Myocardial Perfusion SPECT 2018 in Germany: Results of the 8th Survey.

AIM: This paper presents the results of the 8th survey of myocardial perfusion SPECT (MPS) from the reporting year 2018. METHODS: 291 questionnaires (184 practices (PR), 77 hospitals (HO), 30 university hospitals (UH)) were evaluated. Results of the last survey from 2015 are set in squared brackets. RESULTS: MPS of 145 930 [121 939] patients were reported (+ 19.6 %). 76 % [78 %] of all patients were studied in PR, 16 % [14 %] in HO, and 8 % [8 %] in UH, mostly with a 2-day-protocol 48 % [50 %]. 99.96 % [98 %] of all MPS were performed with Tc-99 m radiopharmaceuticals and in 0.04 % with Tl-201.A pharmacological stress test was applied in 49 % [43 %] (23 % [22 %] adenosine, 26 % [20 %] regadenoson, dipyridamole or dobutamine together < 1 % [1 %]). Attenuation correction was performed in 26 % [25 %] of all MPS, gated SPECT in 86 % [80 %] of stress MPS, in 87 % [78 %] of rest and in 83 % [76 %] of all stress and rest MPS. 67 % [53 %] of the departments performed MPS scoring by default, whereas 16 % [24 %] did not apply this feature at all.69 % [60 %] reported an increase or no changes in their MPS patient numbers. One hundred twenty-six departments which participated in the surveys from 2009 to 2018 reported an increase in MPS by 44 %. 69 % [70 %] of the MPS were requested by ambulatory care cardiologists. CONCLUSION: The 2018 MPS survey reveals a high-grade adherence of routine MPS practice to current guidelines. The positive development in MPS performance and MPS numbers observed since 2012 remains ongoing.

[Development of a national competency-based learning objective catalogue for undergraduate medical education in Germany]. / Entwicklung eines kompetenzbasierten Lernzielkatalogs Nuklearmedizin für das Studium der Humanmedizin in Deutschland.

AIMS: Implementation of the guidelines on the Competency-based Learning Objective Catalogue for Undergraduate Medical Education for a Nuclear Medicine curriculum on behalf of the committee on professional training and continuing education of the German Association of Nuclear Medicine (DGN) METHODS:: In 7 domains 100 learning objectives (LOs) were subject to a prioritization in 3 categories (A, B and C) by means of a questionnaire as part of a Delphi method, in collaboration with all members of the DGN holding a "venia legendi" as experts. Category A defined the essential LOs for each medical practitioner. The prioritization was made by ranking the frequency of the A-classifications. In the 2nd step of the Delphi method, a list of LOs with the ranking positions 1-5 in each domain was presented to the first round's experts as a core curriculum, asking either for acceptance or modifications. RESULTS: The results of the 1st step of the Delphi method deliver a return rate of 29% of the questionnaires (55 out of 184). The 2nd round shows a return rate of 30.9% (57 out of 184) and full approval of the proposed LOs in all LO domains by in median 72 % of the experts consulted (61%-81%). The present final version contains 37 competency-based LOs in the LO domains "legal basis and radiation protection", "basic science", indications and contra-indications for "PET/CT", "scintigraphy and SPECT", "patient preparation", "image interpretation" as well as "therapy". CONCLUSION: The Competency-based Learning Objective Catalogue for Nuclear Medicine describes the knowledge and competencies, every physician should have at the end of his medical studies. The LO catalogue is a living document, which needs to be adapted continuously to the progress of the medical and technological development.

[Policy paper nuclear cardiology - update 2018 - Current status of clinical practice]. / Positionspapier Nuklearkardiologie ­ Update 2018.

The joint position paper of the working community "Cardiovascular Nuclear Medicine" of the German Society of Nuclear Medicine (DGN) and the working group "Nuclear Cardiology Diagnostics" of the German Cardiac Society (DKG) updates the former 2009 paper. It is the purpose of this paper to provide an overview about the application fields, the state-of-the-art and the current value of nuclear cardiology imaging. The topics covered are chronic coronary artery disease, including viability imaging, furthermore cardiomyopathies, infective endocarditis, cardiac sarcoidosis and amyloidosis.

Myocardial perfusion SPECT 2015 in Germany. Results of the 7th survey.

