Chonnam Med J.  2013 Aug;49(2):69-74. 10.4068/cmj.2013.49.2.69.

Indirect Radionuclide Coronary Angiography to Evaluate Gradients of Myocardial Blood Flow and Flow Reserve Through Coronary Stenosis Using N-13 Ammonia PET/CT

• Kim HS
• Cho SG
• Kim JH
• Bom HS

• KMID: 1428265
• DOI: http://doi.org/10.4068/cmj.2013.49.2.69

Abstract

Although quantitative evaluation of myocardial blood flow (MBF) and myocardial flow reserve (MFR) has been perceived as an attractive advantage of positron emission tomography (PET) over other cardiac imaging technologies, application of the information to specific coronary lesions is a difficult task for nuclear cardiologists. We hypothesized that changes in MBF and MFR over a coronary lesion could be identified by use of a hybrid technology of CT coronary angiography (CTCA) and N-13 ammonia PET. To evaluate this hypothesis, we measured the gradient of MBF and MFR through coronary stenosis in seven patients (M:F=3:4, median age 56 years) with coronary artery disease who underwent N-13 ammonia PET, CTCA, and interventional coronary angiography. Two patients had proximal left anterior descending (LAD) coronary artery disease and five patients had mid to distal LAD disease. Mean global stress and rest MBF were 2.62+/-0.58 and 1.03+/-0.19 ml/min/g, respectively. Mean global MFR was 2.6+/-0.73. Regional stress and rest MBF in the LAD territory were 2.36+/-0.75 and 0.96+/-0.21 ml/min/g, respectively. Regional MFR in the LAD territory was 2.55+/-0.83 ml/min/g. Stress MBF changed dramatically according to the location of coronary stenosis. It dropped acutely in proximal lesions, whereas it diminished gradually in mid to distal lesions. In conclusion, by use of a hybrid technology of CTCA and PET, it was feasible to make a direct correlation of coronary lesions with the gradient of MFR and CFR through coronary stenosis, which indicated the severity of the coronary lesion. We named this technique indirect radionuclide coronary angiography.

Keyword

Radionuclide imaging; Coronary angiography; Mycocardium

MeSH Terms

Ammonia
Chimera
Coronary Angiography
Coronary Artery Disease
Coronary Stenosis
Evaluation Studies as Topic
Humans
Imidazoles
Nitro Compounds
Positron-Emission Tomography
Ammonia
Imidazoles
Nitro Compounds

Figure

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  FIG. 1 Gradient of myocardial blood flow during adenosine infusion in patients with proximal (A) or mid to distal (B) left anterior descending artery (LAD) disease. Perfusion drop was significant only in the basal portion of the myocardium in the proximal LAD disease group, whereas it was gradually diminished in the apical portion in the mid to distal LAD disease group.

• 

  FIG. 2 (A) Stress perfusion graph of a 59-year-old male patient with unstable angina showing an acute perfusion drop in the base of the left ventricle, the proximal LAD territory, whereas the rest perfusion graph shows a steady state of myocardial blood flow. (B) Myocardial flow reserve (MFR) diminished from the left ventricular base to the apex. The reference cutoff value of MFR is 2.0 at the authors' institute. (C) Interventional coronary angiography showing a discrete stenotic lesion (arrow) in the proximal LAD. (D) Hybrid image of CT angiography and stress perfusion image of N-13 ammonia PET showing cutting of proximal left anterior descending artery (LAD), which correlated with the large perfusion defect in the LAD territory.

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  FIG. 3 (A) Stress perfusion graph in a 72-year-old male patient with typical angina showing a gradual decrease of perfusion through the left ventricle from the base to the apex, whereas the rest perfusion graph shows a steady state of myocardial blood flow. (B) Myocardial flow reserve (MFR) was lower than 2.0 from the mid portion to the apex of the left ventricle, whereas the basal portion maintained normal MFR. (C) Interventional coronary angiography showing a long stenotic lesion in the mid portion of the left anterior descending artery (mLAD, arrow). (D) Hybrid image of CT angiography and stress perfusion image of N-13 ammonia PET showing a narrowing in mLAD that was correlated with a perfusion defect in the apicoseptal area.

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