4D display of CT LV endocardial and epicardial models morphed from PET Rb-82 perfusion studies accurately quantifies segmental myocardial thickening.

BACKGROUND: MPI-derived LV wall thickening assessments for diagnostic purposes has been part of clinical guidelines for two decades. It relies on visual evaluation of tomographic slices or regional quantification displayed in 2D polar maps. 4D displays have not entered clinical usage nor have they been validated on their potential to provide equivalent information. The purpose of this work was to validate a 4D realistic display recently designed to quantitatively represent the thickening information from gated MPI into CT-morphed endocardial and epicardial moving surfaces. METHODS: Forty patients who underwent 82Rb PET were selected based on LV perfusion quantification. CTA templates of heart anatomy were selected to represent the LV anatomy. Generic CT-derived LV endocardial and epicardial surfaces were modified to represent the end diastolic (ED) phase according to PET-derived ED LV dimensions and wall thickness. These CT myocardial surfaces were then morphed by means of thin plate spline (TPS) techniques, according to the gated PET slices count changes (WThPET) and LV wall motion (WMoPET). A geometric thickening (GeoTh) equivalent to LV WThPET was defined on epicardial and endocardial CT surfaces over the cardiac cycle and the two measures compared. WThPET and GeoTh correlations were performed on a case-by-case basis, by segment and by pooling all 17 segments. Pearson's correlation coefficients (PCC) were calculated to assess the equivalence of the two measures. RESULTS: Two cohorts of patients (normal and abnormal) were identified based on SSS. R coefficients were as follows: for all pooled segments PCCstress and PCCrest were respectively 0.91 and 0.89 (normal), and 0.9 and 0.91 (abnormal); when individual 17 segments were considered mean PCCstress = 0.92 [0.81-0.98] and mean PCCrest = 0.93 [0.83-0.98] for the abnormal perfusion group; mean PCCstress = 0.89 [0.78-0.97] and mean PCCrest = 0.89 [0.77-0.97] for the normal. When individual studies were considered, R was always > .70 with the exception of five abnormal studies. Inter-user analysis was also conducted. CONCLUSIONS: Our novel technique for the visualization of LV wall thickening by means of 4D CT endocardial and epicardial surface models accurately replicated 82Rb slice thickening results showing promise for its usage for diagnostic purposes.

Determination of [N-13]-ammonia extraction fraction in patients with coronary artery disease by calibration to invasive coronary and fractional flow reserve.

BACKGROUND: This study presents a new extraction fraction (EF) model based on physiological measures of invasive coronary flow reserve (CFR) and fractional flow reserve (FFR) in patients with suspected coronary artery disease (CAD) and normal index microcirculatory resistance (IMR). To ascertain the clinical relevance of the new EFs, flow measurements using the newly patient-determined EFs were compared to flow measurements using traditional animal-determined EFs. METHODS: 39 patients were retrospectively selected that included a total of 91 vascular territories with invasive coronary angiography physiological measures. [N-13]-ammonia dynamic rest/adenosine-stress PET imaging was conducted in all patients and absolute myocardial flow was estimated using four published compartmental models. The extraction fraction during hyperemic flow was iteratively estimated by maximizing the agreement between invasive CFR and FFR with the non-invasive analogs myocardial flow reserve (MFR) and relative flow reserve (RFR) at similar physiological states, respectively. RESULTS: Using the new patient-determined EFs, agreement between CFR vs MFR for Model 1 and 2 was moderate and poor for Model 3 and 4. All models showed moderate agreement for FFR vs RFR. When using published models of animal-determined EFs, agreement between CFR vs MFR remained moderate for Model 1 and 2, and poor for Model 3 and 4. Similarly, all models showed moderate agreement for FFR vs RFR using animal-determined EF values. None of the observed differences were statistically significant. CONCLUSIONS: Flow measurements using extraction fraction correction for [N-13]-ammonia based on calibration to invasive intracoronary angiography physiological measures in patients with CAD were not discordant from those reported in the literature. Either patient-determined or traditional animal-determined EF correction, when used with the appropriate flow model, yields moderate agreement with invasive measurements of coronary flow reserve and fractional flow reserve.

