Abstracts Monday AM, April 24
S03-003
S03-001 to S10-033 and P01-034 to P04-091
SERUM CARDIAC MYOSIN AFTER THROMBOLYTIC THERAPY IN ACUTE MYOCARDIAL INFARCTION.
S03-001
JA Sanchez-Martin, JA Jorge, G Lape~a, JA Ari~s, J Romero, C Pardo, P Almeida y T Caparrds. Fundacion Jimenez Diaz, Madrid, Spain.
RELATIONSHIP BETWEEN BMIPP/MIBI UPTAKE A N D C O R O N A R Y F L O W R E S E R V E A F T E R ACUTE M Y O C A R D I A L INFARCTION. P.R. Franken, P Dendale, C De Sadeleer, P Flamen and A Bossuyt. Free University o f Brussels (AZ VUB), Brussels, Belgium. More reduced B M I P P than MIBI uptake (mismatching) may be observed in patients with recent myocardial infarction. W h e n correlated with regional wall motion inotropic reserve and long term functional recovery, these segments have been shown to be closely associated with the presence o f residual viable myocardium in the area at risk. To further characterize those segments, we studied the relationship between rest B M I P P and rest MIBI uptake to the MIBI uptake during dipyridamole stress in 25 patients. Studies were obtained 7+3 days after AMI. Uptakes were compared on quantitative bull's eyes divided into 9 regios. Results: 38 regios showed mismatching (BMIPP uptake >10% below MIBI uptake) and 39 matched defects. Dipyridamole Dipyridamole reversible defects fixed defects B M I P P < MIBI 18 20 B M I P P = MIBI 2 37 Conclusion: Regios with matched B M I P P / M I B I defects are associated with fixed MIBI defects indicating scar. Regios showing reversible defects during Dipyridamole stress had a B M I P P / M I B I mismatched pattern.
We examined serum cardiac myosin levels in patients with acute myocardial infarction (AMI) in order to evaluate: 1) the thrombolytic therapy (TT) effect over seric myosin, and 2) the relationship between cardiac myosin levels, 111In-antimyosin (~IInAM) cardiac imaging and sS'~Tc-MIBI SPECT. Serum cardiac myosin heavy fragment was measured in 133 patients by immunoradiometric assay. The samples for myosin assays were drawn within 6 hours after admission in hospital and each morning thereafter for a period lasting as long as 12 days. The results were expressed as area under the curve (AUC). "~'nTc-MIBI SPECT was obtained in 89 patients between the 2nd and the lOth days after admission. "~InAM cardiac imaging was performed in 12 patients from 4 to 10 days after AM1. The main results of this study were as follows: 1) Myosin AUC without TT (n=87) = 10463 • 4312 (mean • SD); 2) Myosin AUC after TT (n = 46) = 3411 • (t test, p<0,0001); 3) Seric myosin AUC showed significant association with ~'InAM cardiac uptake and significant inverse association with 9~mTc-MIBI cardiac uptake. Both imaging and in vitro procedures could trace the he~rt damage and the therapeutic response in AMI. The combination of these techniques may prove to be useful for clinical and therapeutic assessment in AMI.
S03-002
S03-004
Te-99m ANTIMYOSIN ANTIBODY (3-48) IMAGING FOR DETECTION OF ACUTE MYOCARDIAL INFARCTION. R. Taillefer, L.Boueher, R.Lambert, J.Gr6goire, D.C.Phaneuf, H.Sikorska*, C.Benjamin, A.Gagnon. H6teI-Dieu de Mont~al, and *Rougier Bio-tech ltd, Montr~tl, Canada.
Myocardial Perfusion Scintigraphy for Evaluation of STSegment Elevation During Dobutamine Stress Test in Patients with Myocardial Infarction
Tc-99m-antimyosin antibody imaging (Tc-AM) may have significant advantages over In-III antimyosin in clinical practice. The prupose of this study was to determine the sensitivity of Tc-AM imaging in detection of both acute Q-wave and non Q-wave myocardial infarctions (MI). Forty patients with proven MI (22 Q-wave, 18 non Q-wave) were injected with Tc-AM (20-25mCi) between 5 hours and 7 days after the onset of acute chest pain. Three standard planar views were performed at 6 hours (10rain/view) and 24 hours (15min/view) post-i.v_ Both sets of images were completed in 34 patients while 2 patients were imaged only at 6 hours and 3 patients at 18 hours. One patient was not imaged. Reading was performed by 2 blinded experienced observers. The images performed at 6 hours were analyzed first followed by the 24-hour images. The sensitivity of Tc-AM imaging in detection of MI was 100% (21/21) for Q-wave and 83.3% (15/18) for non Q-wave infarctions. The overall sensitivity was 92.3% (36/39). The 3 false-negative cases were inferoposterior MI. A certain degree of Tc-AM uptake focalization was seen in 27 out of 36 (75%) at 6 hours. At 24 hours, blood pool activity was not seen. Two patients (5.8%) did not show Tc-AM uptake while 22 (64.7%) showed intense focal uptake, 7 (20.6%) moderate and 3 (8.9%) faint Tc-AM uptake. No serious adverse reactions attributable to Tc-AM were reported. No patients developed significant increases in human antimurine antibodies titers. In conclusion, Tc-AM is a safe and highly sensitiveprocedure in detection of actue MI even with early imaging (at 6 hours). These promising results warrant further clinical investigation.