AIM: The working group Cardiovascular Nuclear Medicine of the German Society of Nuclear Medicine presents the results of the 7th survey of myocardial perfusion SPECT (MPS) of the reporting year 2015. METHOD: 268 questionnaires (173 practices [PR], 67 hospitals [HO], 28 university hospitals [UH]) were evaluated. Results of the last survey from 2012 are set in squared brackets. RESULTS: MPS of 121 939 [105 941] patients were reported. 98 % [95 %] of all MPS were performed with Tc-99m radiopharmaceuticals and 2 % [5 %] with Tl-201. 78 % [79 %] of all patients were studied in PR, 14 % [15 %] in HO, and 8 % [6 %] in UH. A pharmacological stress test was performed in 43 % [39 %] (22 % [24 %] adenosine, 20 % [9 %] regadenoson, 1 % [6 %] dipyridamole or dobutamine). Attenuation correction was applied in 25 % [2009: 10 %] of MPS. Gated SPECT was performed in 78 % [70 %] of all rest MPS, in 80 % [73 %] of all stress and in 76 % [67 %] of all stress and rest MPS. 53 % [33 %] of all nuclear medicine departments performed MPS scoring by default, whereas 24 % [41 %] did not apply any quantification. 31 % [26 %] of all departments noticed an increase in their counted MPS and 29 % [29 %] no changes. Data from 89 departments which participated in all surveys showed an increase in MPS count of 11.1 % (PR: 12.2 %, HO: 4.8 %, UH: 18.4 %). 70 % [60 %] of the MPS were requested by ambulatory care cardiologists. CONCLUSION: The 2015 MPS survey reveals a high-grade adherence of routine MPS practice to current guidelines. The positive trend in MPS performance and number of MPS already observed in 2012 continues. Educational training remains necessary in the field of SPECT scoring.

Performance of cardiac cadmium-zinc-telluride gamma camera imaging in coronary artery disease: a review from the cardiovascular committee of the European Association of Nuclear Medicine (EANM).

The trade-off between resolution and count sensitivity dominates the performance of standard gamma cameras and dictates the need for relatively high doses of radioactivity of the used radiopharmaceuticals in order to limit image acquisition duration. The introduction of cadmium-zinc-telluride (CZT)-based cameras may overcome some of the limitations against conventional gamma cameras. CZT cameras used for the evaluation of myocardial perfusion have been shown to have a higher count sensitivity compared to conventional single photon emission computed tomography (SPECT) techniques. CZT image quality is further improved by the development of a dedicated three-dimensional iterative reconstruction algorithm, based on maximum likelihood expectation maximization (MLEM), which corrects for the loss in spatial resolution due to line response function of the collimator. All these innovations significantly reduce imaging time and result in a lower patient's radiation exposure compared with standard SPECT. To guide current and possible future users of the CZT technique for myocardial perfusion imaging, the Cardiovascular Committee of the European Association of Nuclear Medicine, starting from the experience of its members, has decided to examine the current literature regarding procedures and clinical data on CZT cameras. The committee hereby aims 1) to identify the main acquisitions protocols; 2) to evaluate the diagnostic and prognostic value of CZT derived myocardial perfusion, and finally 3) to determine the impact of CZT on radiation exposure.

Nuclear cardiology practice and associated radiation doses in Europe: results of the IAEA Nuclear Cardiology Protocols Study (INCAPS) for the 27 European countries.

