Reporting on Myocardial Perfusion SPECT

Reporting on Myocardial Perfusion SPECT:

Reporting on Myocardial Perfusion SPECT Dr. Muhammad Ayub, FCPS Diplomate Certification Board of Nuclear Cardiology

Components of MPI Report:

Components of MPI Report Clinical Information Indication Procedure Myocardial Perfusion Scan Results Impression / Conclusions

Clinical Information:

Clinical Information • Demographics (age, gender, race) • Body habitus (height, weight) • Symptoms • Medications • Cardiac risk factors • Prior cardiac events • Prior diagnostic tests • Therapeutic cardiac procedures

Indication: (select one) :

Indication: (select one) Diagnosis of coronary disease Evaluation of extent and severity of coronary artery disease Evaluation of myocardial viability Risk stratification-post-MI/preoperative/general Assessment of acute chest pain

Clinical History: Sample:

Clinical History: Sample ____ year old man/woman with (no) known coronary artery disease Cardiac risk factors include: ____ Previous cardiac procedures include: ____ Current symptomatology includes: ____

Procedure :

Procedure • Type and protocol of stress procedure • Pharmacologic agents used, with total dose • Adequacy of stress • Symptoms during stress • Hemodynamic response (heart rate, blood pressure) • ECG changes • Radiopharmaceuticals utilized (with dose) • Imaging protocol • Functional data • Use of attenuation/scatter correction

Procedure: sample:

Procedure: sample Pharmacologic stress testing was performed with adenosine/dipyridamole/ dobutamine with a dose ____. Additionally, low level exercise was performed along with the vasodilator infusion (specify: ____). The heart rate was ____ at baseline and rose to ____ beats per minute during the adenosine/ dipyridamole/ dobutamine infusion. This corresponds with ____% of the maximum predicted heart rate. Blood pressure response was normal/hypertensive/hypotensive during the stress procedure. The patient developed significant symptoms which included ____. The resting electrocardiogram demonstrated _____ and did/did not show ST-segment changes consistent with myocardial ischemia. Myocardial perfusion imaging was performed at rest (___ minutes following the injection of ____ mCi of ____). At peak pharmacologic effect, the patient was injected with ____ mCi of ____. Gating post-stress tomographic imaging was performed ___ minutes after stress (and rest).

Results :

Results • Study quality • Size of left and right ventricle at stress and rest • Defect description (location, size, severity, reversibility) • Extensiveness (TCD/TID, lung activity, RV activity) • Left ventricular function (global, regional) • Extra cardiac activity

BNCS Audit of Quality of MPI:

BNCS Audit of Quality of MPI

Raw Data Review:

Raw Data Review Patient Motion Tissue Attenuation Increased Lung Uptake Extra cardiac Activity

Review of Raw Data:

Review of Raw Data

Cine Review:

Cine Review Patient Motion Motion Corrected

Technical Artifacts:

Technical Artifacts

Attenuation:

Attenuation

Lung Uptake:

Lung Uptake

SPECT Processing Trans axial Slices:

SPECT Processing Trans axial Slices

:

Short Axis: Apex to Base VLA: Septum to lateral wall HLA: Anterior to inferior Normalized to maximal myocardial counts. DISPLAY OF SLICES

Image Display:

Image Display

Nine Segment model:

Nine Segment model

:

Anterior Wall: Apical / Basal Septum: Apical / Basal Apex Inferior Wall: Apical / Basal Lateral Wall: Apical / Basal SEGMENTS

Coronary Territories:

Coronary Territories

Slide 22:

Hachamovitch R, et al. Circulation. 1998;97:535-543. 20 Segment Model for MPI 19 20 Apical Mid Basal Mid 1 6 5 4 3 2 7 8 12 11 9 10 13 14 15 16 18 17

:

Ventricular Configuration Characterisation of Defects Reverse Redistribution Right ventricular abnormalities STEPWISE REPORTING

:

Transient LV dilatation LV Aneurysm Persistent LV dilatation in cases of Chronic CAD, cardiomyopathy LV hypertrophy (Septal ?) VENTRICULAR CONFIGURATION

:

Loca tion of defect Defect Extent: Large, moderate, Small Defect Severity: Marked, moderate, mild Defect Reversibility: Complete, Partial, Partially fixed, Fixed CHARACTERIZATION OF DEFECTS

Location of Defect:

Location of Defect

LAD:

LAD

Lt. Main:

Lt. Main

Multi Vessel Disease:

Multi Vessel Disease

:

LARGE: > 1/3 LAD territory, or > 1/2 RCA / LCx territory MODERATE: 1/6 -1/3 LAD territory or 1/4 to 1/2 RCA/LCx LAD territory SMALL: Anything less than above. ..EXTENT

:

MARKED: < Approx.. 45% of maximal counts MODERATE: 45% - 65% of maximal counts SMALL: 65% - 90% of maximal counts ...SEVERITY

:

COMPLETE > Approx.. 85% reversibility PARTIAL 30%-85% reversible PARTIALLY FIXED 10% -30% reversible FIXED < 10% reversible ….REVERSIBILITY

Reversible Ischaemia:

Reversible Ischaemia

:

Subendocardial scarring distal to a patent proximal coronary artery Post PTCA, CABG “Pseudo-reverse redistribution” (one day rest / stress Tc-99m MIBI) REVERSE REDISTRIBUTION

LCx:

LCx

Quantitative Perfusion SPECT:

Quantitative Perfusion SPECT

Slide 37:

Visual Quantitative

Slide 38:

Visual PTQ

Slide 39:

Segmental Scoring 0 = Normal 1 = Equivocal 2 = Moderate 3 = Severe 4 = Absent Uptake SSS = S Segmental Stress Score SRS = S Segmental Rest Score SDS = SSS - SRS Semiquantitative-Visual Analysis 19 20 Apical Mid Basal Mid 1 6 5 4 3 2 7 8 12 11 9 10 13 14 15 16 18 17 Summed stress scores <4 are classified as normal, with scores from 4 to 8 considered mildly abnormal. Scores from 9-13 are moderately abnormal and scores >13 are severely abnormal.

:

LBBB Hypertension and LVH Hot Spots Myocardial bridges Anomalous origin of Lm from PA Chronic Obstructive Airway Disease Positive SCAN IN ABSENCE OF CAD

Impression:

Impression Normal / Abnormal/ Equivocal study Interpretation of Perfusion defects Infarction, Ischaemia, Artifacts Prognostic Information

Thank You for Listening:

Thank You for Listening