Superimposed single-photon emission computed tomography and X-ray computed tomography of the heart: Methodical aspects

Global radiology and nuclear medicine have recently shown a clear trend towards hybrid (combined, superimposed) studies. Unfortunately, the Russian literature virtually lacks both methodological and research works on this topic. The basis for this paper was the guidelines of the North American Society of Nuclear Medicine and Molecular Imaging, the North American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography and the principles as jointly set out by the European Society of Nuclear Medicine, the European Society of Radiology, and the European Association of Nuclear Medicine.

The purpose of the paper is to familiarize readers with some methodical aspects of performing superimposed single-photon emission computed tomography (SPECT) and X-ray computed tomography (CT) of the heart. This publication discusses the main indications for and contraindications to hybrid cardiological studies and gives other data that are useful to select patients for examination. A patient's preparation and prevention measures are described. There is information on major radiotracers and equipment for superimposed studies. There are imaging parameters and information on the correction of gamma-ray quantum absorption according to CT data. The paper concerns the interpretation of the results of identifying coronary artery calcification and those of CT coronarography and myocardial perfusion scintigraphy. It presents the methodical aspects of superimposition of radionuclide and CT images, the possible sources of errors during superimposed SPECT/CT, and recommendations for making a diagnostic conclusion. The issues of radiation load and radiation safety are discussed.

1. Короткевич А.А., Коков А.Н. Гибридные технологии лучевой диагностики ишемической болезни сердца: современные возможности и перспективы. Комплексные проблемы сердечно-сосудистых заболеваний. 2015; 1: 5–9. [Korotkevich A.A., Kokov A.N. Hybrid technologies of radiation diagnostics of ischemic heart disease: current possibilities and perspectives. Kompleksnye Problemy Serdechnososudistykh Zabolevaniy (Complex Problems of Cardiovascular Diseases, Russian journal). 2015; 1: 5–9 (in Russ.).]

2. Hesse B., Tägil K., Cuocolo A., Anagnostopoulos C., Bardiés M., Bax J. et al. EANM/ESC Group. EANM/ESC procedural guidelines for myocardial perfusion imaging in nuclear cardiology. Eur. J. Nucl. Med. Mol. Imaging. 2005; 32 (7): 855–97.

3. Dorbala S., Di Carli M.F., Delbeke D., Abbara S., DePuey E.G., Dilsizian V. et al. SNMMI/ASNC/SCCT guideline for cardiac SPECT/CT and PET/CT 1.0. J. Nucl. Med. 2013; 54 (8): 1485–507.

4. Flotats A., Knuuti J., Gutberlet M., Marcassa C., Bengel F.M., Kaufmann P.A. et al. Hybrid cardiac imaging: SPECT/CT and PET/CT – a joint position statement by the European Association of Nuclear Medicine (EANM), the European Society of Cardiac Radiology (ESCR) and the European Council of Nuclear Cardiology (ECNC). Eur. J. Nucl. Med. Mol. Imaging. 2011; 38: 201–12.

5. Holly T.A., Abbott B.G., Al-Mallah M., Calnon D.A., Cohen M.C., Di Filippo F.P. et al. Single photonemission computed tomography. American Society of Nuclear Cardiology (ASNC) Imaging Guidelines For Nuclear Cardiology Procedures. J. Nucl. Cardiol. 2010; 17 (5): 941–73.

6. Rodgers G.P., Ayanian J.Z., Balady G., Beasley J.W., Brown K.A., Gervino E.V. et al. American College of Cardiology/American Heart Association clinical competence statement on stress testing: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. Circulation. 2000; 102: 1726–38.

7. Mark D.B., Berman D.S., Budoff M.J., Carr J.J., Gerber T.C., Hecht H.S. et al. ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation. 2010; 121: 2509–43.

8. Abbara S., Arbab-Zadeh A., Callister T.Q., Desai M.Y., Mamuya W., Thomson L. et al. SCCT guidelines for performance of coronary computed tomographic angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J. Cardiovasc. Comput. Tomogr. 2009; 3: 190–204.

9. Kloner R.A. Pharmacology and drug interaction effects of the phosphodiesterase 5 inhibitors: focus on alpha-blocker interactions. Am. J. Cardiol. 2005; 96 (12B): 42M–46M.

10. Chang S.M., Nabi F., Xu J., Raza U., Mahmarian J.J. Normal stress-only versus standard stress/rest myocardial perfusion imaging: similar patient mortality with reduced radiation exposure. J. Am. Coll. Cardiol. 2010; 55: 221–30.

11. Duvall W.L., Wijetunga M.N., Klein T.M., Godbold J., Croft L.B., Henzlova M.J. The prognosis of a normal stress-only Tc-99m myocardial perfusion imaging study. J. Nucl. Cardiol. 2010; 17: 370–7.

12. Dilsizian V., Bacharach S.L., Beanlands R.S., Bergmann S.R., Delbeke D., Gropler R.J. et al. PET myocardial perfusion and metabolism clinical imaging. J. Nucl. Cardiol. 2009; 16 (4): 651.

