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Interventional Cardiology

Nuclear Imaging

Nuclear imaging studies (radionuclide imaging or radionuclide angiography) involve the use of small amounts of a radioactive substance (radionuclide) that targets the heart and a radionuclide detector that traces the absorption of the radioactive substance. The images produced may reveal problems in heart muscle and blood vessels, especially when the images of the heart at work and at rest are compared.

Mycoardial Perfusion Imaging

Myocardial perfusion (blood flow) imaging is the most widely used type of nuclear cardiology test and provides more information than routine exercise stress tests. It can be used to Identify areas of the heart muscle that have an inadequate blood supply, quantify the extent of the heart muscle with a limited blood flow, provide information about the heart’s pumping function, assess the amount of scarring from a heart attack, and evaluate the results of coronary bypass surgery or angioplasty

Thallium stress testing is done along with an exercise or pharmacologic stress test to provide additional information by using a radioactive substance to show how well blood flows to the heart muscle. It is useful in assessing the extent of a coronary artery blockage, damage from a heart attack, the effectiveness of procedures done to improve circulation in coronary arteries, the cause(s) of chest pain, or the level of exercise that a patient can safely perform.

When the patient reaches his/her maximum level of exertion, a small amount of thallium, a radioactive substance, is injected into the bloodstream. It travels with the blood to the heart. A thallium-sensitive “gamma camera” produces images showing where the bloodflow has transported the substance. If a part of the heart muscle doesn't receive a normal blood supply, then less than a normal amount of thallium will be in those heart muscle cells.

The first pictures are made shortly after the stress test and show blood flow to the heart during exercise. The patient then lies quietly for a certain period and another series of pictures is made to show the heart muscle during rest.

If the test is normal during both exercise and rest, then blood flow through the coronary arteries is normal. If the test shows that blood flow is normal during rest but not during exercise, then the heart isn't getting enough blood when it must work harder than normal, which may be due to a blockage in one or more coronary arteries.

If the test is abnormal during both exercise and rest, blood flow to that part of the heart is always limited. When no thallium is seen in some part of the heart muscle, the cells in that part of the heart are dead from a prior heart attack and have become scar tissue.

Positron Emission Tomography (PET) is a nuclear medicine medical imaging technique that produces a three-dimensional image of functional processes in the body. While other imaging scans such as CT and MRI isolate organic anatomic changes in the body, PET scanners are capable of detecting areas of molecular biology detail (even prior to anatomic change). The changing of regional blood flow in various anatomic structures can be visualized and relatively quantified with a PET scan.

Ventricular Function Testing

Another nuclear imaging study, the ventricular function test, is primarily used to evaluate how well the heart is pumping. Like an echocardiography, this test shows how much blood the heart can pump with each beat. It can also help assess the health of the cardiac chambers and valves, as well as monitor the effect of different drugs on the heart muscle.

Nuclear ventriculography – also called multiple-gated acquisition scan (MUGA), cardiac blood pooling imaging or equilibrium radionuclide angiography– is the most common test for determining if the heart’s left and right ventricles (the larger lower chambers of the heart) are functioning properly

The left ventricle, the strongest chamber in the heart, is the main pump of blood through the body. The left ventricular is assessed by measuring the amount (fraction) of all blood in the ventricle that is pumped (ejected) with each heartbeat (the ejection fraction), ventricle filling, and the blood flow into the pumping chamber. A normal ejection fraction is 50 percent or more. The heart's ejection fraction is one of the most important measures of its performance. The right ventricle's ability to pump blood to the lungs is also assessed, and any abnormalities in the heart wall are identified.

During the MUGA scan, electrodes are placed on the patient's body so that an electrocardiogram (ECG) can be conducted. The imaging equipment and computer are synchronized with the ECG so that images of the heart can be recorded without motion or blur. Then a small amount of a mildly radioactive substance called technetium is injected, usually into an arm vein.

The technetium, also called a “tagging agent,” attaches to the red blood cells and passes through the heart in the circulating blood. While the patient lies motionless on the test table, a “gamma scintillation camera” follows the movement of the technetium. The camera, which looks like an x-ray machine and is suspended above the table, moves back and forth over the patient. It displays multiple images of the heart in motion and records them on a computer for later analysis.

The MUGA scan can be done with the patient at rest or exercising (called a stress MUGA). The stress MUGA is often performed in patients who have or are suspected of having coronary artery disease. The resting MUGA is compared with the stress MUGA and changes in the heart's pumping performance are analyzed.

If the patient's heart is normal, the technetium will appear to be evenly distributed in the scans. (In a stress MUGA, patients with normal hearts will exhibit an increase in ejection fraction or no change.)

An uneven distribution of technetium in the heart indicates that the patient has coronary artery disease, a cardiomyopathy, or blood shunting within the heart.