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
Abdou Elhendy, Marcel L Geleijnse, Jan H Cornel, Galal M El-Said, Ron T van Domburg, Eric P Krenning, Jos RTC Roelandt, Paolo M Fioretti. Thoraxcenter and Department of Nuclear Medicine, Erasmus University Rotterdam, The Netherlands. The aim of the study was to assess the relationship between STsegment elevation during dobutamine stress test (DST) and perfusion scintigraphy in patients with previous myocardial infarction (MI). 321 pts with previous MI underwent DST (up to 40 pg/kg/min) in conjunction with 99m Technetium Sestamibi or Thaltium 201 SPECT. 42 pts (13%) had a recent MI (<1 month). The myoeardium was divided into 6 segments and each segment was scored on a 0 (normal) to 3 (severely reduced uptake) scale. Ischemic score was derived by subtracting rest from stress score. ST-segment elevation ~lmm 80 ms after the J point occurred in 60 pts (19%). The prevalence of transient perfusion defects (TPD) was not different with or without ST elevation (60% vs 56%, p=NS) as well as ischemic score (1.8 vs 1.5, p=NS). Pts with ST elevation had a higher perfusion score at rest (6.6 vs 3.7, p=0.0001). Separate analysis of 10ts with recent MI showed no difference in prevalence of TPD or ischemic score with or without ST elevation. Conclusions'. ST-segment elevation during DST 1) is not specific for ischemia in pts with recent or old MI. 2) is associated with more severe fixed perfusion defects.
S1
$2
M
O N D A
Y P M A P R I
L 2 4
Abstracts Monday morning, April 24, 1995
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
S03-O05
S03-007
DIPYRIDAMOLE THALLIUM-201 VERY EARLY AFI'ER ACUTE MYOCARDIALINFARCTIONTREATEDWITH THROMBOLYSIS
Rest Fatty Acid and Stress-RD-RI Thallium S P E C T M y o c a r d i a l I m a g i n g in p r e d i c t i o n of left
S. Pirelli, A. Moreo, G. Piecalo', D. Massa, A. Corato, R. Sara, G. Danzi, L. Ruffini, C. DeVita. Niguarda Hospital, Milan, Italy
ventricular recovery following revascularisation after an acute m y o c a r d i a l infarction.
The aim of this study was to assess the safety and the prognostic value of dipyridamole thallium-201 imaging (DipTl) very early after AM/in lots treated with thrombolytic therapy. 52 consecutive pts with uncomplicated clinical course underwent DipTl 2-5 days after AMI and were followed for a mean of 14:t:7 months.Quantitative analysis of planar images, obtained after dipyridamole infusion(0.56 mg/kg) and 3-4 hours later, was performed. No major complications occurred during the test. Minor side effects of dipyridamole(mild ipotension, flushing, headache) were observed in 12 pts(23%).Chest pain, ST segment depression or both developed during the test in 15 pts(29%). The perfusion defects within the infarct zone were observed in all 52 pts.Redistribution was seen in 30 of 52 pts(57.6%). No death nor reinfarction occurred during hospitalization. 5 of the 30 pts with redistribution (9.6%) developed in-hospital unstable angina compared to 0 of the 22 pts without redistribution. During the follow-up a total of 5 late cardiac events were observed: 2 deaths and 2 cases of unstable angina in the group with reversible defect and 1 reinfarction in the group with fixed defect. Two-year actuarial probability free of cardiac events was 55% and 94% 'in the pts with or without redistribution respectively. In conclusions in pts treated with thrombolysis DipTl very early after uncomplicated AMI is a feasible and safe test. The test allows a early stratification of pts with different degrees of risk for in-hospital and late cardiac events. The pts with negative DipTl appear to be at low risk and may be candidates for early discharge. The presence of redistribution identifies a subgroup of pts who may benefit from further careful clinical evaluation.
