There have been lot of advances in Nuclear Cardiology, it can help every patient - Prof. Mouaz Al-Mallah


Pakistan Cardiac Imaging Summit Prceedings-III
There have been lot of advances in
Nuclear Cardiology, it can help every
patient - Prof. Mouaz Al-Mallah
CMR allows vibrant biopsy of the entire heart-Prof. Purvi Parwani

KARACHI: There have been lot of advances in Nuclear Cardiology. Artificial Intelligence tools are now being used. Myocardial blood flow can be observed and new tracers are quite helpful. It can be used in chest pain assessment. We use the Patient First approach. In fact nuclear cardiology can help every patient and there are lot of modalities which are now being used. Right Heart Test was done for the first time. People are using different modalities in radiology in patient management. This was stated by Prof. Mouaz Al-Mallah President of American Society of Nuclear Cardiology (ASNC) while addressing the participants of the First Annual Pakistan Cardiac Imaging Summit organized by National Institute of Cardiovascular Diseases on May 5th 2023. He was one of the invited guest speakers at the Summit where he delivered his keynote lecture on Updates in Nuclear Cardiology. This session was jointly chaired by Prof. Nadeem Qamar Director of NICVD alongwith Prof. Javed Akbar Seyal President of Pakistan Cardiac Society and Prof.Sabha Bhatti Course Director and Chief Organizer of the Summit.

Prof. Nadeem Qamar, Prof. Abdus Samad, Prof.Zahid Jamal and Prof.Sabha Bhatti chairing one of the sessions during the Paksitan Cardiac Imaging Summit organized by NICVD recently.

Prof. Mouaz then talked about SPECT, SPECT CT, 3D PET, and Tesla CT in detail and then referred to the guidelines of the European Society of Cardiology published in 2019 which gives details of its usage in different conditions. It can be used in Chest Pain assessment, SPECT Myocardial, PRONE imaging, it reduces artifacts and improve specificity. It can be used in detection of atherosclerosis. As regards coronary artery calcium score, PET allows better image quality. It can measure blood flow, myocardial blood flow. He then referred to the patient selection for PET MPI, SPECT CT imaging. It can detect inflammation and sarcoidosis and we can do a lot more. He then showed some pre and post therapy slides with excellent results. PET can also be used in Endocarditis, pace maker infection, he added.

Prof. Sabha Bhatti asked him that we have just about five nuclear cardiologists, how one can attract people to this specialty as this has remained a neglected specialty? Prof. Mouaz remarked that people should be told that it is a very helpful modality, it is very helpful in patient management. One can see vasculitis, Amyloidosis, Endocarditis. Prof. Javed Akbar Seyal remarked that though expensive but it is a neglected specialty in Pakistan. Prof. Mouaz said accuracy is very high with nuclear cardiology. There are different modalities and one should use what is best for your patient. It is very helpful in patients with renal failure, people suffering from diabetes. Prof. Nadeem Qamar said that we have started our journey in cardiac imaging in Paksitan under the supervision of Prof.Sabha Bhatti and there was a need to properly develop this specialty.

Prof. Purvi Parwani also from United States was the next speaker whose presentation was on CMR Evaluation of Cardiomyopathy. She discussed in detail the value of CMR in evaluation of cardiomyopathy and pointed out that we can see what is going on in myocardium. She also discussed the CMR protocol. CMR, she opined, allows vibrant biopsy of the entire heart. It can help in tissue characterization in cardiomyopathy, myocardial infarction, cardiac Amyloidosis, Cardiac Sarcoidosis and myocarditis. It is a highly sensitive Gold Standard Test for detection of abnormality in the cardiac system. She laid emphasis on collaboration between different specialties. Responding to a question she said when genetic test is not available, history becomes very important. Mapping is not essential but it helps to confirm the diagnosis. She was of the view that we need to train more people in CMR.

