The Potential Value of Hybrid Positron Emission Tomography/Dual-Source Computed Tomography Imaging in Coronary Bypass Surgery

Authors

  • Andre Plass
  • Maximilian Y. Emmert
  • Oliver Gaemperli
  • Hatem Alkadhi
  • Philipp Kaufmann
  • Volkmar Falk
  • Jürg Grünenfelder

DOI:

https://doi.org/10.1532/HSF98.20111045

Abstract

Background: We evaluated how comprehensive assessment of coronary artery lesions and their hemodynamic relevance by means of hybrid positron emission tomography (PET) and computed tomography (CT) imaging would affect decision-making in coronary artery bypass surgery (CABG), compared with using invasive coronary angiography (ICA) alone.

Methods: After undergoing ICA, 27 patients (21 men and 6 women; mean SD age, 66 ± 10 years) planned for cardiac surgery were scheduled for myocardial perfusion stress/rest evaluation with [13N]ammonia PET and CT coronary angiography. Only ICA was available to the surgeon. Postoperatively, the performed CABG was compared with the hypothetical strategy based on hybrid PET/CT findings (regional coronary flow reserve [CFR], myocardial perfusion defects). Procedures included CABG (n = 18) alone, CABG combined with valve replacement (n = 6), and CABG combined with isolated valve replacement (n = 3). A total of 56 bypass grafts (28 venous and 28 arterial) and 66 distal anastomoses were placed.

Results: CT evaluation showed 93% concordance (66/71) with ICA regarding significant stenoses, with sensitivity, specificity, positive predictive value, and negative predictive value of 93.1%, 98.7%, 94.4%, and 98.4%, respectively. In the PET scan, 16 patients had 1 ischemic region, and 12 patients had 1 scar region, including 5 patients who presented with mixed conditions (scar and ischemia). One patient had a completely normal myocardium. Compared with the performed surgery, PET/CT fusion evaluation showed that of the performed anastomoses, 48% had documented ischemia (with a CFR <2 in 86%), 38% were nonischemic (although a CFR value <2 was found in 78%), and 14% had scar tissue (fixed perfusion defect).

Conclusions: Although <50% of bypasses were placed to areas with myocardial ischemia, the CFR was low in the majority of nonischemic regions, a finding that may have important prognostic relevance. PET/CT fusion imaging could potentially influence planning for CABG and provide incremental prognostic information.