Stress-RD-RI-T1 S P E C T is p e r f o r m e d for the a s s e s m e n t o f residual viability. Fatty acid (FA) h a v e also been proposed. W e c o m p a r e d the a c c u r a c y o f t h e s e 2 t r a c e r s for t h e prediction o f regional L V recovery a s s e s s e d b y quantitative L V a n g l o (Slager m e t h o d ) 18+12 d a y s before a n d 151+51 days after systematic revascularization. 60 pts were included after a first acute t r a n s m u r a l MI. 35 pts u n d e r w e n t a P T C A , 17 pts a C A B G , and 8 pts h a d no significant stenosis on the I R A . A s t r e s s - R D - R I - T 1 S P E C T w a s p e r f o r m e d 18+14 d a y s after ]VII, followed 24 h o u r s later by a rest F A SPECT. Images were visually analysed by two independant o b s e r v e r s a c c o r d i n g to t h e C e d a r s S i n a i p r o g r a m . A s e g m e n t w a s defined as viable w h e n R D - R I T1 u p t a k e w a s 5 0 % or m o r e , or w h e n F A u p t a k e w a s 75% or m o r e , w h e n c o m p a r e d to the reference area. Results : Positive Predictive Value, Negative Predictive Value and Accuracy were r e s p e c t i v e l y : for R D - R I - T 1 . 5 1 , .65, .59, a n d for r e s t - F A .54, . 6 2 , . 55. C o n c l u s i o n : W h e n p e r f o r m e d i m m e d i a t l y after the acute p h a s e o f MI, T1 a n d F A S P E C T s e e m to be p o o r predictors o f L V i m p r o v e m e n t . Either u s u a l tresholds are n o t accurate in such pts, or L V angio is n o t the optimal gold standart for the a s s e s s e m e n t o f regional wall motion after MI.
S03-006
S03-008
SERIAL ASSESSMENT OF METABOLIC AND FUNCTIONAL CHANGES AFTER ACUTE MYOCARDIAL INFARCTION WITH PLANAR 201TL/FDG IMAGING AND ECHOCARDIOGRAPHY. JM Huitink, FC Visser, JJ Bax, A v Lingen, GJJ Teule, CA Visser. Free University Hospital, Amsterdam, NL
THE LOCATIONOF ISCHEMICPERFUSIONDEFECTSON STRESSTc99m SESTAMIBISPECT SCINTIGRAPHYDOES NOT PREDICTTHE LOCATIONOF A SUBSEQUENTMYOCARDIALINFARCTION
Planar rest myocardial 201T1/FDG imaging has been shown to distinguish between viable and non-viable myocardium. Using this technique 25 patients (20 males, 60 +_ 9 yrs) with acute myocardial infarction were studied within 6 + 2 days of onset of symptoms and 42 + 4 days thereafter. Serial assessmentof wall motion with 2D-echo was performed to determine the prognostic value of metabolic indexes for functional tissue recovery. No revascularization procedure was performed. Segmental 201TI and FDG uptake was evaluated using circumferential profiles. Wall motion was scored as normal, hypokinetic or akinetic. Results: 201T1 uptake was reduced in 71 segments. Twenty six segments showed a match (FDG-201TI < 20%) consistent with the presence of scarred tissue. Regional function improved in only 10% of these segments. In 27 segments a mismatch was present (FDG-20IT1 _> 20 %) of which 25 % showed spontaneous improvement in function, although recovery varied considerably among patients. In 18 flow defects FDG was normal of which 27% had improved function after 6 weeks. All segments with functional improvement in time were also viable by scintJgraphic criteria. Also 56 % of akinetic segments without improvement showed still a mismatch or normal FDG after 6 weeks, indicating the presence of hibernation. Conclusions: absence of residual tissue metabolism shortly after infarction is associated with irreversible injury, while preservation of metabolic activity identifies segments with variable outcome. Planar 201T1/FDG imaging allows early identification of viable but jeopardized tissue and may help select patients who will benefit from aggressive therapy to salvage endangered myocardium.
Noirclerc M, V a n z e t t o G, M a c h e c o u r t J, F a g r e t D, C o m e t M, D e n i s B. University Hospital - Grenoble' - France
Gregory L. Miller, Steven D. Herman, Sunil Kalla, Gary V. Heller, William A. Levin, Kira Stillwell, Mark I. Travin. Roger Williams Medical Center, Providence, Memorial Hospital, Pawtucket, and Brown University School of Medicine, Providence, RI. The location of isehemia on stress Tc-99m sestamibi (MIBI) SPECT scintigraphy for 26 patients(pts) who had a subsequent MI (85% male, mean age: 66 _+ 13 yrs, 58% pharmacologic stress) was correlated with the location o f infarction. For each patient's SPECT images, two territories - anterior (including anterolateral and anteroseptal) and inferior (including inferolateral and inferoseptal) - were assessed for the presence of MIBI defects. MI location was determined from available ECG, eehocardiographic and catheterization data, blinded to SPECT image results. In 6 pts, MI location was indeterminate. O f 19 territories with a reversible MIBI defect, an MI occurred in 9 (47%); of 8 territories with a fixed defect, an MI occurred in 4 (50%); of 13 territories with no defect, an MI occurred in 6 (46%) (p=NS). The remaining pt. had a lateral MI after MIBI images had shown a reversible apical defect. Thus, 11/20 (55%) infarctions occurred in territories that had not shown ischemia on prior MIBI imaging. CONCLUSION: The location o f ischemia on a stress Tc-99m sestamibi SPECT imaging study does not consistently correlate with the location o f a future myocardial infarction.
