CedarsSinai Nuclear Cardiology

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Cedars-Sinai Artificial Intelligence
Program
Guido Germano, PhD Quantitative analysis of gated
myocardial perfusion/function SPECT data
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Disclosure
Cedars-Sinai Medical Center receives royalties
from the licensing of some of the algorithms
described in this talk. A minority portion of
such royalties is shared by the algorithm
developers.
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Minimal QC of quantitative output
Review the rotating projection images for
patient (or organ) motion, extracardiac
activity, flashing patterns, low counts
Verify that the quantitative contours follow the
myocardial surfaces (review images while
toggling contours on and off) If study was
gated, check the time-volume curve to ensure its
shape is not grossly deformed
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Validation of QGS LVEF (I) papers only

pts. LVEF Germano et al 1st
pass 65 r0.91 99mTc JNM
1995112138 He et al. 1st
pass 63 r0.85 99mTc JNC 19994412 He
et al. 1st pass 63 r0.84
201-Tl JNC 19994412 Inubushi et al. 1st
pass 44 r0.92 I-123 JNM
1999111840 Vallejo et al. 1st pass
365 r0.74 99mTc JNC
20005461 Everaert et al. MUGA 40 r0.93
99mTc JNC 19976472 Yoshioka et al.
MUGA 21 r0.87 99mTc JNM
1999101693 Manrique et al. MUGA 55 r0.94
201-Tl EJNM 20006694 Chua et al.
MUGA 62 r0.94 99mTc JNC
20004301 Kikkawa et al. MUGA 24 r0.95
99mTc EJNM 20015593 Kumita et al.
MUGA 48 r0.91-0.94 99mTc JNC
20018568 Nakajima et al. MUGA 30 r0.82
99mTc JNM 2001421571 Higuchi et al.
MUGA 52 r0.90 99mTc EJNM
2001281512 Nanasato et al. MUGA 36 r0.93
99mTc JNM 2001421747
...
5
Validation of QGS LVEF (II) papers only

pts. LVEF Nanasato et al.
MUGA 36 r0.91 I-123 JNM
2001421747 Cwajg et al. Echo
180 r0.72-0.79 201-Tl JNM
1999111857 Bacher-Stier et al. Echo 72
r0.76-0.86 201-Tl EJNM 1999121533 Nichols et
al. Echo 33 r0.75 99mTc JNM
200081308 Abe et al. Contrast
229 r0.78 99mTc JNC 20006569 Vourvouri
et al. Contrast 32 r0.83 99mTc EJNM
2001281610 Atsma et al.
Contrast 74 r0.92 99mTc IJCI
20006447 Vaduganathan et al. MRI 25 r0.93
99mTc JNC 199913 Tadamura et al.
MRI 20 r0.94 99mTc JACC 19994991 Tadamura
et al. MRI 20 r0.92 201-Tl JACC
19994991 Tadamura et al.
MRI 16 r0.89 99mTc EJNM 19997705 Bax et
al. MRI 22 r0.90
99mTc AJC 2000121299 Bavelaar-Croon et al.
MRI 21 r0.85 99mTc Radiology
20002572 Faber et al.
MRI 30 r0.72 99mTc JNC 20018645
...
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Validation of QGS LVEF (III) papers only

pts. LVEF Thorley et al.
MRI 50 r0.82 99mTc NM
Comm 20037763 Lipke et al. MRI
54 r0.90 99mTc EJNM
200431482 TOTAL
1882 r0.87
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Validation of non-QGS LVEF (I) papers
abstracts
Emory Toolbox pts. LVEF
Nakajima et al. MUGA 30 r0.78 99mTc
JNM 2001421571 Higuchi et al.
MUGA 25 r0.88 99mTc JNC 20018S64
(abstr) Faber et al. 1st
pass 79 r0.82 99mTc JNM
199940650 Nichols et al.
echo 33 r0.72 99mTc JNM
2000411308 Faber et al.
MRI 10 r0.88 99mTc JNM
199940650 Vansant et al.
MRI 31 r0.81 99mTc JNM
200081308 Faber et al.
MRI 30 r0.70 99mTc JNC
20018645 4D-MSPECT Nakajima et al.
MUGA 30 r0.69 99mTc JNM
2001421571 Higuchi et al.
MUGA 25 r0.82 99mTc JNC 20018S64
(abstr) Gayed et al. echo 30
r0.84-0.86 99mTc JNM 200142177P
(abstr) Ficaro et al. contrast 90 r0.81
99mTc Circ 1999100I26 (abstr) Chugh et al.
contrast 97 r0.87 unknown JACC
200137394A (abstr) Cahill et al.
MRI 26 r0.97 99mTc JNM 200344197P
(abstr) Lipke et al. MRI 54 r0.89
99mTc EJNM 200431482
...
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Validation of non-QGS LVEF (II) papers
abstracts

