Hybrid Image Visualization Tool for 3D integration of CT coronary anatomy and quantitative myocardial perfusion PET

Purpose: Multimodal cardiac imaging by CTA and quantitative PET enables acquisition of patient-specific coronary anatomy and absolute myocardial perfusion at rest and during stress. In the clinical setting, integration of this information is performed visually or using coronary arteries distribution models. We developed a new tool for CTA and quantitative PET integrated 3D visualization, exploiting XML and DICOM clinical standards. Methods: The Hybrid Image Tool (HIT) developed in the present study included four main modules: (1) volumetric registration for spatial matching of CTA and PET datasets, (2) an interface to PET quantitative analysis software, (3) a derived DICOM generator able to build DICOM dataset from quantitative polar maps, and (4) a 3D visualization tool of integrated anatomical and quantitative flow information. The four modules incorporated in the HIT tool communicate by defined standard XML files: XML-transformation and XML MIST standards. Results: The HIT tool implements a 3D representation of CTA showing real coronary anatomy fused to PET derived quantitative myocardial blood flow distribution. The technique was validated on 16 datasets from EVINCI study population. The validation of the method confirmed the high matching between "original" and derived datasets as well as the accuracy of the registration procedure. Conclusions: Three-dimensional integration of patient-specific coronary artery anatomy provided by CTA and quantitative myocardial blood flow obtained from PET imaging can improve cardiac disease assessment. The HIT tool introduced in this paper may represent a significant advancement in the clinical use of this multimodal approach

Multicentre multi-device hybrid imaging study of coronary artery disease: results from the EValuation of INtegrated Cardiac Imaging for the Detection and Characterization of Ischaemic Heart Disease (EVINCI) hybrid imaging population

AIMS: Hybrid imaging provides a non-invasive assessment of coronary anatomy and myocardial perfusion. We sought to evaluate the added clinical value of hybrid imaging in a multi-centre multi-vendor setting. METHODS AND RESULTS: Fourteen centres enrolled 252 patients with stable angina and intermediate (20-90%) pre-test likelihood of coronary artery disease (CAD) who underwent myocardial perfusion scintigraphy (MPS), CT coronary angiography (CTCA), and quantitative coronary angiography (QCA) with fractional flow reserve (FFR). Hybrid MPS/CTCA images were obtained by 3D image fusion. Blinded core-lab analyses were performed for CTCA, MPS, QCA and hybrid datasets. Hemodynamically significant CAD was ruled-in non-invasively in the presence of a matched finding (myocardial perfusion defect co-localized with stenosed coronary artery) and ruled-out with normal findings (both CTCA and MPS normal). Overall prevalence of significant CAD on QCA (>70% stenosis or 30-70% with FFR 640.80) was 37%. Of 1004 pathological myocardial segments on MPS, 246 (25%) were reclassified from their standard coronary distribution to another territory by hybrid imaging. In this respect, in 45/252 (18%) patients, hybrid imaging reassigned an entire perfusion defect to another coronary territory, changing the final diagnosis in 42% of the cases. Hybrid imaging allowed non-invasive CAD rule-out in 41%, and rule-in in 24% of patients, with a negative and positive predictive value of 88% and 87%, respectively. CONCLUSION: In patients at intermediate risk of CAD, hybrid imaging allows non-invasive co-localization of myocardial perfusion defects and subtending coronary arteries, impacting clinical decision-making in almost one every five subjects

A modular informatics platform for effective support of collaborative and multicenter studies in cardiology

Collaborative and multicenter studies permit a large number of patients to be enrolled within a reasonable time and providing the opportunity to collect different data. Informatics platforms play an important role in management, storage, and exchange of data between the participants involved in the study. In this article, we describe a modular informatics platform designed and developed to support collaborative and multicenter studies in cardiology. In each developed module, data management is implemented following local defined protocols. The modular characteristic of the developed platform allows independent transfer of different kinds of data, such as biological samples, imaging raw data, and patients' digital information. Moreover, it offers safe central storage of the data collected during the study. The developed platform was successfully tested during a European collaborative and multicenter study, focused on evaluating multimodal non-invasive imaging to diagnose and characterize ischemic heart disease

EVINCI study: management, integration and communication of clinical and imaging data

The EVINCI European study (Evaluation of INtegrated Cardiac Imaging for the Detection, Characterization and Monitoring of Ischemic Heart Disease - number 222915) aims to evaluate the impact of a combined non-invasive anatomo-functional cardiac imaging strategy on the detection and management of ischemic heart disease (700 scheduled patients among 17 centers and 9 Countries). To reach this purpose for each patient we collected clinical, biohumoral, functional and anatomical imaging data. The large and complex amount of data required a dedicated technological work package for managing, integrating and reporting them in order to support medical decision and communication. We focused on the development of a system oriented to save and handle information, store raw images and to provide tools for imaging integration, multimodal reporting and educational purposes

