Ernst E. van der Wall - Böcker

Since the introduction of myocardial perfusion imaging and radionuclide angiography in the mid-seventies, cardiovascular nuclear medicine has undergone an explosive growth. The use of nuclear cardiology techniques has become one of the cornerstones of the noninvasive assessment of coronary artery disease. In the past 15 years major steps have been made from visual analysis to quantitative analysis, from planar imaging to tomographic imaging, from detection of disease to prognosis, and from separate evaluations of perfusion, metabolism, and function to an integrated assessment of myocardial viability. In recent years many more advances have been made in cardiovascular nuclear imaging, such as the development of new imaging agents, reevaluation of existing procedures, and new clinical applications. This book describes the most recent developments in nuclear cardiology and also addresses new contrast agents in MRI. What's New in Cardiac Imaging will assist the clinical cardiologist, the cardiology fellow, the nuclear medicine physician, and the radiologist in understanding the most recent achievements in clinical cardiovascular nuclear imaging.

This text is based on a joint symposium organized by the Departments of Cardiology, Diagnostic Radiology and Nuclear Medicine of the University Hospital Leiden and the Cleveland Clinical International Center. Both centers have a long-standing reputation in the various aspects of cardiac imaging techniques and in their clinical applications. Faculty members from each of the two centers have written reviews in those areas in which they have experience, selecting advances in imaging techniques in ischemic heart disease as the central topic. All major imaging techniques are addressed: echocardiography, cardiovascular nuclear medicine, magnetic resonance, and contrast angiography. All chapters are written with the appropriate technique as well as the specific disease in mind. Recent developments in the field mean that the diagnosis of ischemic heart disease has become more accurate, with an inherent improvement in patient management. The book should help the physician differentiate and recognize the viability of the myocardium in ischemic heart disease.

The importance of left ventricular hypertrophy (LVH) in cardiovascular disease has gained wide recognition. LVH is a highly important risk factor associated with major cardiovascular events, including symptomatic heart failure, particularly in patients with systemic hypertension. In recent years much has been learned about the genetics, molecular background, prevalence, incidence and prognosis of LVH. A variety of noninvasive methods has emerged for detecting LVH and the assessment of reversal of hypertrophy, yet a lot of controversy remains about the connotations and clinical implications of LVH. For instance, in the athlete's heart LVH may constitute a physiological adaptation to pressure overload, which normalizes following discontinuation of strenuous physical activity. On the other hand, in particular in patients with hypertension, LVH denotes a serious prognosis in the course of hypertension. In these patients LVH should be regarded as a grave prognostic sign rather than an innocent compensatory phenomenon. The distinction between physiologic and pathophysiologic LVH is the basis for this book.The text is a bibliographical reflection of a Boerhaave Symposium held on April 9, 1999, in Leiden, The Netherlands. At this symposium the major issues in dealing with LVH were discussed, including etiology, genetics, detection, and therapy. In particular, the book includes advances in detection methods for LVH such as magnetic resonance imaging and spectroscopy. Furthermore, much attention was paid to the molecular and genetic approach of LVH. This book should be useful to clinical cardiologists, fellows in cardiology, general internists, radiologists, cardiothoracic surgeons, biochemists, physiologists, pharmacologists, and basic research fellows in understanding the most recent insights in the background of physiologic versus pathologic LVH.

AMI E. ISKANDRIAN & ERNST E. VAN DER WALL The first edition of this book was published in 1994. Since then important advances have occurred in the field of myocardial viability. This, coupled with increasing interest by the scientific community in the broader issues of its relevance to patient care, suggested to us the need to write the second edition. We are most fortunate to have the help of a distinguished group of experts who have helped shape the field; we appreciate their commitments and contributions. Almost all chapters have been radically modified. Chapter 1 deals with pathophysiology of myocardial hibernation and stunning; Chapter 2 with apoptosis; Chapter 3 with the role of positron emission tomography; Chapters 4 and 5 with the role of single photon emission computed tomography with thallium-201 and technetium agents, respectively; Chapter 6 with the role of SPECT fatty acid imaging; Chapter 7 with the role of SPECT FDG imaging; Chapter 8 with the role of cardiac catheterization angiography; Chapter 9 with the role of echocardiography; Chapter 10 with the role of magnetic resonance imaging; and Chapter 11 with clinical applications. Finally, Chapter 12 provides a short summary.

