The present book offers a bird's eye view of the clinical potential of nuclear medical techniques (including nuclear and magnetic resonance) in the practice of cardiology. It is based on 16 review publications which cover the most important areas in clinical cardiovascular nuclear medicine. The book has been grossly divided into three sections: (1) Physiology, (2) Techniques, and (3) Clinical Applications. The Physiology section deals with the nuclear medicine background of myocardial perfusion, myocardial metabolism, and cardiac function (Chapters 1, 2, and 3). The Techniques sections discusses the planar techniques, in particular for the perfusion tracer thallium-201, the Single Photon Emission Computed Tomography (SPECT) technique, and the Positron Emission Tomography (PET) technique (Chapters 4, 5 and 6). This section also addresses the physical background of Magnetic Resonance Imaging (MRI) (Chapter 7). The Clinical Applications section discusses the value of nuclear cardiology for a variety of cardiac diseases from detection ofmyocardial infarction to its merits for evaluating cardiomyopathies (Chapters 8-14). Chapter 10 shortly addresses the experimental and clinical value of Magnetic Resonance Spectroscopy (MRS). Chapter 15 describes the latest developments in nuclear cardiology with an emphasis on new cardiac imaging agents. Finally, Chapter 16 presents the currently advocated Guidelines in Nuclear Cardiology. The book will assist the clinical cardiologist, the cardiology resident, the nuclear medicine physician, and the radiologist in understanding the currently used cardiovascular nuclear medicine techniques. It will broaden knowledge of the nuclear cardiology techniques and will show the reader how indispensable these techniques are in clinical cardiology practice.

This book consists of a total of 32 chapters subdivided into seven Parts, being: 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. In the following chapters in such a Part, individual topics are described in further detail by leading authorities. In this way, the book should be of great interest to the more generalist' reader as well as to the more specialist' reader. It has been quite obvious for a long time that cardiovascular imaging is a field in which quantitative analysis of the corresponding images is a must for clinical research studies. One such example is the quantitative coronary arteriography for the accurate assessment of vessel morphology and their changes over time in interventional cardiology. Particularly with the increasing use of three-dimensional (3D) data as well as 4D ( 3D plus time ), it has been quite clear that the amount of information is so large that the conventional visual interpretation is not suitable anymore, and otherwise would result in unacceptably high inter- and intra-observer variabilities and underutilization of the data. Fortunately, (semi)-automated analysis techniques preferably with automated edge detection approaches begin to appear, thereby providing a wealth of information with small systematic and random errors. Therefore, What's New in Cardiovascular Imaging? will assist the cardiologist, the radiologist, the nuclear medicine physician, the image processing specialist, the physicist, the basic scientist, and the fellow, who is in training for those specialties, in understanding the most recent achievements in cardiovascular imaging techniques and their impact on cardiovascular medicine.

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.

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 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.

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.

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.

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.

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.

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 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.

F.J.Th. WACKERS Metabolic imaging: The future of cardiovascular nuclear imaging? Since cardiovascular nuclear imaging emerged as a new subspecialty in the mid-1970s, the field has gone through an explosive growth. Radionuclide techniques became readily recognized as important new diagnostic aids in the armamentarium of the clinical cardiologist. Initially, cardiovascular nuclear imaging focused on static myocardial imaging using either thallium-201 or technetium-99m-pyrophosphate for diagnosing acute myocardial infarction. Shortly thereafter, multigated equilibrium radionuclide angiocardiography became the most widely used noninvasive method for assessing cardiac function. Furthermore, attention and clinical application shifted towards the use of radionuclide techniques in conjunction with exercise testing, either with thallium-20 1 myocardial perfusion imaging or technetium-99m left ventricular function studies. The future of cardiovascular nuclear imaging appeared exciting and promising. However, around 1980 pessimists predicted the premature demise of cardiovascular nuclear imaging with the introduction of digital subtraction angiography and nuclear magnetic resonance imaging. These doomsayers have been proven wrong: in 1985 cardiovascular nuclear imaging is thriving and, in many centers, even expanding. Although digital substraction angiography and magnetic resonance imaging provided exquisite anatomic detail, for practical evaluation of patients with ischemic heart disease - in the Coronary Care Unit or exercise laboratory - nuclear techniques appeared to be more practical.

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 will be 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.

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 (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. Left Ventricular Hypertrophy - Physiology versus Pathology 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 novel 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 will assist 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.

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.

It has been clear for a long time that cardiovascular imaging is a field in which quantitative analysis of the corresponding images is a must for clinical research studies. One such example is the quantitative coronary arteriography for the accurate assessment of vessel morphology and their changes over time in interventional cardiology. Particularly with the increasing use of three-dimensional (3D) data as well as 4D (3D plus time), it has been clear that the amount of information is so large that the conventional visual interpretation is not suitable anymore, and otherwise would result in unacceptably high inter- and intra-observer variabilities and under-utilization of the data. Fortunately, (semi)-automated analysis techniques, preferably with automated edge detection approaches, begin to appear, thereby providing a wealth of information with small systematic and random errors. This text should assist the cardiologist, the radiologist, the nuclear medicine physician, the image processing specialist, the physicist, the basic scientist, and the fellow training for those specialties, in understanding the most recent achievements in cardiovascular imaging techniques and their impact on cardiovascular medicine. This text consists of a total of 32 chapters subdivided into seven Parts.

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 will be 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.