pts. LVEF Yale CQ
Lam et al. MUGA 24 r0.88 99mTc
JNM 20014293P (abstr) Lam et al. 1st
pass 117 r0.78 99mTc JNM
20014293P (abstr) MultiDim Everaert et al.
MUGA 50 r0.93 99mTc EJNM
1996121628 Everaert et al.
MUGA 40 r0.94 99mTc JNC
19976472 Vera et al. MUGA 32
r0.75-0.88 201-Tl JNM 19994513 Vera et
al. contrast 32 r0.26-0.72 201-Tl
JNM 19994513 TOTAL
831 r0.83
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Validation of QGS volumes (I) papers only

pts. EDV ESV Vaduganathan et al MRI
25 r0.81, r0.92 99mTc JNC
199963 Tadamura et al MRI 20
r0.92, r0.97 99mTc JACC
19994991 Tadamura et al MRI 20
r0.85, r0.94 201-Tl JACC
19994991 Tadamura et al MRI 16
r0.89, r0.93 99mTc EJNM
19997705 Bax et al MRI 22
r0.84, r0.87 99mTc AJC
2000121299 Bavelaar-Croon et al MRI 21
r0.94, r0.95 99mTc Radiology
20002572 Faber et al MRI 30
r0.91, r0.92 99mTc JNC
20018645 Thorley et al MRI
50 r0.90 99mTc NM Comm
20037763 Lipke et al MRI 54
r0.92, r0.96 99mTc EJNM
200431482 Cwajg et al. Echo
180 r0.88, r0.88 both JNM
1999111857 Nichols et al. Echo
33 r0.90, r0.94 99mTc JNM
200081308 Zuber et al. Echo
49 r0.86, r0.86 99mTc JNC
20006655 Vourvouri et al. Echo
32 r0.94, r0.96 99mTc EJNM
2001281610
...
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Validation of QGS volumes (II) papers only
Yoshioka et al. MUGA 21
r0.73, r0.83 99mTc JNM 1999101693 Chua
et al. MUGA 62 r0.88, r0.95
99mTc JNC 20004301 Nakajima et al.
MUGA 30 r0.88
99mTc JNM 2001421571 Nanasato et al.
MUGA 36 r0.85, r0.82 99mTc
JNM 2001421747 Nanasato et al. MUGA
36 r0.85, r0.75 I-123 JNM
2001421747 Abe et al. contrast 229
r0.67, r0.79 99mTc JNC
20006569 Iskandrian et al. Thermodil. 24
r0.89, r0.94 99mTc JNC
19986574 TOTAL
990 r0.86, r0.90
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Validation of non-QGS volumes papers abstracts
Emory Toolbox pts. EDV
ESV Faber et al. MRI 10
r0.97, r0.99 99mTc JNM
19994650 Vansant et al. MRI 31
r0.90, r0.91 99mTc JNM 199940166P
(abstr) Faber et al. MRI 30
r0.97, r0.99 99mTc JNC
20018645 Nichols et al. echo 33
r0.90, r0.94 99mTc JNM
200081308 Nakajima et al. MUGA 30
r0.89 99mTc JNM
2001421571 Faber et al. 1st pass 79
r0.85, r0.91 99mTc JNM
19994650 4D-MSPECT Cahill et al. MRI
26 r0.95, r0.98 99mTc JNM
200344197P (abstr) Lipke et al. MRI
54 r0.89, r0.96 99mTc EJNM
200431482 Nakajima et al. MUGA 30
r0.85 99mTc JNM
2001421571 Yale CQ Liu et al.
phantom
JNC 20018S61 (abstr) Multidim Vera et
al. contrast 32 r0.90, r0.92
201-Tl JNM 19994513 TOTAL
301 r0.91, r0.95

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Cross-correlation of algorithms for LVEF/vol
(I)
pts. LVEF
EDV ESV QGS vs. Emory Nichols et al
33 r0.94 r0.94 99mTc
JACC 19992409A Nichols et al 246
r0.90 r0.91 r0.95 99mTc JNC
20004S20 Sias et al 97
r0.72 99mTc JACC 19992436A Lewis et
al 1006 r0.93 r0.93 r0.80
99mTc JNC 20018S18 Santana et al.
50 r0.87 r0.89 r0.92
99mTc JNC 20015166P Krasnow et al
122 r0.89
99mTc JNC 20018S138 Nakajima et al
30 r0.95 r0.98
99mTc JNM 2001421571 Faber et al
30 r0.95
99mTc JNC 20018645 QGS vs.
4D-MSPECT Dede et al 129
r0.94 r0.97 r0.98 99mTc EJNM
200229S209 Lipke et al 54
r0.92 r0.96 r0.96 99mTc EJNM
200431482 QGS vs. Yale CQ Liu et al
110 r0.87 r0.90 r0.90 99mTc
JNC 20018S65 Krasnow et al 122
r0.82 99mTc
JNC 20018S138
...
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Cross-correlation of algorithms for LVEF/vol
(II)
pts. LVEF
EDV ESV QGS vs. MultiDim Everaert et al
40 r0.93 r0.97 r0.98
99mTc JNC 19976472 Vera et al
43 r0.86 r0.96 r0.97
201-Tl JNC 20004312 TOTAL
2112 r0.89 r0.94 r0.93