A new web-based educational tool for training in multimodal cardiac imaging

Purpose: The dynamic evolution of cardiac multimodal imaging is based on the increasing clinical interest on the use of different and complementary data to evaluate cardiac diseases. This is supported by the development of technologies related to single or hybrid imaging devices. The increasing use of combined imaging for diagnosis and clinical decision requires to choose an appropriate diagnostic path combining, step by step, invasive and/or noninvasive tests. The cost- risk- benefits balance represents the key element of multimodal path definition. The purpose of this work is to present a new web-based educational tool (EduCAD) directed to young cardiologists for training in the appropriate use of multimodal imaging technology for diagnosis of ischemic heart disease, thus promoting the culture of multimodal imaging for cardiac diseases assessment. The main proposal is to allow user to choose among different validated clinical cases and to build up for each case an optimal imaging diagnostic pathway on the basis of clinical evidence and appropriateness criteria for the use of noninvasive and invasive tests. The final user\u27s conclusion and diagnostic imaging pathway is compared to the opinion of expert specialists. EduCAD website offers several clinical cases accurately selected from the EVINCI study (European Project: Evaluation of INtegrated Cardiac Imaging for the Detection, Characterization and Monitoring of Ischemic Heart Disease, 7th FWP, reference number 222915) population in order to train the user in relevant pathological conditions. Methods: The web-based educational software has been developed using Adobe Flash technology (Adobe Systems incorporated, San Jose, California) and included into a dedicated website (Fig. 1). Further project information and useful instructions to the best use of the educational tool are also added to the site. Each clinical case provided by the EduCAD tool is composed by both stress imaging and anatomical imaging (Fig. 2). In the first case, PET or SPECT, for myocardial perfusion evaluation, and MR or ECHO for the assessment of myocardial wall motion are provided. Generally both CTA and ICA anatomical tests, used to estimate the degree of coronary artery stenosis, are supplied. This could be useful to compare noninvasive test with the invasive one that represents the gold standard in anatomic evaluation. For each involved modality, the educational software has been implemented in order to show standard views images, normally used in clinical assessment. EduCAD expert\u27s opinion is given for each modality as well as for diagnostic and therapeutic conclusions. Starting from the evaluation of pre and post stress-ECG CAD probability, the user may choose to start his diagnostic investigation. At each step the user can choose between available imaging modalities, in order to acquire new data with the purpose to give his final opinion on the evaluated clinical case. Two educational constraints limit the player to include at most one stress imaging and not to choose other tests after the selection of the ICA invasive modality. At each step of the pathway, the user is asked to give his modality evaluation and optionally to compare it with the expert\u27s opinion. At the end, the user must give his final diagnosis and related therapy. Moreover, at this stage, a general comment on the clinical case and on the suggested pathway is provided by the expert specialists. If needed the users will be able to review and/or replay the clinical case making a more accurate analysis. Results: The first release of the EduCAD educational tool was tested using 10 clinical cases select from the EVINCI study. The involved young and expert cardiologists gave a good opinion about the developed tool. Conclusion: The proposed educational tool has been developed with the purpose to train young cardiologists in the use of multimodal imaging. This goal has been pursued considering both the accuracy of clinical diagnosis and therapy and the appropriateness of multimodal imaging pathway used to reach the final decision. Moreover, the developed educational tool has the potential to train in the evaluation of hybrid images resulting from the integration and fusion of different modalities. In a more advanced idea the user will be allowed to connect directly with a dedicated imaging server and access the raw imaging data performing his own reconstruction and analysis before giving his interpretation. In the next project scenario the new clinical cases will be validated and selected by a dedicated scientific committee and new technological solutions will be considered

Detection of significant coronary artery disease by noninvasive anatomical and functional imaging.

BACKGROUND The choice of imaging techniques in patients with suspected coronary artery disease (CAD) varies between countries, regions, and hospitals. This prospective, multicenter, comparative effectiveness study was designed to assess the relative accuracy of commonly used imaging techniques for identifying patients with significant CAD. METHODS AND RESULTS A total of 475 patients with stable chest pain and intermediate likelihood of CAD underwent coronary computed tomographic angiography and stress myocardial perfusion imaging by single photon emission computed tomography or positron emission tomography, and ventricular wall motion imaging by stress echocardiography or cardiac magnetic resonance. If ≥1 test was abnormal, patients underwent invasive coronary angiography. Significant CAD was defined by invasive coronary angiography as >50% stenosis of the left main stem, >70% stenosis in a major coronary vessel, or 30% to 70% stenosis with fractional flow reserve ≤0.8. Significant CAD was present in 29% of patients. In a patient-based analysis, coronary computed tomographic angiography had the highest diagnostic accuracy, the area under the receiver operating characteristics curve being 0.91 (95% confidence interval, 0.88-0.94), sensitivity being 91%, and specificity being 92%. Myocardial perfusion imaging had good diagnostic accuracy (area under the curve, 0.74; confidence interval, 0.69-0.78), sensitivity 74%, and specificity 73%. Wall motion imaging had similar accuracy (area under the curve, 0.70; confidence interval, 0.65-0.75) but lower sensitivity (49%, P<0.001) and higher specificity (92%, P<0.001). The diagnostic accuracy of myocardial perfusion imaging and wall motion imaging were lower than that of coronary computed tomographic angiography (P<0.001). CONCLUSIONS In a multicenter European population of patients with stable chest pain and low prevalence of CAD, coronary computed tomographic angiography is more accurate than noninvasive functional testing for detecting significant CAD defined invasively. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00979199