath, and a drop in blood pressure.
The antidote is aminophylline (125 to 250 mg). Some laboratories routinely administer 50 mg of aminophylline after tracer uptake is complete.
2018/7/3

56.  Stress testing for risk stratification after myocardial infarction
(2) Other Applications of myocardial Perfusion Imaging
 Stress testing for risk stratification after
myocardial infarction
Assessment of coronary artery bypass
surgery and angioplasty
2018/7/3

57. DIAGNOSIS OF ACUTE MYOCARDIAL INFARCTION
Rest study are used to:
diagnose acute myocardial infarction.
assess the results of therapeutic interventions such as angioplasty and thrombolysis.
2018/7/3

58. The study is positive immediately post infarction.
Advantage of myocardial perfusion imaging with Tl-201 and Tc-99m-MIBI over Tc-99m pyrophosphate imaging:
The study is positive immediately post infarction.
Areas of complete infarction are completely cold or photon deficient.
Areas of periinfarct ischemia and edema also demonstrate diminished or absent tracer uptake.
edema [i'dimə] 
2018/7/3

59. Limitations:  Inability to distinguish new from old lesions
Difficulty of distinguishing defects caused by
severe ischemia from defects associated with true infarctions.
Delayed (“rest-rest imaging”) imaging may help distinguish ischemia from infarction if the cold defect fills in.
2018/7/3

60. Stunned Myocardium
Abnormal but still viable myocardium in the immediate post-occlusion phase after infarction.
Myocardial tissue may accumulate myocardial perfusion agents in the time immediately after reperfusion (although blood flow is re-established, but it may take several weeks before oxygen consumption returns to normal level).
myocardial segment may be akinetic (stunned) and may or may not survive in the long run. If it does survive, wall motion will improve.
2018/7/3

61. Hibernating Myocardium
severe, chronically ischemic tissue that is viable but appears cold on conventional perfusion imaging.
PET imaging with 18F-FDG has been shown to detect such tissue and correctly indicate its viability.
18F-FDG: Fludeoxyglucose (18F) or fluorodeoxyglucose (18F), commonly abbreviated 18F-FDG or FDG.
Fludeoxyglucose (18F) or fluorodeoxyglucose (18F), commonly abbreviated 18F-FDG or FDG
2018/7/3

62. POSITRON EMISSION TOMOGRAPHY (PET) OF THE HEART
Affords superior spatial resolution compared with single-photon imaging.
Offers the use of a wide variety of physiologically, biochemically, and metabolically useful radiopharmaceuticals.
2018/7/3

63. Pharmaceuticals for PET of the heart See page 90-91
Rubidium-82 chloride：Obtained from strontium-82/Rb- 82 generator system.
Nitrogen-13 ammonia：Cyclotron produced, myocardial perfusion agent.
Fluorine-18 fluorodeoxyglucose (F-18 FDG): Cyclotron produced, myocardial perfusion agent.
2018/7/3

64. FDG is a marker of myocardial glucose metabolism
FDG is a marker of myocardial glucose metabolism. Its principal use in practice is in combination with a perfusion agent to assess myocardial viability.
Under normal conditions 85% of the energy needs of the heart are met through fatty acid metabolism.
Areas of ischemia switch to glucose metabolism and demonstrate increased uptake of FDG.
2018/7/3

65. Imaging is typically begun 45-60 minutes after tracer injection.
In the myocardial cell, FDG is phosphorylated to FDG-6-phosphate. No further metabolism takes place and the FDG stays in the myocardial cell over a prolonged period.
Imaging is typically begun minutes after tracer injection.
2018/7/3

66. 18F-FDG Glucose 18F-FDG-6-PO4 Glucose-6-PO4 Pyruvate（丙酮酸）
intracellular Glucose and 18F-FDG metabolism
Glucose
Hexokinase
Glucose-6-PO4
（果糖）Fructose-6-PO4
Pyruvate（丙酮酸）
（厌氧）Anaerobic
respiration
Citric Acid
Cycle（柠檬酸）
H2O CO2
18F-FDG
Hexokinase
（己糖激酶）
18F-FDG-6-PO4
Trappedin cell
Phosphorylated to
No further metabolism takes place
2018/7/3

67. The state of glucose metabolism in the body highly influences the amount of FDG uptake in the heart.
Different strategies involving glucose loading and even administration of insulin have been used to promote better FDG uptake.
Fig
2018/7/3

68. Diagnosis of CAD See page 91: Rubidium-82 and Nitrogen-13 ammonia are used most commonly for diagnosis of CAD.
Detection of Myocardial Viability
One of the vexing problems with perfusion imaging is the inability to distinguish severely ischemic myocardium (hibernating) from scarred myocardium.
20% to 40% of defects that appear to be “fixed” by perfusion imaging may actually represent severely ischemic areas.
2018/7/3

69. The combination of perfusion imaging and metabolic imaging with FDG is of great benefit in correctly diagnosing and assessing the potential therapeutic outcome in patients with severely ischemic myocardium.
2018/7/3

70. Summary of Myocardial Viability Studies
Condition Blood flow FDG Uptake
(perfusion image) (metabolism image)
Acute ischemia Decreased Normal or increased
Hibernating Decreased Normal or increased
Mismatched (discordant)
Stunned Normal Decreased
Necrosis Decreased Decreased
Matched (concordant)
2018/7/3

71. In areas of perfusion-metabolism mismatch, the functional prognosis following revascularization is very good, with an average of 80% of such segments demonstrating contractile improvement after coronary artery bypass surgery.
Areas of perfusion-metabolism matched pattern indicates a low likelihood of improved function after therapeutic intervention, with only an average of 15% of such segments demonstrating contractile improvement after coronary artery bypass surgery.
Patients may benefit from revascularization
2018/7/3