JOURNAL OF NUCLEAR CARDIOLOGY Volume 2, N u m b e r 2, Part 2
Abstracts Monday morning, April 24, 1995
S04-009
S04-011
ASSESSMENT OF MYOCARDIUM AT RISK DURING CORONARY OCCLUSION BY 99mTn SESTAMIBI : COMPARISON BE'Pa*4EEN THREE TOMOGRAPHIC METHODS OF QUANTIFICATION.
IS PET NECESSARY FOR CARDIAC F-18 FDG IMAGING?
Ceriani L., Giovanella L.,* Verna E., **Bianchi L, Roncari G. and ***Tarolo G.L. -- Dept, of Nuclear Medicine,*Cardiology and **Medical Physic -Regional Hospital of Varese and ***Nuclear Medicine Institute - University of Milan - Italy
V. Kalff, S.U. Berlangieri, B. Van Every, J.L. Rowe, R.M. Lambrecht, G.F. Egan, H.J. Tochon-Danguy, W.J. McKay, MJ. Kelly. Alfred Hospital, Melbourne, Australia.
Aim- The aim of the study was to compare three scintigraphic methods of quantification of the area at risk (AR) using 99mTc Sestamibi SPET. Methods- The AR was assessed in 19 pts with CAD undergoing PTCA injecting the 99mTc Sestamibi during coronary occlusion after ballon inflation. The pts were classified according to hypoperfusion localization in Group A (8 pts) and Group B (t 1 pts) with posterolateral and anteroseptal defects respectively. A technique similar to that described by Tamaky (Circulation, 1982), the method validated by O'Connor (Eur.J.Nucl.Med, 1990) and a planimetric technique based on polar maps , already employed by Verani (JACC,1988) were tested. A cut-off of the 60 % of the maximum left ventricular counts was used to define the limits of perfusion defect .Results- There was no significant difference between the mean values of AR calculated by the three methods. Excellent correlation was demonstrated between the planimetric polar mazps technique and the Tamaky method (y= -2.9 + 1.13x ; r= .95 ; p< 104 ; SEE = 5.04 ) and the O'Connor technique ( y=1.1 + 0.92x ; r = .95; p< 10~ ;SEE = 5.07) respectively. Good linear correlation was also shown between the two last methods (y= -0.12 + 1.06x ; r =.92 ; p< 10~; SEE = 6.2). There was no significant difference between the three methods used to assess AR in the Group A and Group B pts. Intra- and inter-observer variability was < 5 % for each technique. Conclusions- Our results show a good correlation between the three techniques of AR quantification. The location of perfusion defect doesn't affect the performance analysis The intra- and interobserver variability data suggest that a reduction of AR estension <5% shouldn't be considered significant in longitudinal studies.
This study assesses whether planar myocardial perfusion / FDG images obtained on a gamma camera optJmised for 511 keV photon imaging can replace routine N-13 ammonia / FDG PET viability studies. 27 patients with ischemic heart disease (LVEF: 20%+9%) having PET viabili~ studies consented to resting, 4 view, planar myocardial TI-201 and FDG uptake imaging (PPI). The resultant image sets were independently assessed for size of FDG defec~ and peffusion/FDG mismatch, using a 4 point scale, in each of 4 vascular regions (106/108 regions evaluable). There was good overall(70%, Kappa (K) 0.56) and regional agreement for apical (81%, K: 0.5), lett anterior(81%, K: 0.7) and posterior descending coronary artery regions (73%, K: 0.6). However, in the circumflex region (44%, K: 0.3) only, PP~ underestimated FDG defect severity. 3t4 moderate are3s of mismatch seen on PET were also seen on PPI. A few small mismatchs (PPI: 3, PET:l) were seen on only one modality. Thus, for this PET protocol, planar TI-201/FDG imaging with a modified gamma camera gives very similar information on regional FDG uptake& occurrence of mismatch. Hence it may be used instead of a formal PET viability study.