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LVEF quantitation algorithm comparison
Krasnow, JNC 2001 (abstr.)
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Gated measurements are algorithm-dependent
54 pts, 8-frame gating
Lipke et al, EJNM 2004
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Normal values of QGS post-stress EF and volumes
8-frame gating, Tc-99m
Gender LVEF EDV ESV Sharir et
al. MF 45 120 ml 70 ml (Circ 1999)
Sharir et al. F 51 102 ml 46 ml (JNC
2006) (60 ml/m2) (27
ml/m2) M 43 149 ml 75 ml
(75 ml/m2) (39 ml/m2)
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Gender-dependence of LVEF values
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LVEF measurement 8- vs. 16-frame gating
y - 2.9 0.97x r 0.987
LVEF, 8 intervals
Germano et al., JNM 362138, 1995
LVEF, 16 intervals
8-frame gating causes a uniform 3-4 decrease in
LVEF
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LVEF measurement 8- vs. 16-frame gating
QGS algorithm, published data
8-frame underestimation
Ref. Cohade et al. 2-2.8 (low-high
dose) JNM 2000 (abstr.) Germano et al.
3.7 JNM 1995 Imai et al.
3.7 JNC 1999 (abstr.) Kikkawa et al.
4.5 EJNM 2001 Kumita et al.
4.0 JNC 2001 Manrique et al. 3.6-4
(women-men) EJNM 2000 Roelants et al.
3.0 JNC 2003 (abstr.) Navare et al.
6.0 EJNM 2003
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(J-ACCESS)
Eur J Nucl Med 200633(2)127-133
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Gated SPECT reproducibility / repeatability
(QGS)
106 hospitals, 5 workstation types,
institution-specific filters
(variability includes manual reconstruction)
Nakajima et al., Eur J Nucl Med 200633(2)127-133
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Gated SPECT reproducibility / repeatability
(QGS)
106 hospitals, 5 workstation types,
institution-specific filters
(variability includes manual reconstruction)
Nakajima et al., Eur J Nucl Med 200633(2)127-133
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Diastolic function normal limits (QGS)
90 normal patients
Mean values PFR 2.62 0.46 EDV/s TTPF 164.6
21.7 ms
Abnormality thresholds PFR lt 1.71 EDV/s TTPF gt
216.7 ms
Akincioglu, JNM 2005
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Validation of diastolic function quantitation
(QGS)
pts.
Kikkawa et al. MUGA 24
PER r0.87 Tetro EJNM 200128593

TPER r0.84

1/3 FF r0.87

PFR r0.92

TPFR r0.89
Kikkawa et al. MUGA
48 PFR r0.51-0.75 Tetro JNC
20018568 Higuchi et al. MUGA 25
PER r0.88 Mibi EJNM
2001281512
PFR r0.80

1/3 FF r0.82
TOTAL
97 r0.82
12 frames, 32 frames
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Automatic measurement of lung/heart ratio
L/H is a marker of high-risk CAD with 201-Tl and
99mTc-sestamibi
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Lung/heart ratio normal thresholds
201-Tl
LHR lt 0.51
Homma et al., JNM 1987281531
99mTc-sestamibi
LHR lt 0.44
Bacher-Stier et al., JNM 2000411190
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Transient ischemic dilation (TID) measurement
Stress volume 114 ml
Rest volume 72 ml
TID index 1.58
Mazzanti et al., JACC 1996271612
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TID ratio (ungated) normal thresholds (I)
Rest 201-Tl/post-exercise 99mTc-sestamibi TID lt
1.22 Mazzanti, JACC 1996271612 (QGS) TID
lt 1.23 Kritzman, JNM 20014250P (4D-MSPECT)
Rest 201-Tl/post-pharma 99mTc-sestamibi or
tetrofosmin TID lt 1.27 (dipy) Williams,
Circ 2000102(18)II-546 TID lt 1.35 (adeno)
Williams, Circ 2000102(18)II-546 TID lt 1.36
(adeno) Abidov , JNM 200445(12)1999 (QGS)
TID lt 1.40 (dobu) Williams, Circ
2000102(18)II-546
Same day post-exercise/rest 99mTc-sestamibi TID
lt 1.14 Kritzman, JNM 20014250P (4D-MSPECT)
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TID ratio (ungated) normal thresholds (II)
Rest 201-Tl/post-pharma 201-Tl TID lt 1.19
(dipy) Hung, JNC 200512(3)268 (QGS)
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TID ratio (gated) normal thresholds
Two-day stress/rest 99mTc-tetrofosmin TID lt
1.25 (ESV) Bestetti, EJNM 2001281023 (QGS)
TID may be gender dependent
Madison, JNC 200310S85 (4D-MSPECT)
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TID and lung/heart are not correlated
Hansen et al, JACC 1999