In Advanced Imaging in Coronary Artery Disease, the role of several imaging techniques in diagnosing atherosclerosis, assessment of myocardial ischemia, myocardial viability, and heart failure are broadly discussed. The issues derived from cardiac PET are presented in relation to the conventional techniques, such as echocardiography, SPECT and MRI. In addition, newer imaging techniques such as intracoronary ultrasound, electron beam computed tomography, and Raman spectroscopy are given wide attention. The effects of drug treatment, such as anti-ischemic and lipid-lowering drugs, are also evaluated. This book will assist clinical cardiologists, nuclear medicine physicians, fellows in cardiology and nuclear medicine, radiochemists, basic research fellows, and technicians, in understanding the new advances in clinical cardiac PET.

Myocardial viability has become one of the most important issues in clinical cardiology. In particular, absence or presence of viability may be decisive in patient management, and the decision to perform angioplasty (PTCA) or bypass surgery (CABG) is frequently based on the accurate assessment of viability. Although echocardiography and conventional nuclear medicine techniques may provide valuable information on viability, positron emission tomography (PET) is currently considered to be the gold standard for the assessment of myocardial viability. The simultaneous evaluation of myocardial metabolism and perfusion allows precise delineation and accurate quantification of residual myocardial viability in affected regions. In addition, accurate quantification of myocardial perfusion alone may provide insight into the basic mechanisms of syndrome X and may assist in the appropriate clarification of this clinically complicated, but frequently occurring phenomenon. Besides that, cardiac PET may deepen our insight into metabolism and perfusion of cardiac muscle disease, particularly in hypertrophic cardiomyopathy. Furthermore, receptor imaging studies with PET will become important as the study of cardiac neurohumoral regulation in heart failure has gained in interest. Cardiac Positron Emission Tomography: Viability, Perfusion, Receptors and Cardiomyopathy describes the most recent developments in cardiac PET as these are related to myocardial viability and myocardial perfusion studies of syndrome X. The value of PET for receptor imaging and cardiac muscle disease is also discussed. For cardiologists, nuclear medicine physicians, radiochemists, physiologists, technicians and basic researchers interested in understanding the most recent achievements in cardiovascular PET.

In recent years there have been tremendous advances in cardiac imaging techniques covering the complete spectrum from echocardiography, nuclear cardiology, magnetic resonance imaging to contrast angiography. With respect to these noninvasive and invasive cardiac imaging modalities, marked technological developments have allowed the cardiologist to visualize the myocardium in a far more refined manner than conventional imaging was capable of. Echocardiography has extended its domain with intravascular ultrasound, cardiovascular nuclear imaging has added positron emission tomography to its line of research, magnetic resonance imaging has been broadened with magnetic resonance angiography and spectroscopy, and finally contrast angiograp­ hy has widened its scope with excellent quantitation programs. For all these imaging modalities it is true that the application of dedicated quantitative analytic software packages enables the evaluation of the imaging studies in a more accurate, reliable, and reproducible manner. It goes without saying that these extensions and achievements have resulted in improved diagnostics and subsequently in improved patient care. Particularly in patients with ischemic heart disease, major progress has been made to detect coronary artery disease in an early phase of the disease process, to follow the atherosclerotic changes in the coronary arteries, to establish the functional and metabolic consequences of the luminal obstructions, and to accurately assess the results of interventional therapy.