Rationale and design of the quantification of myocardial blood flow using dynamic PET/CTA-fused imagery (DEMYSTIFY) to determine physiological significance of specific coronary lesions.

BACKGROUND: Coronary physiology assessments have been shown by multiple trials to add clinical value in detecting significant coronary artery disease and predicting cardiovascular outcomes. Fractional flow reserve (FFR) obtained during invasive coronary angiography (ICA) has become the new reference standard for hemodynamic significance detection. Absolute myocardial blood flow (MBF) quantification by means of dynamic positron emission tomography (dPET) has high diagnostic and prognostic values. FFR is an invasive measure and as such cannot be applied broadly, while MBF quantification is commonly performed on standard vascular territories intermixing normal flow from normal regions with abnormal flow from abnormal regions and consequently limiting its diagnostic power. OBJECTIVE: The aim of this study is to provide physicians with reliable software tools for the non-invasive assessment of lesion-specific physiological significance for the entire coronary tree by combining PET-derived absolute flow data and coronary computed tomography angiography (CTA)-derived anatomy and coronary centerlines. METHODS: The dynamic PET/CTA myocardial blood flow assessment with fused imagery (DEMYSTIFY) study is an observational prospective clinical study to develop algorithms and software tools to fuse coronary anatomy data obtained from CTA with dPET data to non-invasively measure absolute MBF, myocardial flow reserve, and relative flow reserve across specific coronary lesions. Patients (N = 108) will be collected from 4 institutions (Emory University Hospital, USA; Chonnam National University Hospital, South Korea; Samsung Medical Center, South Korea; Seoul National University Hospital, South Korea). These results will be compared to those obtained invasively in the catheterization laboratory and to a relatively novel non-invasive technique to estimate FFR based on CTA and computational fluid dynamics. CONCLUSIONS: Success of these developments should lead to the following benefits: (1) eliminate unnecessary invasive coronary angiography in patients with no significant lesions, (2) avoid stenting physiologically insignificant lesions, (3) guide percutaneous coronary interventions process to the location of significant lesions, (4) provide a flow-color-coded 3D roadmap of the entire coronary tree to guide bypass surgery, and (5) use less radiation and lower the cost from unnecessary procedures. TRIAL REGISTRY: The DEMYSTIFY study has been registered on ClinicalTrials.gov with registration number NCT04221594.

Vessel-specific quantification of absolute myocardial blood flow, myocardial flow reserve and relative flow reserve by means of fused dynamic 13NH3 PET and CCTA: Ranges in a low-risk population and abnormality criteria.

OBJECTIVES: The goal of the present work is to present a novel methodology for the extraction of MBF, MFR and RFR along coronary arteries by means of multimodality image fusion of dynamic PET and CCTA images. BACKGROUND: FFR is the reference standard to identify flow-limiting lesions, but its invasiveness limits broad application. New noninvasive methodologies are warranted to stratify patients and guide treatment. METHODS: A group of 16 low-risk CAD subjects who underwent both 13NH3 PET and CCTA were analyzed. Image fusion techniques were employed to align the studies and CCTA-derived anatomy used to identify coronaries trajectories. MBF was calculated by means of a 1-tissue compartmental model for the standard vascular territories and along patient-specific vessel paths from the base to the apex of the heart. RESULTS: Low-risk ranges for MBF. MFR and RFR for LAD, LCX and rPDA were computed for the entire cohort and separated by gender. Computed low-risk ranges were used to assess a prospective patient with suspected CAD. CONCLUSIONS: Our vessel-specific functional indexes and 3D displays offer promise to more closely replicate what is commonly performed during a catheterization session and have the potential of providing effective noninvasive tools for the identification of flow-limiting lesions and image-guided therapy.

Diagnostic performance of the quantification of myocardium at risk from MPI SPECT/CTA 2G fusion for detecting obstructive coronary disease: A multicenter trial.