Prof.Sabha Bhatti in her presentation discussed as to what is new in Echocardiography. Echo, she said, is the cornerstone for Valvular heart disease, valve disease evaluation, diastolic assessment. She also talked about stress Echo guiding treatment. Now Artificial In`telligence tools are also being used. Contrast Echo is not available. She also referred to 3D EF which is operational at NICVD. She then spoke about strain imaging, right heart evaluation with 3D, the mobile health devices, and the usefulness of telemedine technology using which one can get expert opinion from remote areas. Some of the tests which used to be done in an hour can now be performed in ten to fifteen minutes. POCUS Prof. Sabha Bhatti said is a new thing. One can use the Butterfly devices and it can be attached to any device. Teleguidance can be used to guide our decisions. 3D TEE is now available at NICVD. Different patients suffering from ASD, VSD can all be managed by using imaging, she remarked.

 Prof. Abdul Hakeem, Prof. Zainab Samad, Prof.Sabha Bhatti and other participants photographed during the Pakistan Cardiac Imaging Summit organized by NICVD at Karachi recently.

Dr. Shahbaz Sarwar discussed imaging updates in pulmonary hypertension. He pointed out that pulmonary hypertension was first diagnosed in 1891. He was of the view that we must do Echo when we are suspecting pulmonary hypertension. He also talked about pulmonary vascular resistance and said that it is important to know how to do it. We are now also doing Right Heart Cath, he added as it helps in patient management. He discussed in detail how to measure it besides speaking about RV-PA coupling. He further stated that Peak TR velocity and left heart function should always be reported. There are various modalities which can be used to diagnose pulmonary hypertension. It was also pointed out that NICVD also does one or two right heart Cath from time to time and it does reduce lot of invasive things for making diagnosis.

Dr. Sohail Abrar from Tabba Heart Institute was the next speaker who made a presentation on Strain imaging: A journey from research to Clinical Practice. He discussed in detail how to calculate strain, effects on cardiac muscle and then showed a longitudinal motion film. Other topics which he discussed included SR Tissue Doppler imaging, clinical uses of strain and pointed out that it picks up dysfunction far earlier than EF. Strain is a very sensitive tool but when to ask for strain imaging is important. Dr. Shahbaz Sarwar remarked that selection of patients was very important. If you have suspicion, it is easy to do, he added.

Prof. Nadeem Qamar remarked that they were doing lot of imaging at NICVD. Future lies in imaging. We will have more Fellows in imaging and it will improve further.

The next session which was devoted to Cardiac CT was chaired by Prof. Babar Hassan from SIUT alongwith Dr. Parveen Akhtar from NICVD. Dr.Abidullah from Peshawar Institute of Cardiology was the first speaker who discussed the present and future applications of coronary CT. His presentation was based on a few case studies. He pointed out that in patients who have previous CABG, CT should always be considered. CA CT makes the Angio quick, safe and it also enhances patient’s satisfaction. FFRCT confirms the lesions. Coronary CT, he opined, is an essential skill which should be learnt by all cardiologists. Prof. Babar Hassan remarked that if one does CT first, it makes the life easier.

Dr.Sadia Nasim from Punjab Institute of Cardiology spoke about Cardiac CTA beyond the Coronaries. She discussed its indications in detail. This she said, was extremely helpful in congenital heart diseases, ASD, VSD, PDA, and ALCAPA. It helps in diagnosis of complex congenital heart diseases besides fistulas and pulmonary stenosis. One can also diagnose pulmonary embolism, coarctation of Aorta, diseases of aorta, sarcoma. She also spoke about pericardial images. It is also useful in prosthetic valve assessment, TAVR, Mitral Clip and NEO CHORD.

Dr. Shazia Mohsin discussed multimodality images in paediatric cardiology and described how to use it in congenital heart diseases. She then described the management of a few cases using multimodality images including TOF repair. However, she cautioned that one must be careful in calculating the dose of CT Angio in children. During the discussion it was pointed out that more than one test can be used to answer clinical questions but one should be mindful to ensure judicious use of the available resources. Prof. Babar Hassan remarked that one should rarely resort to CT if you have good Echo. Cost is important. Even if the facility is available free, remember some one pays for it.

 Group photograph taken during the First Pakistan Cardiac Imaging Summit shows some of the speakers and chairpersons.

The next was a recorded presentation from Dr.Ritu wherein imaging advances in Valvular Heart Diseases were discussed in detail. She mentioned different stages of severe aortic stenosis and opined that one must look beyond calcium score by CT for AS.

