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The use of cardiac PET, and in particular of quantitative myocardial perfusion PET, has been growing during the last years, because scanners are becoming widely available and because several studies have convincingly demonstrated the advantages of this imaging approach. Therefore, there is a need of determining the procedural modalities for performing high-quality studies and obtaining from this demanding technique the most in terms of both measurement reliability and clinical data. Although the field is rapidly evolving, with progresses in hardware and software, and the near perspective of new tracers, the EANM Cardiovascular Committee found it reasonable and useful to expose in an updated text the state of the art of quantitative myocardial perfusion PET, in order to establish an effective use of this modality and to help implementing it on a wider basis. Together with the many steps necessary for the correct execution of quantitative measurements, the importance of a multiparametric approach and of a comprehensive and clinically useful report have been stressed.

Gyrocardiography (GCG) is a new non-invasive technique for assessing heart motions by using a sensor of angular motion – gyroscope – attached to the skin of the chest. In this study, we conducted simultaneous recordings of electrocardiography (ECG), GCG, and echocardiography in a group of subjects consisting of nine healthy volunteer men. Annotation of underlying fiducial points in GCG is presented and compared to opening and closing points of heart valves measured by a pulse wave Doppler. Comparison between GCG and synchronized tissue Doppler imaging (TDI) data shows that the GCG signal is also capable of providing temporal information on the systolic and early diastolic peak velocities of the myocardium. Furthermore, time intervals from the ECG Q-wave to the maximum of the integrated GCG (angular displacement) signal and maximal myocardial strain curves obtained by 3D speckle tracking are correlated. We see GCG as a promising mechanical cardiac monitoring tool that enables quantification of beat-by-beat dynamics of systolic time intervals (STI) related to hemodynamic variables and myocardial contractility.

With this document, we provide a standard for PET/(diagnostic) CT imaging procedures in cardiovascular diseases that are inflammatory, infective, infiltrative, or associated with dysfunctional innervation (4Is). This standard should be applied in clinical practice and integrated in clinical (multicenter) trials for optimal procedural standardization. A major focus is put on procedures using [18F]FDG, but 4Is PET radiopharmaceuticals beyond [18F]FDG are also described in this document. Whilst these novel tracers are currently mainly applied in early clinical trials, some multicenter trials are underway and we foresee in the near future their use in clinical care and inclusion in the clinical guidelines. Finally, PET/MR applications in 4Is cardiovascular diseases are also briefly described. Diagnosis and management of 4Is-related cardiovascular diseases are generally complex and often require a multidisciplinary approach by a team of experts. The new standards described herein should be applied when using PET/CT and PET/MR, within a multimodality imaging framework both in clinical practice and in clinical trials for 4Is cardiovascular indications.

We implemented a two-dimensional convolutional neural network (CNN) for classification of polar maps extracted from Carimas (Turku PET Centre, Finland) software used for myocardial perfusion analysis. 138 polar maps from 15 O–H 2 O stress perfusion study in JPEG format from patients classified as ischemic or non-ischemic based on finding obstructive coronary artery disease (CAD) on invasive coronary artery angiography were used. The CNN was evaluated against the clinical interpretation. The classification accuracy was evaluated with: accuracy (ACC), area under the receiver operating characteristic curve (AUC), F1 score (F1S), sensitivity (SEN), specificity (SPE) and precision (PRE). The CNN had a median ACC of 0.8261, AUC of 0.8058, F1S of 0.7647, SEN of 0.6500, SPE of 0.9615 and PRE of 0.9286. In comparison, clinical interpretation had ACC of 0.8696, AUC of 0.8558, F1S of 0.8333, SEN of 0.7500, SPE of 0.9615 and PRE of 0.9375. The CNN classified only 2 cases differently than the clinical interpretation. The clinical interpretation and CNN had similar accuracy in classifying false positives and true negatives. Classification of ischemia is feasible in 15 O–H 2 O stress perfusion imaging using JPEG polar maps alone with a custom CNN and may be useful for the detection of obstructive CAD.

Impaired left atrial (LA) function in heart failure with preserved ejection fraction (HFpEF) is associated with adverse outcomes. A subgroup of HFpEF may have LA myopathy out of proportion to left ventricular (LV) dysfunction; therefore, we sought to characterize HFpEF patients with disproportionate LA myopathy. In the prospective, multicenter, Prevalence of Microvascular Dysfunction in HFpEF study, we defined disproportionate LA myopathy based on degree of LA reservoir strain abnormality in relation to LV myopathy (LV global longitudinal strain [GLS]) by calculating the residuals from a linear regression of LA reservoir strain and LV GLS. We evaluated associations of disproportionate LA myopathy with hemodynamics and performed a plasma proteomic analysis to identify proteins associated with disproportionate LA myopathy; proteins were validated in an independent sample. Disproportionate LA myopathy correlated with better LV diastolic function but was associated with lower stroke volume reserve after passive leg raise independent of atrial fibrillation (AF). Additionally, disproportionate LA myopathy was associated with higher pulmonary artery systolic pressure, higher pulmonary vascular resistance, and lower coronary flow reserve. Of 248 proteins, we identified and validated 5 proteins (involved in cardiomyocyte stretch, extracellular matrix remodeling, and inflammation) that were associated with disproportionate LA myopathy independent of AF. In HFpEF, LA myopathy may exist out of proportion to LV myopathy. Disproportionate LA myopathy is a distinct HFpEF subtype associated with worse hemodynamics and a distinct proteomic signature, independent of AF.