BACKGROUND: The effective non-invasive identification of coronary artery disease (CAD) and its proper referral for invasive treatment are still unresolved issues. We evaluated our quantification of myocardium at risk (MAR) from our second generation 3D MPI/CTA fusion framework for the detection and localization of obstructive coronary disease. METHODS: Studies from 48 patients who had rest/stress MPI, CTA, and ICA were analyzed from 3 different institutions. From the CTA, a 3D biventricular surface of the myocardium with superimposed coronaries was extracted and fused to the perfusion distribution. Significant lesions were identified from CTA readings and positioned on the fused display. Three estimates of MAR were computed on the 3D LV surface on the basis of the MPI alone (MARp), the CTA alone (MARa), and the fused information (MARf). The extents of areas at risk were used to generate ROC curves using ICA anatomical findings as reference standard. RESULTS: Areas under the ROC curve (AUC) for CAD detection using MARf was 0.88 (CI = 0.75-0.95) and for MARp and MARa were, respectively 0.82 (CI = 0.69-0.92) and 0.75 (CI = 0.60-0.86) using the ≥70% stenosis criterion. AUCs for CAD localization (all vessels) using MARf showed significantly higher performance than either MARa or MARp or both. CONCLUSIONS: Using ICA as the reference standard, MAR as the quantitative parameter, and AUC to measure diagnostic performance, MPI-CTA fusion imaging provided incremental diagnostic information compared to MPI or CTA alone for the diagnosis and localization of CAD.

Motion Correction and Its Impact on Absolute Myocardial Blood Flow Measures with PET.

PURPOSE OF REVIEW: Motion artifacts, due to cardiac and respiratory cycles, myocardial cardiac creep, or gross patient movements, have been extensively investigated in the context of relative myocardial perfusion imaging with SPECT and PET. These movements have been identified as a major source of errors in image quantification and diagnosis. Recently, as dynamic PET quantification for myocardial blood flow assessment has entered clinical practice, similar questions have arisen on the impact of motion on final blood flow values. RECENT FINDINGS: While preliminary investigations have underlined the potential impact of these motions on MBF quantification, their correction on dynamic acquisition remains challenging and limited to research studies. Gross patient's body movements occur in a consistent number of cases, particularly during stress acquisition, typically involving a limited number of image frames. If undetected, these movements can lead to great differences in flow values and consequently misdiagnosis. Quality control routines can be applied to automatically inspect the shape of time activity curves and to help identify motion artifacts. Cyclic cardiac and respiratory motion may have a considerable impact on final flow values. Correction of gross body motion represents a priority in the context of optimizing absolute flow clinical routine utilization and protocol standardization.

Automatic detection of left and right ventricles from CTA enables efficient alignment of anatomy with myocardial perfusion data.

BACKGROUND: Accurate alignment between cardiac CT angiographic studies (CTA) and nuclear perfusion images is crucial for improved diagnosis of coronary artery disease. This study evaluated in an animal model the accuracy of a CTA fully automated biventricular segmentation algorithm, a necessary step for automatic and thus efficient PET/CT alignment. METHODS AND RESULTS: Twelve pigs with acute infarcts were imaged using Rb-82 PET and 64-slice CTA. Post-mortem myocardium mass measurements were obtained. Endocardial and epicardial myocardial boundaries were manually and automatically detected on the CTA and both segmentations used to perform PET/CT alignment. To assess the segmentation performance, image-based myocardial masses were compared to experimental data; the hand-traced profiles were used as a reference standard to assess the global and slice-by-slice robustness of the automated algorithm in extracting myocardium, LV, and RV. Mean distances between the automated and the manual 3D segmented surfaces were computed. Finally, differences in rotations and translations between the manual and automatic surfaces were estimated post-PET/CT alignment. The largest, smallest, and median distances between interactive and automatic surfaces averaged 1.2 ± 2.1, 0.2 ± 1.6, and 0.7 ± 1.9 mm. The average angular and translational differences in CT/PET alignments were 0.4°, -0.6°, and -2.3° about x, y, and z axes, and 1.8, -2.1, and 2.0 mm in x, y, and z directions. CONCLUSIONS: Our automatic myocardial boundary detection algorithm creates surfaces from CTA that are similar in accuracy and provide similar alignments with PET as those obtained from interactive tracing. Specific difficulties in a reliable segmentation of the apex and base regions will require further improvements in the automated technique.