S04-010
S04-012
The pathophysiology of hibernating myocardium studied by PET during hyperinsulinemic-euglycemic clamp
THE INCIDENCE OF SCINTIGRAPHICALLY VIABLE AND NONVIABLE TISSUE IN PREVIOUSLY INFARCTED MYOCARDIUM BY e2Rb AND 18F-FDG PET IMAGING
Norma VS Marinho, Bruce E Keogh, Durval C Costa, Peter J Ell, Adriaan A Lammertsma and Paolo G Camici. MRC Clinical Sciences Centre and RPMS, Hammersmith Hospital and Institute of Nuclear Medicine, UCL Medical School, London, UK. Hibernation [left ventricular (LV) dysfunction distal to a coronary stenosis which improves after coronary revascularization (REV)] is believed to be due to'chronically reduced myocardial blood flow (MBF). To test this hypothesis, we measured absolute MBF with H2150 (ml/min/g of water-perfusable tissue) and glucose utilization (MGU, [.tmol/min/g), during euglycemic hyperinsulinemic clamp, with I8FDG and PET in 30 patients (mean age 56+11 years) before coronary REV. LV function was assessed before and 65:2 months after REV with MUGA. Regional wall motion (WM) was normal (NOR) before and after REV in 130 segments and abnormal before REV in 107. WM after REV improved (IMP) in 59/107 segments (55%) whilst it was unchanged (UNC) in 48/107 (45%). In NOR segments MBF was 0.92+0.25 and MGU 0.45+0.19. MBF was 0.87+0.31 in IMP (p=ns vs NOR) and 0.82+0.40 in UNC (p<0.05 vs NOR). MGU was 0.44+0.15 in the 59/107 IMP segments (p=ns vs NOR) and 0.34_+0.17 in the 48/107 UNC (p<0.01 vs NOR and IMP). In 73/107 dysfunctional segments (68%) MBF was >0.67 (a cut off value corresponding to the mean MBF - 1 SD in NOR segments) and WM after REV was IMP in 45/73 and UNC in 28/73 despite comparable MBF (1.04+0.38 vs 0.99+.24). In the 34/107 segments (32%) with MBF <0.67, WM was IMP in 14 and UNC in 20 despite comparable MBF (0.50+0.15 vs 0.49_+0.16, p=ns). In conclusion: 1) 68% of hibernating segments had an MBF >0.67; 2) The absolute MGU measured during euglycemic hyperinsulinemic clamp correlated with recovery of function independently of MBF.
Raymundo Go, William Maclntyre, Sebastian Cook, Donald Neumann, Richard Brunken, Gopal Saha, Donald Underwood, Thomas Marwick, Eric Chen, Janet King, Shashi Khandekar. Cleveland Clinic Foundation, Cleveland, OH USA Distinction between viable and nonviable myocardium is an important clinical consideration before revascularization. This study was designed to determine the incidence of scintigraphically viable and nonviable myocardium in a large population of patients with previous MI. Rest/dipyridamole stress 82Rb perfusion & 18F-FDG metabolic PET images were performed in 167 consecutive patients with 1410 hypoperfused segments and analyzed whether the segments were reversible (ischemic) or irreversible and then assessed for their ~eF-FDG uptake. PET perfusion/metabolic imaging identified 12% of reversible subsegmental defects with varied 18F-FDG uptake, 27% of irreversible defects with normal-to-enhanced 18F-FDG uptake, and 61% of irreversible defects with decreased ~eF-FDG uptake. There were 14% of patients with reversible defects of ischemia, 28% with perfusion/metabolism mismatch of hibernating myocardium and 58% with the match pattern of myocardial scar. The ability to distinguish between hibernating myocardium and scar was possible only by adding 1BF-FDG PET imaging and may facilitate the decision to consider revascularization.