PURPOSE: Nuclear cardiology is widely used to diagnose coronary artery disease and to guide patient management, but data on current practices, radiation dose-related best practices, and radiation doses are scarce. To address these issues, the IAEA conducted a worldwide study of nuclear cardiology practice. We present the European subanalysis. METHODS: In March 2013, the IAEA invited laboratories across the world to document all SPECT and PET studies performed in one week. The data included age, gender, weight, radiopharmaceuticals, injected activities, camera type, positioning, hardware and software. Radiation effective dose was calculated for each patient. A quality score was defined for each laboratory as the number followed of eight predefined best practices with a bearing on radiation exposure (range of quality score 0 - 8). The participating European countries were assigned to regions (North, East, South, and West). Comparisons were performed between the four European regions and between Europe and the rest-of-the-world (RoW). RESULTS: Data on 2,381 European patients undergoing nuclear cardiology procedures in 102 laboratories in 27 countries were collected. A cardiac SPECT study was performed in 97.9 % of the patients, and a PET study in 2.1 %. The average effective dose of SPECT was 8.0 ± 3.4 mSv (RoW 11.4 ± 4.3 mSv; P < 0.001) and of PET was 2.6 ± 1.5 mSv (RoW 3.8 ± 2.5 mSv; P < 0.001). The mean effective doses of SPECT and PET differed between European regions (P < 0.001 and P = 0.002, respectively). The mean quality score was 6.2 ± 1.2, which was higher than the RoW score (5.0 ± 1.1; P < 0.001). Adherence to best practices did not differ significantly among the European regions (range 6 to 6.4; P = 0.73). Of the best practices, stress-only imaging and weight-adjusted dosing were the least commonly used. CONCLUSION: In Europe, the mean effective dose from nuclear cardiology is lower and the average quality score is higher than in the RoW. There is regional variation in effective dose in relation to the best practice quality score. A possible reason for the differences between Europe and the RoW could be the safety culture fostered by actions under the Euratom directives and the implementation of diagnostic reference levels. Stress-only imaging and weight-adjusted activity might be targets for optimization of European nuclear cardiology practice.

Cardiac shock wave therapy and myocardial perfusion in severe coronary artery disease.

BACKGROUND: Ultrasound guided cardiac shock wave therapy (CSWT) is a noninvasive therapeutic option in the treatment of chronic-refractory angina. Clinical trials have shown that CSWT reduces angina symptoms, improves regional systolic function, LV ejection fraction, myocardial perfusion and quality of life parameters. Absolute measurements of myocardial perfusion before and after CSWT have not been performed so far. METHODS AND RESULTS: We studied a total of 21 CCS III patients with history of CAD and multiple interventions who suffered from disabling angina despite individually optimized medical therapy. An N-13 NH3 PET perfusion scan under adenosine was performed before and after CSWT treatment. CSWT was well tolerated in all patients. Absolute perfusion under adenosine of the global left-ventricular myocardium did not change under therapy or minimal coronary resistance. The treated segments, however, showed in terms of both perfusion and resistance a mild but significant improvement, by 11 and 15 %, respectively, whereas no change could be observed in the remote segments. Considering a threshold of increased perfusion of 5 %, 10 (77 %) out of 13 patients with a better target perfusion improved in their CCS class, whereas 3 (43 %) out of 7 patients without improved target perfusion improved in their CCS class too. CONCLUSION: Standard CSWT has the potential to improve myocardial perfusion of the therapy zone and clinical CAD symptomatology without affecting global myocardial perfusion. As a noninvasive and well tolerated therapeutic option, these data suggest the use of CSWT in patients with end-stage CAD.

Myocardial perfusion scintigraphy in Germany in 2009: utilization and state of the practice.

PURPOSE: Since 2006, the working group Cardiovascular Nuclear Medicine of the German Society of Nuclear Medicine, in cooperation with the working group Nuclear Cardiology of the German Cardiac Society, has been surveying the utilization and technical realization of myocardial perfusion scintigraphy (MPS) in Germany. This paper presents the results of the reporting year 2009. METHODS: A total of 291 centres participated in the inquiry, including 179 private practices (PP), 86 hospitals (HO) and 26 university hospitals (UH). RESULTS: MPS of 98,103 patients were reported. The MPS numbers per million population (pmp) were estimated at 2,360; 76% of the MPS were performed in PP, 17% in HO and 7% in UH. The ratio of MPS to coronary angiography to revascularization was 0.5 to 2.3 to 1. Data from 134 centres which participated in the surveys from 2005 to 2009 showed a decrease in MPS utilization of 2.2%. Nearly half of the MPS were requested by ambulatory care cardiologists. Of all MPS studies, 89% were conducted with (99m)Tc perfusion tracers. Ergometry was the preferred stress test (69%). Adenosine was used in 16%, adenosine + exercise in 7%, dipyridamole in 3%, dipyridamole + exercise in 5% and dobutamine in <1%. Gated single proton emission computed tomography (SPECT) acquisition was performed in 56% of all rest MPS and in 56% of all stress MPS. Both rest and stress MPS were ECG gated in 41%. Only 33% of the centres always performed a quantification of the perfusion studies, whereas 51% did not apply any quantification; 4% of the MPS studies were corrected for attenuation, and 17 centres used transmission sources of 12 CT-based systems. CONCLUSION: A scan activity of 2,380 MPS pmp is in the upper third of the European range. The ratios to coronary angiography and to revascularization suggest that angiography dominates diagnosis and management of coronary artery disease (CAD). The clinical and technical realizations reveal that the predominant goals of further trainings to optimize MPS are in the field of gated SPECT and quantitative perfusion SPECT.

