Rolle der nuklearmedizinischen Verfahren und der Magnetresonanztomographie in der kardialen Diagnostik

Zusammenfassung

Nuklearmedizinische Untersuchungsmethoden finden ebenso wie die Magnetresonanztomographie (MRT) in der kardialen Diagnostik eine breite Anwendung. Zur Beurteilung der regionalen und globalen Wandbewegung sowie der Bestimmung von Ejektionsfraktion und Herzvolumina sind beide Techniken ausreichend evaluiert und äquivalent einsetzbar, wenngleich die MRT hier mittlerweile als Goldstandard angesehen wird. Hinsichtlich Untersuchungen der myokardialen Perfusion liegen für die nuklearmedizinischen Verfahren umfangreiche Daten vor, die neben einer hohen diagnostischen Genauigkeit zur Erkennung der koronaren Herzerkrankung eine zusätzliche prognostische Aussage belegen und eine unabhängige Risikostratifizierung der Patienten erlauben. Die kardiale MRT bietet, dank des raschen technischen Fortschritts, ebenfalls die Möglichkeit zur Beurteilung der myokardialen Perfusion. Die bisherigen Studien hierzu erscheinen vielversprechend, allerdings ist die Datenlage im Gegensatz zur Myokardszintigraphie noch wenig umfangreich. In der Vitalitätsdiagnostik bei ischämisch bedingter Herzinsuffizienz gilt gegenwärtig die Positronen-Emissions-Tomographie mit FDG als Goldstandard. Die Single-Photonen-Emissionscomputertomographie (SPECT) mit Tl-201 oder Tc-99m-markierten Tracern, wie auch die MRT als niedrig dosierte Dobutamin-Stress-Untersuchung oder als kontrastmittelverstärkte MRT weisen aber ähnlich gute Ergebnisse auf.
Nuklearmedizinische Verfahren und MRT liefern in einigen diagnostischen Teilbereichen Ergebnisse, die mit der jeweils anderen Methode nicht zu erzielen sind. Beispiele hierfür sind die Evaluierung der sympathischen Innervation, der Endothelfunktion, der Zellapoptose und des Gentransfers auf nuklearmedizinischer Seite sowie die Beurteilung der dreidimensionalen myokardialen Kontraktion, die nicht-invasive Koronarangiographie, die Gefäßwanddarstellung und die Echtzeitbildgebung mit der MRT.
Bildfusionen aus nuklearmedizinischen Verfahren und MRT werden gegenwärtig nur zur vergleichenden Evaluation beider Methoden verwendet. Zukünftig sind aber klinische Anwendungen denkbar, z. B. durch Projektion funktioneller nuklearmedizinischer Bilder auf hochauflösende, morphologische MRT-Bilder.
Aufgrund der zunehmenden Bedeutung der nichtinvasiven Diagnostik in der Kardiologie werden sowohl der Nuklearkardiologie als auch der Kardio-MRT, die nicht nur kompetitiv sondern auch komplementär einsetzbar sind, zukü nftig eine wesentliche diagnostische Rolle zukommen.

Abstract

Nuclear medicine and magnetic resonance imaging (MRI) are widely used in cardiac diagnostics. Both techniques have been carefully evaluated and are equivalent for the assessment of regional and global wall motion as well as the evaluation of ejection fraction and cardiac volumes, though MRI is herein currently seen as gold standard. For evaluation of myocardial perfusion, extensive data exist for nuclear imaging, that, next to high diagnostic accuracy for evaluation of coronary artery disease, show incremental prognostic information and allow for independent risk stratification. Because of rapid technical advance, myocardial perfusion imaging has also become feasible with cardiac MRI. Results of recent studies are promising, but the data are few compared to perfusion scintigraphy. For viability assessment in patients with ischemic cardiomyopathy, positron emission tomography (PET) with FDG is currently seen as gold standard. However, single photon emission computed tomography (SPECT) with Tl-201 or Tc-99m based tracers and MRI with low dose dobutamine or late enhancement-technique show almost similar results.
In some areas, nuclear imaging and MRI each provide information, which can not be achieved with the other technique. Nuclear medicine examples are the evaluation of cardiac sympathetic innervation, endothelial function, cell apoptosis and gene transfer, while the assessment of three-dimensional contraction, non-invasive coronary angiography, vessel wall imaging and real-time imaging may be listed for MRI.
Image fusion of nuclear studies and MRI are currently used only for comparative evaluation of both methods. Future clinical applications however may be possible, e. g., for the projection of functional nuclear images on high resolution, morphological MR-images.
Because of the increasing importance of non-invasive diagnostics in cardiology, nuclear cardiology and cardiac MRI, which can be used not only competitively but also complementarily, will both play an important future role.

Myokardszintigraphie - kardiale PET - kardiale MRT

Myocardial perfusion scintigraphy - cardiac PET - cardiac MRI

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