Abstract
Nuclear Medicine enables functional assessment of the pediatric cardiovascular and respiratory systems. Various nuclear imaging modalities, including myocardial perfusion scintigraphy [single photon emission computerized tomography (SPECT) and positron emission tomography (PET)], fluorodeoxyglucose (FDG)-PET, radiolabeled leukocyte scintigraphy, somatostatin receptor imaging, and methaiodobenzylguanidine scintigraphy, are analyzed in the context of congenital heart disease, Kawasaki disease, heart transplantation, cardiomyopathies, and pulmonary vascular anomalies. Myocardial perfusion imaging using SPECT and PET is essential for evaluating coronary anomalies and post-surgical follow-up. FDG-PET is a valuable tool for assessing infection, inflammation, and myocardial viability. F-18 FDG PET/computed tomography demonstrates high sensitivity in diagnosing infections related to ventricular assist devices and prosthetic materials in congenital heart repair. Pulmonary perfusion scintigraphy is a reliable method for detecting pulmonary artery stenosis, venous obstruction, and embolism. Additionally, mucociliary clearance imaging contributes to understanding and monitoring diseases such as cystic fibrosis. With the advancement of new radiopharmaceuticals and high-resolution imaging systems, diagnostic accuracy increases while minimizing radiation exposure. Consequently, nuclear imaging is becoming not merely complementary but a core diagnostic tool in pediatric cardiology and pulmonology. This review aims to present the indications, radiopharmaceuticals, imaging techniques, and clinical relevance of Nuclear Medicine applications in pediatric cardiac and pulmonary conditions based on current scientific evidence.
Keywords: Pediatric nuclear medicine, myocardial perfusion, PET/CT, pulmonary scintigraphy, pediatric cardiology
References
McCrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, treatment, and long-term management of kawasaki disease: a scientific statement for health professionals from the American Heart Association. Circ J [Internet]. 2017 Apr 25 [cited 2025 May 3];135.
Fukazawa R, Kobayashi J, Ayusawa M, et al. JCS/JSCS 2020 guideline on diagnosis and management of cardiovascular sequelae in Kawasaki disease. Circ J. 2020;84:1348-1407.
Fukuda T, Ishibashi M, Yokoyama T, et al. Myocardial ischemia in Kawasaki disease: evaluation with dipyridamole stress technetium 99m tetrofosmin scintigraphy. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2002;9:632-637.
Gravel H, Curnier D, Dallaire F, Fournier A, Portman M, Dahdah N. Cardiovascular response to exercise testing in children and adolescents late after Kawasaki disease according to coronary condition upon onset. Pediatr Cardiol. 2015;36:1458-1464.
Schwaiger M, Hess J, Hauser M, et al. Myocardial blood flow and coronary flow reserve in children with normal epicardial coronary arteries after the onset of Kawasaki disease assessed by positron emission tomography. Pediatr Cardiol. 2004;25:108-112.
Moscatelli S, Bianco F, Cimini A, et al. The use of stress cardiovascular ımaging in pediatric population. Children. 2023;10:218.
Dodge-Khatami A, Mavroudis C, Backer CL. Anomalous origin of the left coronary artery from the pulmonary artery: collective review of surgical therapy. Ann Thorac Surg. 2002;74:946-955.
Venet M, Friedberg MK, Mertens L, et al. Nuclear imaging in pediatric cardiology: principles and applications. Front Pediatr. 2022;10:909994.
Fricke TA, Bell D, Daley M, et al. The influence of coronary artery anatomy on mortality after the arterial switch operation. J Thorac Cardiovasc Surg. 2020;160:191-199.e1.
Kumar K, Sharma A, Patel C, et al. Feasibility and utility of adenosine stress echocardiography in children following post-arterial switch operation: a comparison with technetium 99m-sestamibi myocardial perfusion SPECT (MPS). Pediatr Cardiol. 2021;42:891-897.
Sterrett LE, Schamberger MS, Ebenroth ES, Siddiqui AR, Hurwitz RA. Myocardial perfusion and exercise capacity 12 years after arterial switch surgery for D-transposition of the great arteries. Pediatr Cardiol. 2011;32:785-791.
Sugiyama H, Tsuda E, Ohuchi H, Yamada O, Shiraishi I. Chronological changes in stenosis of translocated coronary arteries on angiography after the arterial switch operation in children with transposition of the great arteries: comparison of myocardial scintigraphy and angiographic findings. Cardiol Young. 2016;26:638-643.