References

Alkadhi H, Stolzmann P, Desbiolles L 2010. Low-dose, 128-slice, dual-source CT coronary angiography: accuracy and radiation dose of the high-pitch and the step-and-shoot mode. Heart 96:933-8.nAusten WG, Edwards JE, Frye RL 1975. A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation 51:5-40.nBucher HC, Hengstler P, Schindler C, Guyatt GH. 2000. Percutaneous transluminal coronary angioplasty versus medical treatment for nonacute coronary heart disease: meta-analysis of randomised controlled trials. BMJ 321:73-7.nBudoff MJ, Dowe D, Jollis JG 2008. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 52:1724-32.nCerqueira MD, Verani MS, Schwaiger M, Heo J, Iskandrian AS. 1994. Safety profile of adenosine stress perfusion imaging: results from the Adenoscan Multicenter Trial Registry. J Am Coll Cardiol 23:384-9.nCerqueira MD, Weissman NJ, Dilsizian V 2002. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: a statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 105:539-42.nFox K, Garcia MA, Ardissino D 2006. Guidelines on the management of stable angina pectoris: executive summary: the Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J 27:1341-81.nGaemperli O, Husmann L, Schepis T 2009. Coronary CT angiography and myocardial perfusion imaging to detect flow-limiting stenoses: a potential gatekeeper for coronary revascularization? Eur Heart J 30:2921-9.nGaemperli O, Schepis T, Kalff V 2007. Validation of a new cardiac image fusion software for three-dimensional integration of myocardial perfusion SPECT and stand-alone 64-slice CT angiography. Eur J Nucl Med Mol Imaging 34:1097-106.nGaemperli O, Schepis T, Valenta I 2007. Cardiac image fusion from stand-alone SPECT and CT: clinical experience. J Nucl Med 48:696-703.nGaemperli O, Schepis T, Valenta I 2008. Functionally relevant coronary artery disease: comparison of 64-section CT angiography with myocardial perfusion SPECT. Radiology 248:414-23.nGibbons RJ, Abrams J, Chatterjee K 2003. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients with Chronic Stable Angina). J Am Coll Cardiol 41:159-68.nGo RT, Marwick TH, MacIntyre WJ 1990. A prospective comparison of rubidium-82 PET and thallium-201 SPECT myocardial perfusion imaging utilizing a single dipyridamole stress in the diagnosis of coronary artery disease. J Nucl Med 31:1899-905.nHecht HS. 2009. Is coronary computed tomographic angiography the "gold standard" for coronary artery disease? J Cardiovasc Comput Tomogr 3:334-9.nHerzog BA, Husmann L, Valenta I 2009. Long-term prognostic value of 13N-ammonia myocardial perfusion positron emission tomography added value of coronary flow reserve. J Am Coll Cardiol 54:150-6.nKoepfli P, Hany TF, Wyss CA 2004. CT attenuation correction for myocardial perfusion quantification using a PET/CT hybrid scanner. J Nucl Med 45:537-42.nLeschka S, Stolzmann P, Desbiolles L 2009. Diagnostic accuracy of high-pitch dual-source CT for the assessment of coronary stenoses: first experience. Eur Radiol 19:2896-903.nMachac J, Bacharach SL, Bateman TM 2006. Positron emission tomography myocardial perfusion and glucose metabolism imaging. J Nucl Cardiol 13:e121-51.nMagee MJ, Alexander JH, Hafley G 2008. Coronary artery bypass graft failure after on-pump and off-pump coronary artery bypass: findings from PREVENT IV. Ann Thorac Surg 85:494-9; discussion 499-500.nMeijboom WB, Meijs MF, Schuijf JD 2008. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol 52:2135-44.nMiller JM, Rochitte CE, Dewey M 2008. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 359:2324-36.nNamdar M, Hany TF, Koepfli P 2005. Integrated PET/CT for the assessment of coronary artery disease: a feasibility study. J Nucl Med 46:930-5.nNarula J, Garg P, Achenbach S 2008. Arithmetic of vulnerable plaques for noninvasive imaging. Nat Clin Pract Cardiovasc Med 5(suppl 2):S2-10.nOng AT, Serruys PW. 2006. Complete revascularization: coronary artery bypass graft surgery versus percutaneous coronary intervention. Circulation 114:249-55.nPlass A, Azemaj N, Scheffel H 2009. Accuracy of dual-source computed tomography coronary angiography: evaluation with a standardised protocol for cardiac surgeons. Eur J Cardiothorac Surg 36:1011-7.nSchindler TH, Magosaki N, Jeserich M 1999. Fusion imaging: combined visualization of 3D reconstructed coronary artery tree and 3D myocardial scintigraphic image in coronary artery disease. Int J Card Imaging 15:357-68; discussion 369-70.nSchroeder S, Achenbach S, Bengel F 2008. Cardiac computed tomography: indications, applications, limitations, and training requirements: report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT of the European Society of Cardiology and the European Council of Nuclear Cardiology. Eur Heart J 29:531-56.nStein PD, Yaekoub AY, Matta F, Sostman HD. 2008. 64-Slice CT for diagnosis of coronary artery disease: a systematic review. Am J Med 121:715-25.nStewart RE, Schwaiger M, Molina E 1991. Comparison of rubidium-82 positron emission tomography and thallium-201 SPECT imaging for detection of coronary artery disease. Am J Cardiol 67:1303-10.nTahara N, Imaizumi T, Virmani R, Narula J. 2009. Clinical feasibility of molecular imaging of plaque inflammation in atherosclerosis. J Nucl Med 50:331-4.nTamaki N, Yonekura Y, Senda M 1988. Value and limitation of stress thallium-201 single photon emission computed tomography: comparison with nitrogen-13 ammonia positron tomography. J Nucl Med 29:1181-8.nTonino PA, De Bruyne B, Pijls NH 2009. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 360:213-24.nWijns W, Kolh P, Danchin N 2010. Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 31:2501-55.nWyss CA, Koepfli P, Fretz G 2003. Influence of altitude exposure on coronary flow reserve. Circulation 108:1202-7.n

Published

2011-10-13

How to Cite

Plass, A., Emmert, M. Y., Gaemperli, O., Alkadhi, H., Kaufmann, P., Falk, V., & Grünenfelder, J. (2011). The Potential Value of Hybrid Positron Emission Tomography/Dual-Source Computed Tomography Imaging in Coronary Bypass Surgery. The Heart Surgery Forum, 14(5), E283-E290. https://doi.org/10.1532/HSF98.20111045

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