13. Gaemperli O., Schepis T., Valenta I., Husmann L., Scheffel H., Duerst V. et al. Cardiac image fusion from stand-alone SPECT and CT: clinical experience. J. Nucl. Med. 2007; 48: 696–703.

14. Dey D., Slomka P.J., Hahn L.J., Kloiber R. Automatic three-dimensional multimodality registration using radionuclide transmission CT attenuation maps: a phantom study. J. Nucl. Med. 1999; 40: 448–55.

15. Gaemperli O., Schepis T., Kalff V., Namdar M., Valenta I., Stefani L. et al. Validation of a new cardiac image fusion software for threedimensional integration of myocardial perfusion SPECT and standalone 64-slice CT angiography. Eur. J. Nucl. Med. Mol. Imaging. 2007; 34: 1097–106.

16. Javadi M.S., Lautamaki R., Merrill J., Voicu C., Epley W., McBride G. et al. Definition of vascular territories on myocardial perfusion images by integration with true coronary anatomy: a hybrid PET/CT analysis. J. Nucl. Med. 2010; 51: 198–203.

17. Reyes E., Stirrup J., Roughton M., D'Souza S., Underwood S.R., Anagnostopoulos C. Attenuation of adenosine-induced myocardial perfusion heterogeneity by atenolol and other cardioselective betaadrenoceptor blockers: a crossover myocardial perfusion imaging study. J. Nucl. Med. 2010; 51: 1036–43.

18. Raff G.L., Abidov A., Achenbach S., Berman D.S., Boxt L.M., Budoff M.J. et al. SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography. J. Cardiovasc. Comput. Tomogr. 2009; 3: 122–36.

19. Douglas P.S., Hendel R.C., Cummings J.E., Dent J.M., Hodgson J.M., Hoffmann U. et al. ACCF/ACR/1. Короткевич А.А., Коков А.Н. Гибридные технологии лучевой диагностики ишемической болезни сердца: современные возможности и перспективы. Комплексные проблемы сердечно-сосудистых заболеваний. 2015; 1: 5–9. [Korotkevich A.A., Kokov A.N. Hybrid technologies of radiation diagnostics of ischemic heart disease: current possibilities and perspectives. Kompleksnye Problemy Serdechnososudistykh Zabolevaniy (Complex Problems of Cardiovascular Diseases, Russian journal). 2015; 1: 5–9 (in Russ.).]

20. Hesse B., Tägil K., Cuocolo A., Anagnostopoulos C., Bardiés M., Bax J. et al. EANM/ESC Group. EANM/ESC procedural guidelines for myocardial perfusion imaging in nuclear cardiology. Eur. J. Nucl. Med. Mol. Imaging. 2005; 32 (7): 855–97.

21. Dorbala S., Di Carli M.F., Delbeke D., Abbara S., DePuey E.G., Dilsizian V. et al. SNMMI/ASNC/SCCT guideline for cardiac SPECT/CT and PET/CT 1.0. J. Nucl. Med. 2013; 54 (8): 1485–507.

22. Flotats A., Knuuti J., Gutberlet M., Marcassa C., Bengel F.M., Kaufmann P.A. et al. Hybrid cardiac imaging: SPECT/CT and PET/CT – a joint position statement by the European Association of Nuclear Medicine (EANM), the European Society of Cardiac Radiology (ESCR) and the European Council of Nuclear Cardiology (ECNC). Eur. J. Nucl. Med. Mol. Imaging. 2011; 38: 201–12.

23. Holly T.A., Abbott B.G., Al-Mallah M., Calnon D.A., Cohen M.C., Di Filippo F.P. et al. Single photonemission computed tomography. American Society of Nuclear Cardiology (ASNC) Imaging Guidelines For Nuclear Cardiology Procedures. J. Nucl. Cardiol. 2010; 17 (5): 941–73.

24. Rodgers G.P., Ayanian J.Z., Balady G., Beasley J.W., Brown K.A., Gervino E.V. et al. American College of Cardiology/American Heart Association clinical competence statement on stress testing: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. Circulation. 2000; 102: 1726–38.

25. Mark D.B., Berman D.S., Budoff M.J., Carr J.J., Gerber T.C., Hecht H.S. et al. ACCF/ACR/ AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation. 2010; 121: 2509–43.

26. Abbara S., Arbab-Zadeh A., Callister T.Q., Desai M.Y., Mamuya W., Thomson L. et al. SCCT guidelines for performance of coronary computed tomographic angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J. Cardiovasc. Comput. Tomogr. 2009; 3: 190–204.

27. Kloner R.A. Pharmacology and drug interaction effects of the phosphodiesterase 5 inhibitors: focus on alpha-blocker interactions. Am. J. Cardiol. 2005; 96 (12B): 42M–46M.

28. Chang S.M., Nabi F., Xu J., Raza U., Mahmarian J.J. Normal stress-only versus standard stress/rest myocardial perfusion imaging: similar patient mortality with reduced radiation exposure. J. Am. Coll. Cardiol. 2010; 55: 221–30.

29. Duvall W.L., Wijetunga M.N., Klein T.M., Godbold J., Croft L.B., Henzlova M.J. The prognosis of a normal stress-only Tc-99m myocardial perfusion imaging study. J. Nucl. Cardiol. 2010; 17: 370–7.