Bengel FM, Hauser M, Duvernoy CS, et al. Myocardial blood flow and coronary flow reserve late after anatomical correction of transposition of the great arteries. J Am Coll Cardiol. 1998;32:1955-1961.
Harris KM, Spirito P, Maron MS, et al. Prevalence, clinical profile, and significance of left ventricular remodeling in the end-stage phase of hypertrophic cardiomyopathy. Circulation. 2006;114:216-225.
Maron MS, Olivotto I, Maron BJ, et al. The case for myocardial ischemia in hypertrophic cardiomyopathy. J Am Coll Cardiol. 2009;54:866-875.
Hallioglu O, Ceylan Gunay E, Unal S, Erdogan A, Balci S, Citirik D. Gated myocardial perfusion scintigraphy in children with sickle cell anemia: correlation with echocardiography. Rev Esp Med Nucl. 2011;30:354-359.
Jaeggi E, Bolens M, Friedli B. Reversible second degree atrioventricular block after a severe sickle cell crisis. Pediatr Cardiol. 1998;19:171-173.
Ergul Y, Nisli K, Kayserili H, et al. Evaluation of coronary artery abnormalities in Williams syndrome patients using myocardial perfusion scintigraphy and CT angiography. Cardiol J. 2012;19:301-308.
Lee ML. Regression of cardiac enzyme and ventriculocoronary communication in an infant with pulmonary atresia and intact ventricular septum after radiofrequency valvulotomy and valvuloplasty. Pediatr Cardiol. 2005;26:792-796.
Maiers J, Hurwitz R. Identification of coronary artery disease in the pediatric cardiac transplant patient. Pediatr Cardiol. 2008;29:19-23.
Sogbein OO, Pelletier-Galarneau M, Schindler TH, Wei L, Wells RG, Ruddy TD. New SPECT and PET radiopharmaceuticals for imaging cardiovascular disease. BioMed Res Int. 2014;2014:1-24.
Hernandez-Pampaloni M, Allada V, Fishbein MC, Schelbert HR. Myocardial perfusion and viability by positron emission tomography in infants and children with coronary abnormalities. J Am Coll Cardiol. 2003;41:618-626.
Chhatriwalla AK, Prieto LR, Brunken RC, Cerqueira MD, Younoszai A, Jaber WA. Preliminary data on the diagnostic accuracy of rubidium-82 cardiac PET perfusion imaging for the evaluation of ischemia in a pediatric population. Pediatr Cardiol. 2008;29:732-738.
Werner RA, Chen X, Rowe SP, Lapa C, Javadi MS, Higuchi T. Moving into the next era of PET myocardial perfusion imaging: introduction of novel 18F-labeled tracers. Int J Cardiovasc Imaging. 2019;35:569-577.
Shimoni S, Zoghbi WA, Xie F, et al. Real-time assessment of myocardial perfusion and wall motion during bicycle and treadmill exercise echocardiography: comparison with single photon emission computed tomography. J Am Coll Cardiol. 2001;37:741-747.
Doan TT, Wilkinson JC, Loar RW, Pednekar AS, Masand PM, Noel CV. Regadenoson stress perfusion cardiac magnetic resonance imaging in children with Kawasaki disease and coronary artery disease. Am J Cardiol. 2019;124:1125-1132.
Caobelli F, Kamani CH, Nkoulou R, Buechel RR. The importance of 18F-FDG cardiac PET/CT for the assessment of myocardial viability in ischaemic heart disease: a position paper endorsed by the Swiss Society of Nuclear Medicine (SGNM). Swiss Med Wkly. 2021;151:w20511.
Knuuti MJ, Nuutila P, Ruotsalainen U, et al. Euglycemic hyperinsulinemic clamp and oral glucose load in stimulating myocardial glucose utilization during positron emission tomography. J Nucl Med. 1992;33:1255-1262.
Hardisky D, Tricarico R, Kelly JM, Bobbey AJ, Stacy MR. Utility of 18F-FDG PET/CT imaging in diagnosing pulmonary prosthetic valve endocarditis in a pediatric patient. Clin Nucl Med. 2021;46:e567-e569.
Saby L, Laas O, Habib G, et al. Positron emission tomography/computed tomography for diagnosis of prosthetic valve endocarditis. J Am Coll Cardiol. 2013;61:2374-2382.
Ly R, Compain F, Gaye B, et al. Predictive factors of death associated with infective endocarditis in adult patients with congenital heart disease. Eur Heart J Acute Cardiovasc Care. 2021;10:320-328.
Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis: the task force for the management of infective endocarditis of the European Society of Cardiology (ESC) Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36:3075-3128.