72. The detection and distinction of severely ischemic (hibernating) from scarred myocardium are crucial to clinical management.
Patients with viable but severely ischemic myocardium have better survival and outcomes from surgical revascularization.
Patients with only myocardial scar do not benefit from revascularization surgery.
Patients may benefit from revascularization
Fig
2018/7/3

73. RADIONUCLIDE VENTRICULOGRAPHY
The goal is to evaluate global and regional ventricular function.
 First-pass study: all data collection occurs during the initial transit of a tracer bolus through the central circulation.
 Equilibrium study: data are collected over many cardiac cycles, using gating technique and a tracer that remain in the blood pool.
2018/7/3

74. Radiopharmaceuticals See page 93-94
Blood pool agents:
Tc-99m-RBCs,
Tc-99m-HAS: Human Serum Albumin
First-pass agents: most of the agents may be
administered by a bolus injection technique.
Tc-99m-HAS: Human Serum Albumin
2018/7/3

75. Acquisition Techniques
First-pass studies: first-pass studies are obtained by injecting a compact bolus of a suitable radiopharmaceutical intravenously. Usually a medial vein at the antecubital fossa is employed.
Data acquisition depend on the computer system used. The goal is to obtain 16 to 30 frames per second while the bolus passes through the central circulation.
2018/7/3

76. Typically a RAO 20o to 30o angulation is chosen
Typically a RAO 20o to 30o angulation is chosen. This view best separates the right atrium and the right ventricle.
Cardiac structures are sequentially visualized as the bolus passes through the right side of the heart into the lung and then returns to the left side.
Fig. 95
2018/7/3

77. Equilibrium gated blood pool studies
In this approach, ECG leads are placed on the patient and a gating signal that triggers the R wave of the ECG is sent to the nuclear medicine computer system.
2018/7/3

78. The cardiac cycle is divided into 16 to 24 frames in typical commercially available computer system.
During the heartbeat data are acquired sequentially into the frame buffers spanning the cardiac cycle and added together from corresponding segments of the cardiac cycle over the entire time of study.
With imaging of more than 100 to 300 cardiac cycles, sufficient counts are obtained.
2018/7/3

79. Observe a cinematic closed loop display on the computer screen.
Data Analysis and Study Interpretation
Qualitative analysis
Observe a cinematic closed loop display on the computer screen.
Wall motion: wall motion is inferred from “shrinkage” of the ventricular activity from diastole to systole.
2018/7/3

80. Akinesis: complete absence of wall motion.
Hypokinesis: abnormal areas demonstrating residual but diminished contraction.
Dyskinesis: areas demonstrating paradoxical wall motion (an actual outward bulge during systole).
Tardokinesis: motion is still present but delayed compared with adjacent segments.
Fig
2018/7/3

81. Areas of ventricular scar typically akinetic or dyskinetic.
In normal subjects all wall segments should contract, with the largest excursion seen in the left ventricular free wall and apex.
Areas of ventricular scar typically akinetic or dyskinetic.
Areas of ventricular ischemia are akinetic or hypokinetic with exercise.
Tardokinesis may be the result of ischemia or conduction abnormalities such as bundle-branch block.
2018/7/3

82. Quantitative analysis Functional parameters--see page 98, Box 5-16
Ejection fraction: the most frequently calculated quantitative parameter of ventricular function, defined as the fraction of the left ventricular end-diastole volume expelled during contraction.
2018/7/3

83. many nuclear medicine departments use 0.50 as cutoff for normal.
The average ejection fraction in normal subjects is 0.55 to 0.75.
many nuclear medicine departments use 0.50 as cutoff for normal.
End-diastolic and end-systolic ventricular volume (EDV/ESV)
Ventricular filling and emptying rates (peak and average)
Fourier phase analysis See page 101
2018/7/3

84. Clinical Applications
Acute MI
The hallmark of acute MI on RNV is the development of a wall motion abnormality in the region of infarct and a decrease in the global EF.
2018/7/3

85. Exercise-induced myocardial ischemia can be detected with RNV.
CAD
Many patients with CAD have no clinical manifestations and have normal ventricular function at rest.
Exercise-induced myocardial ischemia can be detected with RNV.
The hallmarks of ischemia are the development of wall motion abnormality during exercise stress testing that was not present at rest and an EF that fails to increase or even decreases in response to exercise.
2018/7/3

86. Evaluation after coronary artery bypass graft (CABG) surgery
Since resting studies are frequently normal before CABG, the comparison is the preoperative versus postoperative response to exercise stress.
Assessment of drug therapy
The role of RNV has been studied extensively to assess the therapeutic effects of cardiac drugs and toxic effects of noncardiac drugs.
2018/7/3

87. INFARCT AVID IMAGING Cardiomyopathy-myocarditis Pulmonary disease
Congenital heart disease
INFARCT AVID IMAGING
See page
2018/7/3

88. Case 1
SPECT images at stress and rest: Transient ischemia in Ant/Lat wall
2018/7/3

89. Polar map
2018/7/3

90. 2018/7/3

91. Polar map analysis ：black region could be seen in anterior and lateral myocardium
2018/7/3

92. Coronary angiography: LAD stenosis >80%
2018/7/3

93. Stenosis in left circumflex branches
2018/7/3

94. Case 2 Infarction: Apex？ Severe myocardial ischemia: Ant/Sep/Inf wall
2018/7/3

95. 2018/7/3

96. 18F-FDG PET: Viable myocardium in Apex/Ant/Sep/Inf wall
2018/7/3

97. Case 3
Infarction/ Severe myocardial ischemia : Apex/Inf wall
2018/7/3

98. 18F-FDG PET: Viable myocardium in Inf wall; Scar in Apex
2018/7/3

99. 2018/7/3