Myocardial perfusion imaging-derived left ventricular strain: Regional abnormalities associated with transthyretin cardiac amyloidosis.

Background: Transthyretin (ATTR) cardiac amyloidosis is associated with an apical-sparing strain pattern on TTE. We hypothesize that strain indices derived from myocardial perfusion imaging (MPI) can identify this abnormality. Methods: A group with ATTR amyloidosis was compared to age-matched controls with LVH but without amyloidosis who underwent PET or SPECT MPI. Strain values were used to calculate the apical strain index (ASI), apex-to-base ratio (ABR), and ejection fraction to global strain ratio in multiple planes. Results: A direct comparison using Welch's t-tests reveals 6 statistically significant metrics. After regression analysis, the circumferential ASI and ABR at rest remain significantly greater in the ATTR group compared to controls. Conclusion: MPI-derived strain from the circumferential plane at rest may distinguish cardiac amyloidosis from other forms of LVH. If these findings are confirmed with validation studies, routine MPI-derived strain analysis could identify patients with subclinical amyloidosis who may benefit from further testing.

Stress-Induced Autonomic Dysfunction is Associated With Mental Stress-Induced Myocardial Ischemia in Patients With Coronary Artery Disease.

BACKGROUND: Mental stress-induced myocardial ischemia (MSIMI) is associated with adverse cardiovascular outcomes in individuals with coronary artery disease, but the mechanisms underlying this phenomenon are unknown. We examined the relationship between stress-induced autonomic dysfunction, measured by low heart rate variability (HRV) in response to stress, and MSIMI in patients with stable coronary artery disease. We hypothesized that stress-induced autonomic dysfunction is associated with higher odds of MSIMI. METHODS: In 735 participants with stable coronary artery disease, we measured high- and low-frequency HRV in 5-minute intervals before and during a standardized laboratory-based speech stressor using Holter monitoring. HRV at rest and stress were categorized into low HRV (first quartile) versus high HRV (second to fourth quartiles); the low category was used as an indicator of autonomic dysfunction. Multivariable logistic regression models were used to examine the association of autonomic dysfunction with MSIMI. RESULTS: The mean age was 58 (SD, ±10) years, 35% were women, 44% were Black participants, and 16% developed MSIMI. Compared with high HRV during stress, low HRV during stress (both high and low frequencies) was associated with higher odds of MSIMI after adjusting for demographic and clinical factors (odds ratio for high-frequency HRV, 2.1 [95% CI, 1.3-3.3]; odds ratio for low-frequency HRV, 2.1 [95% CI, 1.3-3.3]). Low-frequency HRV at rest was also associated with MSIMI but with slightly reduced effect estimates. CONCLUSIONS: In individuals with coronary artery disease, mental stress-induced autonomic dysfunction may be a mechanism implicated in the causal pathway of MSIMI.

Preparing for the Artificial Intelligence Revolution in Nuclear Cardiology.

A major opportunity in nuclear cardiology is the many significant artificial intelligence (AI) applications that have recently been reported. These developments include using deep learning (DL) for reducing the needed injected dose and acquisition time in perfusion acquisitions also due to DL improvements in image reconstruction and filtering, SPECT attenuation correction using DL without need for transmission images, DL and machine learning (ML) use for feature extraction to define myocardial left ventricular (LV) borders for functional measurements and improved detection of the LV valve plane and AI, ML, and DL implementations for MPI diagnosis, prognosis, and structured reporting. Although some have, most of these applications have yet to make it to widespread commercial distribution due to the recency of their developments, most reported in 2020. We must be prepared both technically and socio-economically to fully benefit from these and a tsunami of other AI applications that are coming.

Left Ventricular Strain from Myocardial Perfusion PET Imaging: Method Development and Comparison to 2-Dimensional Echocardiography.

