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HYBRID AND FUSION IMAGING
There is a complex relationship between coronary stenosis and myocardial ischemia. A number of landmark studies in the last two decades have consistently demonstrated that the angio- graphic severity of coronary lesions is a poor predictor of hemo- dynamic relevance.91–93 Importantly, stenosis alone is insufficient to identify flow-limiting lesions among patients with stable CAD. A comparison study of CCTA and SPECT showed that only 32% of obstructive coronary lesions, defined as 50% stenosis, were associated with perfusion defects on SPECT.94 Similarly, the FAME trial demonstrated that stenoses of 50–70% on coronary angiography can be functionally significant according to a FFR

of 0.8, while coronary lesions with >70% stenosis may not be ischemia-inducing based on an FFR value of >0.8.95 Thus, in the last two decades there has been a paradigm shift in the treatment of CAD with emphasis on the importance of myocardial ischemia to guide clinical management.
Hybrid cardiac imaging, which combines morphologic and anatomic results with functional evaluations of myocardial perfusion, has the ability to detect the presence of coronary lesions and their hemodynamic significance and therefore has superior diagnostic performance compared with anatomic or functional modalities alone. A hybrid approach utilizing SPECT or PET and cardiac CT has been allowed for the simultaneous identification of flow-limiting coronary stenosis and ischemia quantification in a single assessment, which may be useful for informing clinical management.96 Furthermore, when nuclear myocardial perfusion imaging is used in conjunction with CT, the hybrid imaging approach minimizes attenuation artifact and dramati- cally improves diagnostic and prognostic robustness.97 .98 Image coregistration and fusion of 3D information about myocardial territories and their coronary supply can accurately identify the culprit ischemic lesion in multivessel CAD, which is important since there is evidence that perfusion defects do not correspond to the expected coronary distribution in >50% of cases.99,100 Hybrid imaging with PET and CT or CMR has also been utilized in the evaluation of cardiac sarcoidosis , which permits the simultaneous evaluation of myocardial inflammation with LGE sequences and correlative metabolic activity on PET images that aids in the differentiation of inflammation and scar (Figure 12).101
The 21st century has also seen the rise of fusion imaging, whereby images obtained separately with different modalities are fused into a composite image. Harmonizing two modalities provides a better understanding of the 3D relationship of anatomy and devices, increases procedural efficiency, and improves clinical outcomes.102 The overlay of TEE or CT images and fluoroscopy has significantly aided the successful deployment of percutaneous interventions for congenital and structural heart disease.103,104 CCTA or CMR images superimposed on electrical mapping systems i ...

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