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Low-Dose Quantitative Myocardial Blood Flow Imaging Using ¹⁵O-Water and PET Without Attenuation Correction

¹ Department of Nuclear Medicine and PET Research, VU University Medical Centre, Amsterdam, The Netherlands; and ² Department of Cardiology, VU University Medical Centre, Amsterdam, The Netherlands

Correspondence: For correspondence or reprints contact: Mark Lubberink, VU University Medical Centre, Department of Nuclear Medicine and PET Research, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. E-mail: mark.lubberink{at}vumc.nl

Misalignment between PET and low-dose CT (LD-CT) can cause severe artifacts in cardiac PET/CT because of attenuation-correction errors, even when using slow or cine LD-CT. Myocardial blood flow (MBF), as measured by ¹⁵O-water, can be determined from the rate of ¹⁵O-water washout from myocardial tissue, which is independent of tissue attenuation. The purpose of the present study was to assess the accuracy of these MBF measurements in the absence of attenuation correction. Methods: Twenty-five patients referred for evaluation of myocardial perfusion underwent 6-min rest and adenosine stress PET scans after the administration of 370 MBq of ¹⁵O-water; both scans were followed by slow LD-CT. Data were acquired on a PET/CT scanner and reconstructed by a 3-dimensional row-action maximum likelihood algorithm both with (CTAC) and without (NAC) attenuation correction. An ascending aorta volume of interest was used as input function. MBF and coronary flow reserve (CFR) were calculated for 17 myocardial segments using nonlinear regression of the standard single-tissue-compartment model with corrections for left and right ventricular spillover and perfusable tissue fraction. Results: High correlation (r² = 0.99 and 0.97, with slopes of 0.96 and 0.91 for rest and stress, respectively) and excellent agreement (intraclass correlation coefficient [ICC], 1.00 and 0.98) between NAC- and CTAC-based MBF values were found. Absolute rest and stress MBF values were 3% and 8%, respectively, lower for NAC scans. The correlation coefficient between all NAC and CTAC CFR values was 0.95 (ICC, 0.95; slope, 0.92) and 0.97 (ICC, 0.99; slope, 1.01) when only CFR values below 2 were considered. Deviations between CTAC and NAC values were smallest for basal segments and increased toward the apex. Conclusion: MBF and CFR can be measured accurately using ¹⁵O-water and PET without correcting for attenuation, reducing the effective dose to the patient to 0.8 mSv for a complete rest–stress protocol. This dose is an order of magnitude lower than typical values for ⁸²Rb, ^99mTc-methoxyisobutylisonitrile, or CT perfusion scans.

Key Words: cardiology (basic/technical) • PET • PET/CT • ¹⁵O-water • coronary flow reserve • myocardial blood flow

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