This study aimed to develop a measure of longitudinal, radial, and circumferential myocardial strain at rest and regadenoson during pharmacologic stress using 82Rb PET electrocardiography-gated myocardial perfusion imaging (MPI). Methods: We retrospectively identified 80 patients who underwent rest and regadenoson-stress CT attenuation-corrected 82Rb PET and had a standard resting transthoracic echocardiogram (TTE) with global longitudinal strain (GLS) analysis within 3 mo. A method was developed to compute longitudinal, radial, and circumferential strain from PET MPI at stress and rest. PET MPI-derived strain and left ventricular function were compared with resting TTE measures as the clinical reference standard. Interobserver agreement of PET MPI strain and left ventricular ejection fraction processing was reported. Results: Longitudinal strain assessed with resting TTE GLS showed good correlation with PET MPI at stress (r = 0.68, P < 0.001) and rest (r = 0.58, P < 0.001). Resting TTE GLS also correlated with PET MPI radial strain at stress (r = -0.70, P < 0.001) and rest (r = -0.59, P < 0.001) and circumferential strain at stress (r = 0.67, P < 0.001) and rest (r = 0.69, P < 0.001). The left ventricular ejection fraction showed good correlation between resting TTE and PET MPI at stress (r = 0.83, P < 0.001) and rest (r = 0.80, P < 0.001). Bland-Altman analysis indicated positive bias of TTE GLS compared with PET MPI longitudinal strain at stress (mean difference = 5.1%, 95% CI = [-2.5, 12.7]) and rest (mean difference = 4.2%, 95% CI = [-4.3, 12.8]). Reproducibility of PET MPI longitudinal strain showed good agreement at stress (concordance correlation coefficient = 0.73, P < 0.001) and rest (concordance correlation coefficient = 0.74, P < 0.001), with Bland-Altman analysis showing a small bias in the longitudinal direction at stress (mean difference = -0.2%) and rest (mean difference = -1.0%). Conclusion: Strain measured with PET MPI using an automated technique correlated well with resting GLS strain obtained by TTE, and the measure is reproducible. Strain from PET MPI should be investigated further to establish reference ranges and assess its value in routine clinical practice.

A Pilot Study of Neurobiological Mechanisms of Stress and Cardiovascular Risk.

Objective: Coronary heart disease is a leading cause of death and disability. Although psychological stress has been identified as an important potential contributor, mechanisms by which stress increases risk of heart disease and mortality are not fully understood. The purpose of this study was to assess mechanisms by which stress acts through the brain and heart to confer increased CHD risk. Methods: Coronary Heart Disease patients (N=10) underwent cardiac imaging with [Tc-99m] sestamibi single photon emission tomography at rest and during a public speaking mental stress task. Patients returned for a second day and underwent positron emission tomography imaging of the brain, heart, bone marrow, aorta (indicating inflammation) and subcutaneous adipose tissue, after injection of [18F]2-fluoro-2-deoxyglucose for assessment of glucose uptake followed mental stress. Patients with (N=4) and without (N=6) mental stress-induced myocardial ischemia were compared for glucose uptake in brain, heart, adipose tissue and aorta with mental stress. Results: Patients with mental stress-induced ischemia showed a pattern of increased uptake in the heart, medial prefrontal cortex, and adipose tissue with stress. In the heart disease group as a whole, activity increase with stress in the medial prefrontal brain and amygdala correlated with stress-induced increases in spleen (r=0.69, p=0.038; and r=0.69, p=0.04 respectfully). Stress-induced frontal lobe increased uptake correlated with stress-induced aorta uptake (r=0.71, p=0.016). Activity in insula and medial prefrontal cortex was correlated with post-stress activity in bone marrow and adipose tissue. Activity in other brain areas not implicated in stress did not show similar correlations. Increases in medial prefrontal activity with stress correlated with increased cardiac glucose uptake with stress, suggestive of myocardial ischemia (r=0.85, p=0.004). Conclusions: These findings suggest a link between brain response to stress in key areas mediating emotion and peripheral organs involved in inflammation and hematopoietic activity, as well as myocardial ischemia, in Coronary Heart Disease patients.