Venet M, Jalal Z, Ly R, et al. Diagnostic value of 18F-fluorodeoxyglucose positron emission tomography computed tomography in prosthetic pulmonary valve infective endocarditis. JACC Cardiovasc Imaging. 2022;15:299-308.
Pelletier-Galarneau M, Abikhzer G, Harel F, Dilsizian V. Detection of native and prosthetic valve endocarditis: incremental attributes of functional FDG PET/CT over morphologic imaging. Curr Cardiol Rep. 2020;22:93.
Jeewa A, Imamura M, Canter C, et al. Long-term outcomes after transplantation after support with a pulsatile pediatric ventricular assist device. J Heart Lung Transplant. 2019;38:449-455.
Mahmood M, Kendi AT, Ajmal S, et al. Meta-analysis of 18F-FDG PET/CT in the diagnosis of infective endocarditis. J Nucl Cardiol. 2019;26:922-935.
Van Der Geest KSM, Treglia G, Glaudemans AWJM, et al. Diagnostic value of [18F]FDG-PET/CT for treatment monitoring in large vessel vasculitis: a systematic review and meta-analysis. Eur J Nucl Med Mol Imaging. 2021;48:3886-3902.
Weisert M, Harake D, Hede S, Russell M, Alejos J, Menteer J. A multicenter survey on post‐transplant lymphoproliferative disorders in pediatric heart transplant recipients: a case for development of consensus guidelines for screening, surveillance, and treatment? Pediatr Transplant. 2020;24:e13730.
Sica A, De Rimini ML, Sagnelli C, et al. Post-heart transplantation lymphoproliferative diseases (PTLDs) and the diagnostic role of [18f] FDG-PET/CT. Minerva Med [Internet]. 2021 May [cited 2025 May 4];112.
Kim MS, Kim EK, Choi JY, Oh JK, Chang SA. Clinical utility of [18F]FDG-PET /CT in pericardial disease. Curr Cardiol Rep. 2019;21:107.
Martineau P, Dilsizian V, Pelletier-Galarneau M. Incremental value of FDG-PET in the evaluation of cardiac masses. Curr Cardiol Rep. 2021;23:78.
Chang SA, Oh JK. Constrictive pericarditis: a medical or surgical disease? J Cardiovasc Imaging. 2019;27:178.
Sarrazin JF, Philippon F, Trottier M, Tessier M. Role of radionuclide imaging for diagnosis of device and prosthetic valve infections. World J Cardiol. 2016;8:534.
Aydın F, Kın Cengiz A, Güngör F. Tc-99m labeled HMPAO white blood cell scintigraphy in pediatric patients. Mol Imaging Radionucl Ther. 2012;21:13-18.
Aparici CM, Narula J, Puig M, et al. Somatostatin receptor scintigraphy predicts impending cardiac allograft rejection before endomyocardial biopsy. Eur J Nucl Med. 2000;27:1754-1759.
Buchmann I, Henze M, Engelbrecht S, et al. Comparison of 68Ga-DOTATOC PET and 111In-DTPAOC (Octreoscan) SPECT in patients with neuroendocrine tumours. Eur J Nucl Med Mol Imaging. 2007;34:1617-1626.
Grupper A, Gewirtz H, Kushwaha S. Reinnervation post-heart transplantation. Eur Heart J. 2017;ehw604.
Ono S, Ohuchi H, Miyazaki A, Abe T, Kiso K, Yamada O. Heterogeneity of ventricular sympathetic nervous activity is associated with clinically relevant ventricular arrhythmia in postoperative patients with tetralogy of fallot. Pediatr Cardiol. 2015;36:1515-1522.
Zhao C, Shuke N, Yamamoto W, et al. Impaired cardiac sympathetic nerve function in patients with Kawasaki disease: comparison with myocardial perfusion. Pediatr Res. 2005;57:744-748.
Possner M, Buechel RR, Vontobel J, et al. Myocardial blood flow and cardiac sympathetic innervation in young adults late after arterial switch operation for transposition of the great arteries. Int J Cardiol. 2020;299:110-115.
Nygaard S, Christensen AH, Rolid K, et al. Autonomic cardiovascular control changes in recent heart transplant recipients lead to physiological limitations in response to orthostatic challenge and isometric exercise. Eur J Appl Physiol. 2019;119:2225-2236.
Muller KD, Jakob H, Neuzner J, Grebe SF, Schlepper M, Pitschner HF. 123I-metaiodobenzylguanidine scintigraphy in the detection of irregular regional sympathetic innervation in long QT syndrome. Eur Heart J. 1993;14:316-325.