Coronary artery disease is one of the leading causes of morbidity and mortality worldwide. Although it can present with an acute coronary syndrome, it is often characterised by long periods of stability, known as chronic coronary artery disease. This Review presents a comprehensive overview of the diagnosis of the disease, with a focus on cardiac imaging. We discuss various cardiac imaging modalities, including CT coronary angiography, stress echocardiogram, stress single-photon emission CT, PET, and stress cardiac magnetic resonance. We also compare the roles of anatomical (eg, CT coronary angiography) versus functional (eg, stress echocardiogram) tests and examine the potential utility of artificial intelligence in more detail.

Abstract Cardiotoxicity may present as (pulmonary) hypertension, acute and chronic coronary syndromes, venous thromboembolism, cardiomyopathies/heart failure, arrhythmia, valvular heart disease, peripheral arterial disease, and myocarditis. Many of these disease entities can be diagnosed by established cardiovascular diagnostic pathways. Nuclear medicine, however, has proven promising in the diagnosis of cardiomyopathies/heart failure, and peri- and myocarditis as well as arterial inflammation. This article first outlines the spectrum of cardiotoxic cancer therapies and the potential side effects. This will be complemented by the definition of cardiotoxicity using non-nuclear cardiovascular imaging (echocardiography, CMR) and biomarkers. Available nuclear imaging techniques are then presented and specific suggestions are made for their application and potential role in the diagnosis of cardiotoxicity.

The European Society of Cardiology (ESC) has recently published new guidelines on the diagnosis and management of chronic coronary syndromes (CCS). Due to variable symptoms, objective tests are often necessary to confirm the diagnosis, exclude alternative diagnoses, and assess the severity of underlying disease. This review provides a summary of the main diagnostic strategies listed in the guidelines for evaluation of patients suspected of having obstructive coronary artery disease (CAD). Based on data from contemporary cohorts of patients referred for diagnostic testing, the pre-test probabilities of obstructive CAD based on age, sex, and symptoms have been adjusted substantially downward compared with the previous guidelines. Further, a new concept of “clinical likelihood of CAD” was introduced accounting for the impact of various risk factors and modifiers on the pre-test probability. Noninvasive functional imaging for myocardial ischemia, coronary computed tomography angiography, or invasive coronary angiography combined with functional evaluation is recommended as the initial strategy to diagnose CAD in symptomatic patients, unless obstructive CAD can be excluded by clinical assessment alone. When available, imaging tests are recommended as noninvasive modalities instead of exercise electrocardiograms.

This preliminary study investigated if VEGFR-2 selective adenoviral Vammin (AdVammin) gene therapy could induce angiogenesis and increase perfusion in the healthy porcine myocardium. Also, we determined using a clinically relevant large animal model if AdVammin gene therapy could improve the function of a chronically ischemic heart. Low doses of AdVammin (dose range 2 × 10 9 –2 × 10 10 vp) gene transfers were performed into the porcine myocardium using an endovascular injection catheter. AdCMV was used as a control. The porcine model of chronic myocardial ischemia was used in the ischemic studies. The AdVammin enlarged the mean capillary area and stimulated pericyte coverage in the target area 6 days after the gene transfers. Using positron emission tomography 15 O-radiowater imaging, we demonstrated that AdVammin gene therapy increased perfusion in healthy myocardium at rest. AdVammin treatment also increased ejection fraction at stress in the ischemic heart, as detected using left ventricular cine angiography. In addition, we demonstrated successful in vivo imaging of enhanced angiogenesis using [ 68 Ga]NODAGA-RGD peptide. However, AdVammin also increased tissue permeability and was associated with significant pericardial fluid accumulation, limiting AdVammin’s therapeutic potential and emphasizing the importance of correct dosage.

PurposeWe evaluated the value of reduced global and segmental absolute stress myocardial blood flow (sMBF) quantified by [15O] water positron emission tomography (PET) for predicting cardiac events in patients with suspected obstructive coronary artery disease (CAD).MethodsGlobal and segmental sMBF during adenosine stress were retrospectively quantified in 530 symptomatic patients who underwent [15O] water PET for evaluation of coronary stenosis detected by coronary computed tomography angiography.ResultsCardiovascular death, myocardial infarction, or unstable angina occurred in 28 (5.3%) patients at a 4-year follow-up. Reduced global sMBF was associated with events (area under the receiver operating characteristic curve 0.622, 95% confidence interval (95% CI) 0.538–0.707, p = 0.006). Reduced global sMBF (< 2.2 ml/g/min) was found in 22.8%, preserved global sMBF despite segmentally reduced sMBF in 35.3%, and normal sMBF in 41.9% of patients. Compared with normal sMBF, reduced global sMBF was associated with the highest risk of events (adjusted hazard ratio (HR) 6.970, 95% CI 2.271–21.396, p = 0.001), whereas segmentally reduced sMBF combined with preserved global MBF predicted an intermediate risk (adjusted HR 3.251, 95% CI 1.030–10.257, p = 0.044). The addition of global or segmental reduction of sMBF to clinical risk factors improved risk prediction (net reclassification index 0.498, 95% CI 0.118–0.879, p = 0.010, and 0.583, 95% CI 0.203–0.963, p = 0.002, respectively).ConclusionIn symptomatic patients evaluated for suspected obstructive CAD, reduced global sMBF by [15O] water PET identifies those at the highest risk of adverse cardiac events, whereas segmental reduction of sMBF with preserved global sMBF is associated with an intermediate event risk.