Semi-Automatic Reconstruction of Patient-Specific Stented Coronaries based on Data Assimilation and Computer Aided Design.

PURPOSE: The interplay between geometry and hemodynamics is a significant factor in the development of cardiovascular diseases. This is particularly true for stented coronary arteries. To elucidate this factor, an accurate patient-specific analysis requires the reconstruction of the geometry following the stent deployment for a computational fluid dynamics (CFD) investigation. The image-based reconstruction is troublesome for the different possible positions of the stent struts in the lumen and the coronary wall. However, the accurate inclusion of the stent footprint in the hemodynamic analysis is critical for detecting abnormal stress conditions and flow disturbances, particularly for thick struts like in bioresorbable scaffolds. Here, we present a novel reconstruction methodology that relies on Data Assimilation and Computer Aided Design. METHODS: The combination of the geometrical model of the undeployed stent and image-based data assimilated by a variational approach allows the highly automated reconstruction of the skeleton of the stent. A novel approach based on computational mechanics defines the map between the intravascular frame of reference (called L-view) and the 3D geometry retrieved from angiographies. Finally, the volumetric expansion of the stent skeleton needs to be self-intersection free for the successive CFD studies; this is obtained by using implicit representations based on the definition of Nef-polyhedra. RESULTS: We assessed our approach on a vessel phantom, with less than 10% difference (properly measured) vs. a customized manual (and longer) procedure previously published, yet with a significant higher level of automation and a shorter turnaround time. Computational hemodynamics results were even closer. We tested the approach on two patient-specific cases as well. CONCLUSIONS: The method presented here has a high level of automation and excellent accuracy performances, so it can be used for larger studies involving patient-specific geometries.

Clinically viable myocardial CCTA segmentation for measuring vessel-specific myocardial blood flow from dynamic PET/CCTA hybrid fusion.

BACKGROUND: Positron emission tomography (PET)-derived LV MBF quantification is usually measured in standard anatomical vascular territories potentially averaging flow from normally perfused tissue with those from areas with abnormal flow supply. Previously we reported on an image-based tool to noninvasively measure absolute myocardial blood flow at locations just below individual epicardial vessel to help guide revascularization. The aim of this work is to determine the robustness of vessel-specific flow measurements (MBFvs) extracted from the fusion of dynamic PET (dPET) with coronary computed tomography angiography (CCTA) myocardial segmentations, using flow measured from the fusion with CCTA manual segmentation as the reference standard. METHODS: Forty-three patients' 13NH3 dPET, CCTA image datasets were used to measure the agreement of the MBFvs profiles after the fusion of dPET data with three CCTA anatomical models: (1) a manual model, (2) a fully automated segmented model and (3) a corrected model, where major inaccuracies in the automated segmentation were briefly edited. Pairwise accuracy of the normality/abnormality agreement of flow values along differently extracted vessels was determined by comparing, on a point-by-point basis, each vessel's flow to corresponding vessels' normal limits using Dice coefficients (DC) as the metric. RESULTS: Of the 43 patients CCTA fully automated mask models, 27 patients' borders required manual correction before dPET/CCTA image fusion, but this editing process was brief (2-3 min) allowing a 100% success rate of extracting MBFvs in clinically acceptable times. In total, 124 vessels were analyzed after dPET fusion with the manual and corrected CCTA mask models yielding 2225 stress and 2122 rest flow values. Forty-seven vessels were analyzed after fusion with the fully automatic masks producing 840 stress and 825 rest flow samples. All DC coefficients computed globally or by territory were ≥ 0.93. No statistical differences were found in the normal/abnormal flow classifications between manual and corrected or manual and fully automated CCTA masks. CONCLUSION: Fully automated and manually corrected myocardial CCTA segmentation provides anatomical masks in clinically acceptable times for vessel-specific myocardial blood flow measurements using dynamic PET/CCTA image fusion which are not significantly different in flow accuracy and within clinically acceptable processing times compared to fully manually segmented CCTA myocardial masks.