In the past few years it has become clear that left ventricular dysfunction, even of severe degree, may be reversible after coronary revascularization in some patients. As a result, myocardial viability has captured the imagination of researchers and clinicians seeking to unravel the cellular and subcellular mechanisms and define appropriate diagnostic modalities. These diagnostic modalities include: cardiac catheterization, positron-emission tomography, magnetic resonance imaging, two-dimensional echocardiography and single-photon imaging. This book, for the first time, brings together a diverse array of information in a comprehensive and concise fashion using a template of ten chapters written by experts in the field. It will be required reading for cardiologists, radiologists, nuclear medicine specialists, cardiac surgeons, anesthesiologists, internists and basic researchers and their trainees who are involved in the management of patients with coronary artery disease in whom myocardial viability is a clinically relevant issue.

Since the introduction of myocardial perfusion imaging and radionuclide angiography in the mid-seventies, cardiovascular nuclear medicine has undergone an explosive growth. The use of nuclear cardiology techniques has become one of the cornerstones of the noninvasive assessment of coronary artery disease. In the past 15 years major steps have been made from visual analysis to quantitative analysis, from planar imaging to tomographic imaging, from detection of disease to prognosis, and from separate evaluations of perfusion, metabolism, and function to an integrated assessment of myocardial viability. In recent years many more advances have been made in cardiovascular nuclear imaging, such as the development of new imaging agents, reevaluation of existing procedures, and new clinical applications. This book describes the most recent developments in nuclear cardiology and also addresses new contrast agents in MRI. What's New in Cardiac Imaging will assist the clinical cardiologist, the cardiology fellow, the nuclear medicine physician, and the radiologist in understanding the most recent achievements in clinical cardiovascular nuclear imaging.

In recent years there have been major advances in the fields of cardiovascular nuclear medicine and cardiac magnetic resonance imaging. In nuclear cardiology more adequate tomographic systems have been designed for routine cardiac use, as well as new or improved quantitative analytic software packages both for planar and tomographic studies implemented on modern state-of-the-art workstations. In addition, artificial intelligence techniques are being applied to these images in attempts to interpret the nuclear studies in a more objective and reproducible manner. Various new radiotracers have been developed, such as antimyosin, labeled isonitriles, metabolic compounds, etc. Furthermore, alternative stress testing with dipyridamole and dobutamine has received much attention in clinical cardiac practice. Magnetic resonance imaging is a relative newcomer in cardiology and has already shown its merits, not only for anatomical information but increasingly for the functional aspects of cardiac performance. This book covers almost every aspect of quantitative cardiovascular nuclear medicine and magnetic resonance imaging. It will assist the nuclear medicine physician, the radiologist, the physicist/image processing specialist and the clinical cardiologist in understanding the nuclear medicine techniques used in cardiovascular medicine, and in increasing our knowledge of cardiac magnetic resonance imaging.

Cardiovascular nuclear medicine emerged 15 years ago as a new noninvasive technique for the detection of human cardiac disease. It arised from the fields of nuclear medicine and cardiology and the cooperation of both specialties has been very productive. At present, nuclear cardiology techniques belong to the routine armamentarium of the clinical cardiologist. Results obtained by perfusion markers, metabolic tracers, and radionuclide angiography have shown to have important impact on patient management. Although exercise electrocardiography and echocar­ diography yield the large bulk of necessary data in the cardiac patient, nuclear cardiology provides important data that go far beyond the results obtained by the standard procedures. Magnetic resonance imaging is a relative newcomer in cardio­ logy and has still to prove its value in clinical cardiology . Yet, initial results have been encouraging both in congenital heart disease and in coronary artery disease. This book is based on 16 review publications that have been written throughout the period of 1985 till present time. Most chapters have been published in the period 1989 until 1991; the preceding review papers have been updated as much as possible. Furthermore, Chapter 15 entitled" What's new in cardiac imaging" has been espe­ cially written for this book. The Chapters 9, 11 and 13 have been recently written and have not been published yet.