Sirolimus-eluting stent implantation versus beta-irradiation for the treatment of in-stent restenotic lesions: clinical and ultrasound results from a randomised trial.

AIMS: Recent trials with different designs indicated that drug-eluting stents may be superior to vascular brachytherapy (VBT) for the treatment of in-stent restenosis (ISR). We performed a randomised, double-centre, clinical, quantitative coronary angiographic (QCA) and intravascular ultrasound (IVUS) acute and 3-years comparison of 90Sr/90Y-VBT and sirolimus-eluting stent implantation (SES) for ISR. METHODS AND RESULTS: Ninety-one (91) consecutive patients were included. By QCA, SES led to a higher acute gain (2.08 ± 0.41 mm vs. 1.54 ± 0.70 mm, p < 0.0001), higher postprocedural minimum lumen diameter (2.76 ± 0.39 mm vs. 2.39 ± 0.52 mm; p < 0.0001), lower late lumen loss at follow-up (0.09 ± 0.29 vs. 0.39 ± 0.79 mm, p = 0.042), and a higher net lumen gain of the target lesion (2.05 ± 0.51 vs 1.18 ± 1.08 mm, p < 0.0001). By IVUS, the smaller acute gain following VBT was the result of residual intima hyperplasia, the intima hyperplasia formation following SES was extremely low, and the edge-effect was virtually absent after SES, respectively. At 6-month follow-up, both the angiographic restenosis rate (4.7 vs. 22.7%; p < 0.0001) and target lesion revascularisation rate (2.3 vs. 10.4%; p = 0.025) were lower in SES. Importantly, SES showed a stable clinical course at 3-year follow-up while VBT was associated with a sustained incidence of target vessel failure (11.6 vs. 46.7%; p < 0.0001). CONCLUSIONS: SES for ISR is associated with superior QCA, IVUS and clinical results at 6-month and 3-year of follow-up when compared with VBT.

Primary malignant pericardial mesothelioma - a rare cause of pericardial effusion and consecutive constrictive pericarditis: a case report.

INTRODUCTION: Primary malignant pericardial mesothelioma is a very rare pericardial tumor of unknown etiology. CASE PRESENTATION: A 61-year-old Caucasian woman was admitted to our hospital complaining of exertional dyspnea due to a large pericardial effusion. Intrapericardial fluid volume declined after repeated pericardiocentesis, but the patient progressively developed a hemodynamically relevant pericardial constriction. Pericardiectomy revealed a pericardial mesothelioma. Subsequently, four cycles of chemotherapy (dosage according to recently published trials) were administered. The patient remained asymptomatic, and there was no recurrence of the tumor after three years. CONCLUSION: Pericardial mesothelioma should be considered and managed appropriately in non-responders to pericardiocentesis, and in patients who develop constrictive pericarditis late in their clinical course.

Respiratory resistance of patients during cardiac stress testing with adenosine: is dyspnea a sign of bronchospasm?

BACKGROUND: Adenosine is widely used for stress-testing in myocardial perfusion imaging. During adenosine infusion, dyspnea is one of the main complaints of patients. The aim of this study was to determine whether dyspnea during adenosine infusion is caused by bronchospasm. METHODS: Fifty-four patients were enrolled in the study. Seven of these 54 suffered from mild chronic obstructive pulmonary disease (COPD). We continuously measured respiratory resistance (Rrs), using impulse oscillometry. Respiratory resistance was measured before, during, and after a continuous infusion of 140 microg/kg/min adenosine. RESULTS: Sixty-seven percent of patients suffered from dyspnea during adenosine infusion. In patients with mild COPD, Rrs was higher compared with other patients (0.48 vs 0.27 kPa/L/s, P < .05). Neither patients with COPD nor those without COPD exhibited a significant increase in Rrs during adenosine infusion. The Rrs of patients with dyspnea was insignificantly lower compared with patients without dyspnea (P = .469). CONCLUSIONS: Dyspnea as a side effect of adenosine infusion is not correlated with impaired respiratory resistance in nonasthmatic patients and in patients with mild COPD. Thus bronchospasm is ruled out as cause of this clinical symptom. Despite the small number of COPD patients enrolled in the study, adenosine infusion might be possible in patients with mild COPD.