Porcari A, De Angelis G, Romani S, et al. Current diagnostic strategies for dilated cardiomyopathy: a comparison of imaging techniques. Expert Rev Cardiovasc Ther. 2019;17:53-63.
Karasawa K, Ayusawa M, Noto N, Sumitomo N, Okada T, Harada K. [Assessment of cardiac sympathetic nerve activity in children with chronic heart failure using quantitative iodine-123 metaiodobenzylguanidine imaging]. J Cardiol. 2000;36:387-395.
Kelesidis I, Travin MI. Use of cardiac radionuclide imaging to identify patients at risk for arrhythmic sudden cardiac death. J Nucl Cardiol. 2012;19:142-152.
Olguntürk R, Turan L, Tunaoğlu FS, et al. Abnormality of the left ventricular sympathetic nervous function assessed by I‐123 metaiodobenzylguanidine imaging in pediatric patients with neurocardiogenic syncope. Pacing Clin Electrophysiol. 2003;26:1926-1930.
Snoussi NEH, Radi F, Oussou Y, Manouri K, El Hattab F, Cherti M. Left ventricular metastasis of osteosarcoma: a report of an unusual case. J Card Surg. 2020;35:3596-3599.
Purz S, Sabri O, Viehweger A, et al. Potential pediatric applications of PET/MR. J Nucl Med. 2014;55(Supplement 2):32S-39S.
Nensa F, Bamberg F, Rischpler C, et al. Hybrid cardiac imaging using PET/MRI: a joint position statement by the European Society of Cardiovascular Radiology (ESCR) and the European Association of Nuclear Medicine (EANM). Eur Radiol. 2018;28:4086-4101.
Ciofetta G, Piepsz A, Roca I, et al. Guidelines for lung scintigraphy in children. Eur J Nucl Med Mol Imaging. 2007;34:1518-1526.
Fathala A. Quantitative lung perfusion scintigraphy in patients with congenital heart disease. Heart Views. 2010;11:109.
Sanchez-Crespo A. Lung ventilation/perfusion single photon emission computed tomography (SPECT) in infants and children with nonembolic chronic pulmonary disorders. Semin Nucl Med. 2019;49:37-46.
Feltes TF, Bacha E, Beekman RH, et al. Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. Circulation. 2011;123:2607-2652.
Latus H, Kuehne T, Beerbaum P, et al. Cardiac MR and CT imaging in children with suspected or confirmed pulmonary hypertension/pulmonary hypertensive vascular disease. Expert consensus statement on the diagnosis and treatment of paediatric pulmonary hypertension. The European Paediatric Pulmonary Vascular Disease Network, endorsed by ISHLT and DGPK. Heart. 2016;102(Suppl 2):ii30-ii35.
Drubach LA, Jenkins KJ, Stamoulis C, Palmer EL, Lee EY. Evaluation of primary pulmonary vein stenosis in children: comparison of radionuclide perfusion lung scan and angiography. Am J Roentgenol. 2015;205:873-877.
Patocka C, Nemeth J. Pulmonary embolism in pediatrics. J Emerg Med. 2012;42:105-116.
Shammas A, Vali R, Charron M. Pediatric nuclear medicine in acute care. Semin Nucl Med. 2013;43:139-156.
Glaser JE, Chamarthy M, Haramati LB, Esses D, Freeman LM. Successful and safe implementation of a trinary interpretation and reporting strategy for V/Q lung scintigraphy. J Nucl Med. 2011;52:1508-1512.
Gelfand MJ, Gruppo RA, Nasser MP. Ventilation-perfusion scintigraphy in children and adolescents ıs associated with a low rate of indeterminate studies. Clin Nucl Med. 2008;33:606-609.
Roach PJ, Gradinscak DJ, Schembri GP, Bailey EA, Willowson KP, Bailey DL. SPECT/CT in V/Q scanning. Semin Nucl Med. 2010;40:455-466.
Laube BL, Carson KA, Evans CM, et al. Characterizing mucociliary clearance in young children with cystic fibrosis. Pediatr Res. 2022;91:612-620.
Corcoran T, Muthukrishnan A. Measurements of mucociliary clearance and small molecule absorption for researching airways disease. J Nucl Med. 2018;59(supplement 1):1617.
Kawamura J, Ueno K, Taimura E, et al. Case report: 18F-FDG PET-CT for diagnosing prosthetic device-related infection in an infant with CHD. Front Pediatr. 2021;9:584741.