$3
$4
M O N D A Y P M A P R I L
Abstracts Monday morning, April 24, 1995
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
$04-013
S04-O15
REVERSIBLE RESTING Tr SESTAMIBI DEFECTS F O L L O W I N G CORONARY REVASCULARIZATION INDICATE UNDERESTIMATION OF MYOCARDIAL VIABILITY BY RESTING SESTAMIBI SCINTIGRAPHY J. vom Daht, C. Altehoefer, G. Schulz, E.R. Schwarz, U. Buell, P. Hanrath. Univ, of Aachen, Aachen, Germany
THE EVALUATION OF MYOCARDIAL V[AI3IL['I'Y BY 99m'f'cTETROFOSMIN IMAGING -A COMPARISON WITH REST 2~ITHALL[UM IMAGING-
To evaluate the outcome of preoperative resting perfusion defects by Tc-99m isonitrile (MIBt) SPECT, 40 patients underwent serial angiography and MIBI SPECT prior to and 5_+2 months following revascutarization. All had preoperative F-I8 FDG PET for assessment of myocardial viability in regions with reduced MIBI-uptake (< normal mean - 2 SD). Regional analysis of MIBI and FDG uptake was performed after normalization to the region with highest MIBI uptake and expressed in %. MIBI uptake increased from 52_+16% to 65+18% (p<.01) in 122 segments with good long-term result (diameter stenosis <50%). Improvement was highest in segments with preoperatively reduced MIBI but preserved FDG uptake, whereas baseline MIBI and FDG uptake alone did not correlate to outcome, tn contrast, MIBI uptake did not change in 32 non-revascularized segments. Improvement did not depend on the severity of baseline MIBI defects, since regions with severe defects demonstrated increased uptake by >10% in 78% of regions as well as those with only mild or moderate defects (improvement in 55%). In patients with chronic coronary artery disease, Tc-99m MIBI uptake can increase after coronary revascularization and, thus, underestimate preoperative viability.
Hitoshi Matsuo,Sachiro Watanabe,Motoo Kano, Shintaro Tanihata, Yoshio Nishida,Tetsuo MatsubaraHiroshi Oda,Yasum)ri Kotoo, Itiroshige Oohashi and Motoyuki [shiguro" Gifu Prefectural Hospital,'Hirano General Hospital.Gifu Japan. ~g=Tc tetrofosmin is a rLewperfusion agent and its use for viability assessment is an area of interest and uncerlainty.To evaluate the potential availability of this tracer in viability assessment,thallium SPECT at rest(T1) and 99~Tctetrofosmin SPECT at rest(TF) were carried out using 16 patients with old myocardial infarction whose infarct reIated arteries were totally or subtotally occluded. Twenty regions of interest were positioned in the 3 reDeresentative slices of short axis images and %uptake nt each tracer in the correspond~ ing regions were correlated. Excell ~ lent correlation was demonstrated between the uptakes of these 2 so o tracers(Fig). If the myocardial re~6o ~ ~ : gions showing nptake of each trac~ ~ ers more than 40%uptake were re40 garded as viable, and regions with less than 40%uptake were defined 2o as a scar, Complete agreement was obtained in 92.2% of regions,and disagreement of 2 tracers were ob~'~ ~o ,0 ~o *o ~oo served onIv in 7.8% of ~.p~k~9~r regions(Tablei.Thus.the uptake of 9~Tc tetrofosmin showed excellent I~ I,~ u.,.k..,o,, h~ ,c2~ correlation with that of 2mthallium I"-",-~-,,o [ ,,,,,.,~I . . . . . . . in patients with severely stenosed infarct related arteries(with severely reduced coronary flow reserve) suggesting the usefulness of this tracer as a marker of cellular viability.
$04-014
S04-016
PERSISTIZNCE OF HYPOPERFUSED BUT STILL VIABLE MYOCARDIUM IN PATIENTS WITH CHRONIC ISCHEMIC LEFT VENTRtCULAR DYSFUNCTION.
EARLY DIPYRIDAMOLE 2~ SPECT DOES NOT PREDICT LATE RESTENOSIS AFTER PTCA. A. Belloni, B. Palagi, A. Colombo, S. Boccolari, R. Picozzi, A. Polese. Cardiology Division, "L. Saceo" Hospital, Milano, Italia. The aim of our study was to assess the value of early dipyridamole 2~ SPECT for the prediction of late restenosis after PTCA. Thirty-five consecutive monovascular patients (aged 57 +_8 yrs) with a critical coronary stenosis relieved by PTCA underwent :~ myocardial perfusion SPECT immediately after 0.56 mg/kg i.v. dipyridamole and 4 hours later (circumferential profiles method) 3 to I 8 days after the procedure. The study was classified positive in the presence of a reversible :~ defect in the region of the dilated vessel. Positive scans were found in 14 cases (40%): all these subjects had repeat angiography by 1 week, which showed no change with respect to immediate post-PTCA results. In the subsequent 4 to 12 (median 7)months follow-up all patients had control coronary angiography; 6 out of 14 (43%) of the initially 2~ positive patients underwent restenosis, a s compared to 10 of the 21 initially 2~ negative. The related positive and negative predictive values were 43% and 52%, respectively. We conclude that a positive ~~ test early after PTCA does not accurately predict subsequent restenosis. We hypothesize that an abnormal stress perfusion after relief of an epicardial stenosis may reflect a derangement in regional coronary microvascular reserve in a subset of patients.
