Current Role of Myocardial Blood Flow Quantification with PET/CT in the Management of Coronary Artery Disease

Giubbini, Raffaele; Milan, Elisa

doi:10.36660/ijcs.20240115

Raffaele Giubbini

Conception and design of the research

acquisition of data

analysis and interpretation of the data and writing of the manuscript

critical revision of the manuscript for intellectual content

University of Brescia, Brescia, BS – Italy

https://orcid.org/0000-0003-4275-2799

Elisa Milan

critical revision of the manuscript for intellectual content

Ospedale Ca' Foncello, Treviso, Veneto – Italy

https://orcid.org/0000-0002-6402-0313

Mailing Address: Raffaele Giubbini University of Brescia, DSC. Viale Europa Brescia, 25128 – Italy E-mail: raffaele.giubbini@unibs.it

Potential Conflict of Interest
No potential conflict of interest relevant to this article was reported.

Editor responsible for the review
Claudio Tinoco Mesquita

Figures (6)
Tables (1)

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Central Illustration
: Current Role of Myocardial Blood Flow Quantification with PET/CT in the Management of Coronary Artery Disease

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Figure 1
– Top: ROI selection of the left ventricular output track (input function) and myocardial regions according to the distribution of the coronary territories (LAD, RCA, LCX). Bottom: Time-activity curves for input function, whole left ventricle, and standard territories assigned to coronary territories: LAD, LCX, and RCA regions. See text for further information. LAD: left anterior descending artery; LCX: left circumflex artery; RCA: right coronary artery; ROI: region of interest.

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Figure 2
– Top: MBF and CFR measured at rest and after hyperemia. Bottom: Segmental assessment of perfusion at rest and after exercise and MBF and MFR values expressed as a color scale and as absolute values. LAD: left anterior descending artery; LCX: left circumflex artery; RCA: right coronary artery; TOT: total.

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Figure 3
– Scatter plot of CFR and maximal MBF by cardiovascular death. Concordant and discordant impairment of CFR and maximal MBF identify unique prognostic phenotypes of patients. Reprinted with permission from Gupta et al. ¹⁰10.Gupta A, Taqueti VR, van de Hoef TP, Bajaj NS, Bravo PE, Murthy VL, et al. Integrated Noninvasive Physiological Assessment of Coronary Circulatory Function and Impact on Cardiovascular Mortality in Patients with Stable Coronary Artery Disease. Circulation. 2017;136(24):2325-36. doi: 10.1161/CIRCULATIONAHA.117.029992.
https://doi.org/10.1161/CIRCULATIONAHA.1... CFR: coronary flow reserve; CV: cardiovascular.

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Figure 4
– Diagram of CFC; see text for description. Reprinted with permission from Johnson and Gould. ¹¹11.Johnson NP, Gould KL. Integrating Noninvasive Absolute Flow, Coronary Flow Reserve, and Ischemic Thresholds into a Comprehensive Map of Physiological Severity. JACC Cardiovasc Imaging. 2012;5(4):430-40. doi: 10.1016/j.jcmg.2011.12.014.
https://doi.org/10.1016/j.jcmg.2011.12.0... CFR: coronary flow reserve.

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Figure 5
– Same clinical case as and ²2.Uren NG, Crake T. Resistive Vessel Function in Coronary Artery Disease. Heart. 1996;76(4):299-304. doi: 10.1136/hrt.76.4.299.
https://doi.org/10.1136/hrt.76.4.299... , but studied with SPECT technology (cadmium-zinc-telluride SPECT) and SPECT tracer for myocardial perfusion (99mTc-tetrofosmin). The absolute values of coronary flow and reserve, but especially their clinical significance, are absolutely equivalent to those obtained with 13NH3. In particular, the low flow values obtained at rest.

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Table 1
– PET tracers used for myocardial perfusion imaging

Tracer	Half-life	Production	First-pass myocardial extraction	Kinetics	Limitations
¹⁵15.Ben Bouallègue F, Roubille F, Lattuca B, Cung TT, Macia JC, Gervasoni R, et al. SPECT Myocardial Perfusion Reserve in Patients with Multivessel Coronary Disease: Correlation with Angiographic Findings and Invasive Fractional Flow Reserve Measurements. J Nucl Med. 2015;56(11):1712-7. doi: 10.2967/jnumed.114.143164. https://doi.org/10.2967/jnumed.114.14316... O-water	2.1 min	On-site cyclotron	100%	Diffusion	Requires cyclotron, complicated administration, sub-optimal imaging
¹³13.Gould KL, Kitkungvan D, Johnson NP, Nguyen T, Kirkeeide R, Bui L, et al. Mortality Prediction by Quantitative PET Perfusion Expressed as Coronary Flow Capacity with and without Revascularization. JACC Cardiovasc Imaging. 2021;14(5):1020-34. doi: 10.1016/j.jcmg.2020.08.040. https://doi.org/10.1016/j.jcmg.2020.08.0... N-ammonia	10 min	On-site cyclotron	80%	Diffusion/active transport	Requires cyclotron
⁸²Rubidium	72 s	Generator	70%	Na+/K+ cotransporter	Expensive, sub-optimal imaging
¹⁸18.Nkoulou R, Fuchs TA, Pazhenkottil AP, Kuest SM, Ghadri JR, Stehli J, et al. Absolute Myocardial Blood Flow and Flow Reserve Assessed by Gated SPECT with Cadmium-Zinc-Telluride Detectors Using 99mTc-Tetrofosmin: Head-to-Head Comparison with 13N-Ammonia PET. J Nucl Med. 2016;57(12):1887-92. doi: 10.2967/jnumed.115.165498. https://doi.org/10.2967/jnumed.115.16549... F-flurpiridaz	110 min	Centralized radiopharmacy	94%	Mitochondrial complex	Long half-time for same day procedure

[1] Mailing Address: Raffaele Giubbini University of Brescia, DSC. Viale Europa Brescia, 25128 – Italy E-mail: raffaele.giubbini@unibs.it

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Current Role of Myocardial Blood Flow Quantification with PET/CT in the Management of Coronary Artery Disease

Abstract