It is with pleasure that I write this foreword for the book "Magnetic Resonance Imaging in Coronary Artery Disease", edited by Dr. van der Wall and Dr. de Roos. I am pleased for two reasons. Firstly, as chairman of the Scientific Board of the Interuniversity Cardiology Institute of the Netherlands (ICIN), because ever since the technique became available for use in medicine and biology our Institute has tried and succeeded to promote the introduction and dev- opment of magnetic resonance imaging in cardiology in the Netherlands. ICIN was the first cardiological institute on the European continent to purchase its own nuclear magnetic resonance spectroscope for the study of myocardial metabolism. Secondly, because I have always been infatuated with this noninvasive technique that can produce cardiac images without ionic radiation and at the same time allows for the study of myocardial metabolism as well. And even more so because nuclear magnetic resonance imaging in medicine is one of the shining examples of medical progress as a result of breakthrough discoveries in physics and chemistry.

AMI E. ISKANDRIAN & ERNST E. VAN DER WALL The first edition of this book was published in 1994. Since then important advances have occurred in the field of myocardial viability. This, coupled with increasing interest by the scientific community in the broader issues of its relevance to patient care, suggested to us the need to write the second edition. We are most fortunate to have the help of a distinguished group of experts who have helped shape the field; we appreciate their commitments and contributions. Almost all chapters have been radically modified. Chapter 1 deals with pathophysiology of myocardial hibernation and stunning; Chapter 2 with apoptosis; Chapter 3 with the role of positron emission tomography; Chapters 4 and 5 with the role of single photon emission computed tomography with thallium-201 and technetium agents, respectively; Chapter 6 with the role of SPECT fatty acid imaging; Chapter 7 with the role of SPECT FDG imaging; Chapter 8 with the role of cardiac catheterization angiography; Chapter 9 with the role of echocardiography; Chapter 10 with the role of magnetic resonance imaging; and Chapter 11 with clinical applications. Finally, Chapter 12 provides a short summary.

The importance of left ventricular hypertrophy in cardiovascular disease has gained wide recognition. Left ventricular hypertrophy is a highly important risk factor associated with major cardiovascular events, including symptomatic heart failure, particularly in patients with systemic hypertension. Over the past years much has been learned about the genetics, molecular background, prevalence, incidence and prognosis of left ventricular hypertrophy. A variety of noninvasive methods has emerged for detecting left ventricular hypertrophy and the assessment of reversal of hypertrophy. Yet, a lot of controversy remains about the connotations and clinical implications of left ventricular hypertrophy. For instance, in the athlete's heart left ventricular hypertrophy may constitute a physiological adaptation to pressure overload, which normalizes following discontinuation of strenuous physical activity. On the other hand, in particular in patients with hypertension, left ventricular hypertrophy denotes a serious prognosis in the course of hypertension. In these patients left ventricular hypertrophy should be regarded as a grave prognostic sign rather than an innocent compensatory phenomenon. The distinction between physiologic and pathophysiologic left ventricular hypertrophy has been the basis for this book.

What's New in Cardiovascular Imaging is a bibliographical "image" of a Symposium held June 22-24, 1998 in Leiden, the Netherlands. At this Symposium all the major advances in car­ diovascular imaging in all the cardiovascular imaging modalities (X-ray, (intravascular) ultra­ sound, magnetic resonance, scintigraphy and CT) were addressed by the leading authorities in this field. Based on the presentations of the invited Faculty, this book consists of a compi­ lation of manuscripts related to most of the topics discussed at this particular meeting. We express our gratitude to all authors and coauthors for having made great efforts in preparing their superb up-to-date chapters under a great time pressure, so that this book was available at the time of the Symposium. The authors are all excellent investigators in one or more fields of cardiovascular imaging and they have stimulated progress in cardiovascular imaging with the aim to improve patient care and clinical research. This book consists of a total of 32 chapters subdivided into seven Parts. Each part describes a particular field in cardiovascular imaging. These Parts are: Coronary quantitation by QCA and intracoronary ultrasound (QCU), angiographic trials, progress in intravascular ultrasound, magnetic resonance (MR) coronary and vascular imaging, nuclear cardiovascular imaging, echocardiography, and cine and spiral CT coronary imaging. In general, each Part begins with a chapter that provides a broad overview of the advances in the field described in that particular Part, as well as a view towards the future.