Alberto Cuocolo, Carmine Morisco, Leonardo Pace, Emanuele Nicolai, Simone Maurea, Bruno Ricciardelli, Nicola De Luca, Antonio Nappi, Bruno Trimarco, Marco Salvatore. Universit& "Federico I1"and Istituto Nazionale dei Tumori, Napo~, Italy. Hibernation represents an adaptive response to chronic hypoperfusion which allows the survival of the myocardium. However, it is still unclear how long this condition may be maintained. Therefore, we performed a prospective study on 36 patients (35 men, mean age 53+_9years)with angiographically documented chronic ischemic [eft ventricular dysfunction and evidence of hypoperfused but still viable myocardium. All patients underwent rest-redistribution thallium-201 (TI) imaging and 2-D eehocardiography before (study 1)and after (study 2) a follow-up of 22~9 months (range 12-41 months), Myocardial segments were classified as normal (normal wall: motion and T[ uptake >75% of peak activity), viable (hypokinesia or akinesia and TI uptake >50%) or necrotic (akinesia and TI uptake <50~ Seven patients (19%) died during the follow-up. In the remaining 29 patients, no significant changes in the ejection fraction (39_+10%vs 40+_12%)and in the occurrence of normal (53% vs 54%), viable (34% vs 32%) and necrotic (12% vs 13%) myocardial segments between study 1 and study 2 were observed. In conclusion, our results suggest that the chronic perfusion-contractionmatching allows a long-term survival of the myocardium.
JOURNAL OF NUCLEAR CARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Monday morning, April 24, 1995
S05-017
S05-019
DOBUTAMINE STRESS TEST FOR THE ASSESSMENT OF PATIENTS WITH REDUCED LEFT VENTRICULAR FUNCTION BEFORE AND AFTER CABG J. Postma-Tjoa, JH. Cornel, E. Boersma, PM. Fioretti. Department of Nuclear Medicine and Thoraxcenter, University Hospital Dijkzigt, Rotterdam, the Netherlands.
THREE-DIMENSIONAL THRESHOLD ANALYSIS OF 1-123 IODOPHENYLPENTADECANOIC ACID MYOCARDIAL SCINTIGRAPHY.
Aims: to assess the changes of stress induced ischemia and of left ventricular (LV) function after uncomplicated surgical revascularization (CABG) in 35 patients with a reduced LV EF (<50%). Methods: high dose dobutamine (up to 40 pg/kg/min)-atropine Thallium-reinjection SPECT (6 major LV regions, visual and quantitative assessment) and gated blood pool ventriculography (at rest and low-dose, 10 pg/kg/min, dobutamine) were repeated before and 3 months after CABG. Results: 1) stress induced ischemia: no complication occurred during the test; the number of patients with transient perfusion defects decreased after CABG from 28 to 17. Consistently, the number of LV regions with ischemia decreased from 101 to 55. 2) LV function: pre-operative LV ejection fraction, peak filling and peak ejection rate were respectively 33+-11%, 1.3• and 2.1 +_0.81, increased during low-dose dobutamine to 43+_11, 2.3_+0.9 and 3.6_+1.04 (p<0.01), but were unchanged after CABG. Conclusions: dobutamine stress test is a feasible and useful test for the functional assessment of patients with reduced LV function after CABG. The results of the present study indicate a significant reduction of stress induced ischemia without a concomitant recovery of LV function after CABG.
Joseph K Russell, Seydl Aksut, Nasaraiah Nallamothu, Jaekyeong Heo, And S Iskandrian. Philadelphia Heart Institute, Presbyterian Medical Center, Philadelphia, PA. This study examined the optimal threshold setting for a threedimensional surface shaded image (3D) using 1-123 iodophenylpentadecanoic acid (IPPA) acquired at different times. SPECT images of 180" were acquired using 32 frames, over 8 min following injection of 4 mCi at rest in 10 normal volunteers aged 415:8 years. The images were obtained at 4 min, 15 min and 25 rain post-injection. Images were evaluated independently by 4 observers using threshold settings at 40, 45, 50, 55, 60 and 65% for image quality. The 4 min images were considered of high quality using the 50% and 55% thresholds. The 15 min images were considered of high quality using the 55% threshold. None of the thresholds was satisfactory for the 25 min images.
In conclusion, the optimal threshold setting for 3D IPPA images was 55%. The rapid myocardial washout of IPPA may degrade the late 3D images. Thus, 3D imaging may not be practical to study initial and redistribution IPPA images.