In the session devoted to Cardiac MRI, Dr.Sajjad Hussain from Army Cardiac Center Lahore was the first speaker. The topic of his presentation was MRI image acquisition and protocols. He pointed out that cardiac MRI is lot more complicated hence many people may be making lot of errors. This is a combination of software protocols hence one should not miss anything and all essential information should be collected.

He then discussed the real time CINE advantages and disadvantages. Different tissues have different T1 relation time. He also talked about T1 mapping and when to do it, T1 and T2 weighted images, fat suppression images were discussed and also showed a case of myocardial infarction, hypertrophic cardiomyopathy. He then discussed CMR images protocol for HCM, dilated cardiomyopathy. Amyloidosis, he stated, is under diagnosed in Pakistan.

Prof. Nadeem Qamar and Prof. Samad pointed out that they see lot of cases of constrictive pericarditis which are treated. Problem is with the diagnosis and with such images, 100% diagnosis is possible.
Dr.Saira Bukhari from Aga Khan Univesity was the next speaker whose topic of presentation was Updates in Cardiac MRI. She discussed the indications and advantages in shunt, valve lesions, and arterial lesions. Its indications include coronary artery disease CMR of cardiomyopathy. She also talked about indications for CMR in pericardial diseases, T1 mapping of hypertrophic cardiomyopathy, ECV expansion. Cardiac MRI, she opined, is complex and it helps in automate image sequences. During the discussion it was once again emphasized that these are very costly investigations and even if they are free, someone pays for it. Hence be careful and see what test the patient needs.

Prof.Sabha Bhatti showed a number of interesting cases using multimodality imaging case based approach. It included use of cardiac CT, use of these modalities in TAVR planning. Cardiac MRI, she stated, provides multifold data. One of the patients had prosthetic AVR many years ago. Another was a forty five years old male diabetic ex-smoker. In one case there was an incidental finding of left arterial aneurysm. Another patient was diagnosed suffering from TakaYasu disease who was referred to rheumatologist. Yet another case was diagnosed to be suffering from TB and put on Anti-TB treatment. A cyst was diagnosed in another patient. Another patient was found to be of amyloidosis.

Communing on these cases, Prof. Samad remarked that these were fantastic images and fantastic pathology not seen in the West. Prof. Nadeem Qamar remarked that this is what imaging has done at NICVD. Imaging is going to make the results of our surgeons much better. Prof. Zainab Samad suggested to Prof.Sabha Bhatti to make an Atlas of all these excellent images and fantastic pathology.

In the session devoted to Nuclear Cardiology, Dr. Kirthikeyan from USA gave a keynote lecture on Cardiac PET- a case based approach. He said one may ask why to use PET and discussed what its role in detection of multivessel disease is. Its advantages include radio tracers, image quality and it is evidence based. He then discussed the diagnosis and risk assessment in different cases. One of his patients was seventy six years old who had three vessel calcification. He discussed in detail CABG, 3AAA risk with complications and also showed pre and post CTO intervention slides. His next patients was sixty six years old female who had chest pain on episodic exertion.

CTA shows no CAD with zero calcium score. Cardiac PET, he opined, is helpful in micro vascular disease assessment. Another patient he discussed was forty four years old with heart transplant having neo diastolic dysfunction but on Echo his EF was 60%. SPECT, he opined, has zero contraindication. Cardiologists and Radiologists should have a team for training in all these modalities. Others who spoke in this session included Mohammad Ayub from Alnoor Institute of Radiology Lahore who discussed Nuclear and CT multimodality cases while Dr. Shazia Rasool from NICVD also presented a few nuclear cases. Dr. Sumyia Gurmani made a presentation on Bicycle Stress Echo. Her patient was a forty five years old female who had mitral commissurotomy in 1995. She complained of shortness of breath and palpitation. She had mitral valve replacement and was now doing well.

Prof. Abdul Hakeem discussed an Interventional cardiologist’s perspective in structural cases. Imaging, he opined, was the backbone for structural heart disease intervention. If one cannot do structural heat intervention, one cannot be called an interventional cardiologist. This is expensive and one must have fair understanding of anatomy. Imaging guides and directs the procedure. Planning is extremely important for all these procedures for which advances in 3D Echo and CT have revolutionized this field. He further stated that understanding of these images is also important and one should use these images intelligently and then plan the procedure. Interventional cardiologists, he felt, must know and understand imaging better.

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