Posttraumatic Stress Disorder, Myocardial Perfusion, and Myocardial Blood Flow: A Longitudinal Twin Study.

BACKGROUND: The link between posttraumatic stress disorder (PTSD) and ischemic heart disease remains elusive owing to a shortage of longitudinal studies with a clinical diagnosis of PTSD and objective measures of cardiac compromise. METHODS: We performed positron emission tomography in 275 twins who participated in two examinations approximately 12 years apart. At both visits, we obtained a clinical diagnosis of PTSD, which was classified as long-standing (both visit 1 and visit 2), late onset (only visit 2), and no PTSD (no PTSD at both visits). With positron emission tomography, we assessed myocardial flow reserve (MFR), which, in absence of significant coronary stenoses, indexes coronary microvascular function. We compared positron emission tomography data at visit 2 across the three categories of longitudinally assessed PTSD and examined changes between the two visits. RESULTS: Overall, 80% of the twins had no or minimal obstructive coronary disease. Yet, MFR was depressed in twins with PTSD and was progressively lower across groups with no PTSD (2.13), late-onset PTSD (1.97), and long-standing PTSD (1.93) (p = .01). A low MFR (a ratio <2.0) was present in 40% of the twins without PTSD, in 56% of those with late-onset PTSD, and in 72% of those with long-standing PTSD (p < .001). Associations persisted in multivariable analysis, when examining changes in MFR between visit 1 and visit 2, and within twin pairs. Results were similar by zygosity. CONCLUSIONS: Longitudinally, PTSD is associated with reduced coronary microcirculatory function and greater deterioration over time. The association is especially noted among twins with chronic, long-standing PTSD and is not confounded by shared environmental or genetic factors.

Obstructive sleep apnea, myocardial perfusion and myocardial blood flow: A study of older male twins.

BACKGROUND: Obstructive sleep apnea (OSA) has been associated with incidence of cardiovascular disease and with nocturnal angina, but evidence of a link with coronary atherosclerosis and myocardial ischemia is limited and previous studies may have been affected by selection bias or unmeasured confounding factors. METHODS: We performed overnight polysomnography in 178 older male twins. The Apnea/Hypopnea Index (AHI) was calculated to assess OSA from the overnight sleep evaluation. AHI ≥15 was used as indicator of moderate/severe OSA. The following day, twins underwent myocardial perfusion imaging with [82Rb]-chloride positron emission tomography. Quantitative and semiquantitative measures of myocardial perfusion and absolute myocardial blood flow were obtained. RESULTS: The mean age was 68 years and 40% of the sample had an AHI≥15, which indicates moderate to severe OSA. Abnormal myocardial perfusion, both with stress and at rest, was more common in twins with elevated AHI. After adjusting for clinical, lifestyle and behavioral factors, and previous history of cardiovascular disease, twins with AHI ≥15 had 3.6 higher odds (95% CI, 1.5-8.9) of an abnormal total severity score, defined as a score ≥100, and for each 5-point increment in AHI, the odds of abnormality increased by 20% (95% CI, 7%-34%). Twin pairs where both twins had OSA exhibited the greatest risk. There were no differences in measures of ischemia and absolute myocardial blood flow and flow reserve by AHI status. CONCLUSIONS: OSA is associated with myocardial perfusion abnormalities that suggest prior subclinical myocardial scarring or infarction. Early environmental factors that affect both twins equally may play a role and should be further explored.

Automatic Alignment of Myocardial Perfusion Images With Contrast-Enhanced Cardiac Computed Tomography.

Explicit fusion of perfusion data from Positron Emission Tomography (PET) or Single Photon Emission Computed Tomography (SPECT) with coronary artery anatomy from Computed Tomographic Coronary Angiography (CTA) has been shown to improve the diagnostic yield for coronary artery disease (CAD) compared to either modality alone. However, most clinically available methods were developed for multimodal scanners or require interactive alignment prior to display and analysis. A new approach was developed to register the two distributions obtained either from a single multimodal imager or from separate scanners, and a preliminary validation was undertaken to compare the automatic alignment to interactive alignment by two experts.