Based on a number of collaborative efforts between basic researchers and clinicians from different institutions in Leiden, this book covers the initial and promising results of these efforts. The role of the endothelium, especially of the coronary intravascular species is a relatively new and fascinating development in the diagnosis and treatment of cardiac disease. Three major aspects of endothelial function receive attention in this volume: its regulatory role in myocardial function, evidence for which is gradually forthcoming, with possible great implications for disease states such as volume overload and failure its role in the calcium metabolism of vascular smooth muscle cells and the effects of calcium antagonists and the endothelial dysfunction generated by coronary angioplasty and its possible restoration by cholesterol reduction. The topic of imaging atherosclerotic lesions in the coronary arteries is discussed with the emphasis on advanced methods: single photon emission computed tomography (SPECT), positron emission tomography (PET), and magnetic resonance imaging techniques. A wholly new development is the characterization of the atherosclerotic lesion by Raman spectroscopy using a laser beam to illuminate the vascular wall. Various aspects of inflammation related to the pathogenesis of acute coronary syndromes, in particular unstable angina, are illuminated, as well as the role of blood-borne substances as risk factors for atherosclerosis. Transgenic mice carrying the gene for human APOE*3 Leiden are being used successfully to study the environmental and genetic factors that influence the remnant lipoprotein metabolism. Possibilities for gene therapy to treat atherosclerosis in the clinic are being investigated in animal models. Finally, as the book is based on 50 years of Cardiology in Leiden, the history of its development up to the present day is the topic of a separate chapter. This book is intended for cardiologists, internal medicine specialists, nuclear medicine specialists, thoracic surgeons, cardiovascular radiologists and basic scientists in the field of the cardiovascular system.

In the past, coronary arteriography was the only modality available to provide high quality images of the coronary anatomy. Quantitative coronary arteriography (QCA) was developed, implemented, validated and extensively applied to obtain accurate and reproducible data about coronary morphology and the functional significance of coronary obstructions. Over the last few years extensive basic technological research supported by clinical investigations has created competing modalities to visualize coronary morphology and the associated perfusion of the myocardial muscle. Currently, the following modalities are available: X-ray coronary arteriography, intracoronary ultrasound, contrast- and stress-echocardiography, angioscopy, nuclear cardiology, magnetic resonance imaging, and cine and spiral CT imaging. For all these imaging modalities, the application of dedicated quantitative analytical software packages enables the evaluation of the imaging studies in a more accurate, reliable, and reproducible manner. These extensions and achievements have resulted in improved diagnostics and subsequently in improved patient care. Particularly in patients with ischaemic heart disease, major progress has been made to detect coronary artery disease in an early phase of the disease process, to follow the atherosclerotic changes in the coronary arteries, to establish the functional and metabolic consequences of the luminal obstructions, and accurately to assess the results of interventional therapy. Aside from all these high-tech developments in cardiac imaging techniques, the transition from the analogue to the digital world has been going on for some time now. For the future, it has been predicted that the CD-R will be the exchange medium for cardiac images and DICOM-3 the standard file format. This has been a major achievement in the field of standardization activities. Since these developments will have a major impact on the way images willbe stored, reviewed and exchanged in the near future, an important part of this book has been dedicated to DICOM and the filmless catheterization laboratory. Cardiovascular Imaging will assist cardiologists, radiologists, nuclear medicine physicians, image processing specialists, physicists, basic scientists, and fellows in training for these specialties to understand the most recent achievements in cardiac imaging techniques and their impact on cardiovascular medicine.