Attenuation correction of myocardial SPECT perfusion images with low-dose CT: evaluation of the method by comparison with perfusion PET.

UNLABELLED: In cardiac SPECT, specificity is significantly affected by artifacts due to photon absorption. As the success of attenuation correction depends mainly on high-quality attenuation maps, SPECT low-dose CT devices are promising. We wanted to evaluate the usefulness of a SPECT low-dose CT device in myocardial perfusion scintigraphy. For the evaluation of attenuation correction systems, primarily comparisons with coronary angiography are used. Because the comparison of a method showing myocardial perfusion with an investigation displaying the morphology of vessels yields some difficulties, we chose perfusion PET with (13)N-ammonia as the reference method. METHODS: We prospectively analyzed 23 patients (6 women, 17 men) with known or suspected coronary artery disease. Rest studies and studies under pharmacologic stress with adenosine were performed. After simultaneous injection of (13)N-ammonia and (99m)Tc-sestamibi, a dynamic PET acquisition was started. The SPECT study was performed about 2 h later. Based on 20-segment polar maps, SPECT with and without attenuation correction was compared with PET-derived perfusion values and ammonia uptake values. The PET uptake images were also smoothed to adjust their resolution to the resolution of the SPECT images. RESULTS: The concordance of SPECT and PET studies was improved after attenuation correction. The main effect was seen in the inferior wall. Especially in the apex and anterolateral wall, there were differences between SPECT and PET studies not attributable to attenuation artifacts. Because these differences diminished after smoothing of the PET studies, they might be due to partial-volume effects caused by the inferior resolution of the SPECT images. CONCLUSION: The x-ray-derived attenuation correction leads to SPECT images that represent myocardial perfusion more accurately than nonattenuation-corrected SPECT images. The benefit of the method is seen primarily in the inferior wall. The low resolution of the SPECT system may lead to artifacts due to partial-volume effects. This phenomenon must be considered when perfusion PET is used as a reference method to investigate the effect of attenuation correction.

Performance of a device to minimise radiation dose to the hands during radioactive syringe calibration.

The preparation of syringes for routine applications in nuclear medicine, and in particular the calibration procedure, is associated with high radiation exposure to the hands. To reduce this radiation burden, our group developed a modified calibration procedure based on a device that we refer to as the ActivoFix, which allows syringes to be drawn up inside the dose calibrator. This study investigated the performance of the new device as compared to the usual procedure of syringe calibration with regard to the absorbed radiation dose to the hands (fingertips and middle finger bases), the precision of the calibration procedure and the time required to calibrate syringes. Fourteen experienced nuclear medicine technologists drew up syringes from an initial eluate of 8.2 GBq using the conventional technique and the new calibration procedure. All technologists had to calibrate syringes with 50 MBq, 250 MBq and 650 MBq. This sequence was repeated four times using the conventional technique and then the new procedure. The equivalent dose to the hands was measured with thermoluminescent dosimeters. The exact amount of radioactivity in the syringe and the time needed for the calibration procedure were also recorded. The reduction in equivalent dose using the new device compared with the routine procedure ranged from 8.3- to 19.6-fold (mean 14.3-fold) for the fingers of the dominant hand and from 13.6- to 40.3-fold (mean 27-fold) for those of the non-dominant hand (total mean 21.3-fold). For small volumes, time could be saved with the ActivoFix, whereas for greater volumes time was lost. The device produced less variability in calibrating doses at 250 MBq and 650 MBq. Following the ALARA principle, the new device can be recommended for syringe calibration in nuclear medicine because the use of the ActivoFix-based procedure reduces finger dose by an average factor of 21, improves the precision of calibration and reduces the filling time for small volumes.