30. Dilsizian V., Bacharach S.L., Beanlands R.S., Bergmann S.R., Delbeke D., Gropler R.J. et al. PET myocardial perfusion and metabolism clinical imaging. J. Nucl. Cardiol. 2009; 16 (4): 651.

31. Gaemperli O., Schepis T., Valenta I., Husmann L., Scheffel H., Duerst V. et al. Cardiac image fusion from stand-alone SPECT and CT: clinical experience. J. Nucl. Med. 2007; 48: 696–703.

32. Dey D., Slomka P.J., Hahn L.J., Kloiber R. Automatic three-dimensional multimodality registration using radionuclide transmission CT attenuation maps: a phantom study. J. Nucl. Med. 1999; 40: 448–55.

33. Gaemperli O., Schepis T., Kalff V., Namdar M., Valenta I., Stefani L. et al. Validation of a new cardiac image fusion software for threedimensional integration of myocardial perfusion SPECT and standalone 64-slice CT angiography. Eur. J. Nucl. Med. Mol. Imaging. 2007; 34: 1097–106.

34. Javadi M.S., Lautamaki R., Merrill J., Voicu C., Epley W., McBride G. et al. Definition of vascular territories on myocardial perfusion images by integration with true coronary anatomy: a hybrid PET/CT analysis.J. Nucl. Med. 2010; 51: 198–203.

35. Reyes E., Stirrup J., Roughton M., D'Souza S., Underwood S.R., Anagnostopoulos C. Attenuation of adenosine-induced myocardial perfusion heterogeneity by atenolol and other cardioselective betaadrenoceptor blockers: a crossover myocardial perfusion imaging study. J. Nucl. Med. 2010; 51: 1036–43.

36. Raff G.L., Abidov A., Achenbach S., Berman D.S., Boxt L.M., Budoff M.J. et al. SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography. J. Cardiovasc. Comput. Tomogr. 2009; 3: 122–36.

37. Douglas P.S., Hendel R.C., Cummings J.E., Dent J.M., Hodgson J.M., Hoffmann U. et al. ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 health policy statement on structured reporting in cardiovascular imaging. Endorsed by the Society of Nuclear Medicine and Molecular Imaging. Circulation. 2009; 119 (1): 187–200.

38. Hendel R.C., Budoff M.J., Cardella J.F., Chambers C.E., Dent J.M., Fitzgerald D.M. et al. ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SIR 2008 key data elements and definitions for cardiac imaging: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Cardiac Imaging). J. Am. Coll. Cardiol. 2009; 53: 91–124.

39. Weigold W.G., Abbara S., Achenbach S., Arbab-Zadeh A., Berman D., Carr J.J. et al. Standardized medical terminology for cardiac computed tomography: a report of the Society of Cardiovascular Computed Tomography. J. Cardiovasc. Comput. Tomogr. 2011; 5: 136–44.

40. Husmann L., Tatsugami F., Aepli U., Herzog B.A., Valenta I., VeitHaibach P. et al. Prevalence of noncardiac findings on low dose 64-slice computed tomography used for attenuation correction in myocardial perfusion imaging with SPECT. Int. J. Cardiovasc. Imaging. 2009; 25: 859–65.

41. International Commission on Radiological Protection. Radiation dose to patients from radiopharmaceuticals: Addendum 2 to ICRP publication 53. Ann. ICRP. 1998; 28 (3): 1–126.

42. Einstein A.J., Moser K.W., Thompson R.C., Cerqueira M.D., Henzlova M.J. Radiation dose to patients from cardiac diagnostic imaging. Circulation. 2007; 116 (11): 1290–305.

43. Sharir T., Slomka P.J., Hayes S.W., DiCarli M.F., Ziffer J.A., Martin W.H. et al. Multicenter trial of high-speed versus conventional single-photon emission computed tomography imaging: quantitative results of myocardial perfusion and left ventricular function. J. Am. Coll. Cardiol. 2010; 55: 1965–74.

44. DePuey E.G., Bommireddipalli S., Clark J., Thompson L., Srour Y. Wide beam reconstruction “quarter-time” gated myocardial perfusion SPECT functional imaging: a comparison to “full-time” ordered subset expectation maximum. J. Nucl. Cardiol. 2009; 16: 736–52.

45. Labounty T.M., Leipsic J., Min J.K., Heilbron B., Mancini G.B., Lin F.Y. et al. Effect of padding duration on radiation dose and image interpretation in prospectively ECG-triggered coronary CT angiography. Am. J. Roentgenol. 2010; 194: 933–7.

46. Hausleiter J., Meyer T., Hermann F., Hadamitzky M., Krebs M., Gerber T.C. et al. Estimated radiation dose associated with cardiac CT angiography. JAMA. 2009; 301 (5): 500–7.

47. Achenbach S., Marwan M., Ropers D., Schepis T., Pflederer T., Anders K. et al. Coronary computed tomography angiography with a consistent dose below 1 mSv using prospectively electrocardiogram-triggered high-pitch spiral acquisition. Eur. Heart J. 2010; 31 (3): 340–6.