S05-018
S05-020
THALLIUM-201 I M A G I N G W I T H P H A R M A C O L O G I C VASODILATION: COMPARISON BETWEEN DIPYRIDAMOLE AND ADENOSINE IN DETECTION OF CORONARY ARTERY DISEASE. A. Gagnon, R, Taillefer, R, Amyot, S. Turpin, R. Lambert., R. Essiambre, C. Pilon. Httel-Dieu de Montrtal, Canada. Both dipyridamole (DIP) and adenosine (ADE) are widely used as pharmacologic stressor with 201-TI (T1) imaging for detection of CAD. The purpose of this study was to directly compare DIP and ADE TI imaging in patients with proven CAD. Thirthy-three patients were submitted to two planar TI studies: one with DIP and the other with ADE. The time interval between the 2 studies varied from 2 to 7 days and the order was randomly assigned.Three standard planar views were obtained at 10 min. and 4 hours after injection of 3 mCi of T1. Administrationof DIP was as follows: 0.142 mg/kg/min during 4 min., slight exercise and injection. The infusion of ADE was as follows: 0.142 mg/kg/min, during 6 min. with injection of T1 after the third minute of infusion, Patients were asked to give their preference considering the number, severity, and duration of side effects on a scale from 0 (worst) to 5 (best). Reading was done by 2 experienced observers.The heart was divided into 3 segments/view.The change in systolic blood pressure was -11 • 11 mmHg for ADE and -6 • 9 for DIP (p=0.0006) and the change in heart rate was +18 • 8 bpm for ADE and +9 • 8 bpm for DIP (p=0.0001). Using ROI's, ischemic/normal waal ratios were determined: 0.79 • 0.06 for ADE and 0.82 • 0.08 for DIP (p=0.005). ADE detected 178 normal, 105 ischemic and 14 scar while DIP detected 204, 78 and 15 respectively. Patients prefered ADE (4.1 • 1.0 for ADE vs 3.5 • 1,5 for DIP, (p=0.04) mainly because of the short duration of side effects. In conclusion,this preliminary study shows that the use of ADE with 201-T1 imaging may have advantagesover DIP.
IDENTIFICATION OF OPTIMAL ACQUISITION AND RECONSTRUCTION PARAMETERS FOR 123-IPPA MYOCARDIAL METABOLISM IMAGING. A Gagnon, R, Taillefer, G. Bavaria, C, Benjamin, S. Lacombe. Httel-Dieu de Montrtal, Canada. 123- IPPA is being investigated in phase flI clinical trials as an imaging agent for the assessment of viable myocardium and ability to predict functional recovery after CABG, Unlike 201-Thallium, acquisition and reconstrution protocols are not well established for the identification of viable myocardium. The purpose of this study is to evaluate the optimal acquisition and reconstructionparameters for 123-IPPA. Thirty normal volunteers (19 M, 11 F) were administered a dose of 4.9 mCi (in a fasting state). Count statistics obtained during tomographic acquisitions with a dual head gamma camera equiped with two GAP collimators were determined at 4, 20 and 30 minutes after 123-IPPA injection, From the data gathered, maximum count activity over the heart was evaluated and washout curves were drawn. Acquisition times of 20 sec/frame at 4 and 20 min. and 30 sec./frame at 30 min. were arbitrarely used. Seventeen patients with known CAD (12 M, 5 F) were also imaged at 4 and 30 minutes using the same parameters as before. All raw data was evaluated for patient motion. Three different types of reconstruction filters were evaluated: Butterworth with cutoff at .3, .35 and .4 Nyquist with a power of 5. Two experienced observerswere asked to give a preference on the resulting images based on count homogeinity and overall image quality. Results: Myocardial uptake as an absolute percentage at 4, 20 and 30 minutes was 100%, 97% and 65% respectively in women and 100%, 99.5% and 68% for men. Average count density in the full SPECT study over the heart was 363, 356 and 362 kcounts at 4, 20 and 30 minutes, The overall preference from the observer was reconstructionwith the use of the Butterworthat ,35 Nyquist cutoff and power at 5. The washout analysis confirmed that 4 and 30 minutes were optimal times to initiate imaging for identification of viable myocardium.
$5
$6
Abstracts
JOURNAL OF NUCLEARCARDIOLOGY
Monday morning, April 24, 1995
M O N D A Y P M A P R I L
March/April 1995, Part 2
S05-021
S09-023
SELECTION OF 180 ~ OR 360 ~ RECONSTRUCTION AFFECTS THE DETERMINATION OF CHANGES IN II23-PH~/kBELPENTADECANOIC ACID (IPPA) DEFECT MAGNITUDE, WL Bruni, E Daher/ Y-H Liu, M A Saari, FJTh Wackers, AJ sinusas. Yale University, New Haven, CT, USA.
FUNCTIONAL SIGNIFICANCE OF CORONARY COLLATERALS DURING EXERCISE ASSESSED BY 99'~Tc-SESTAMIBISPECT IN PATIENTS WITH ONE-VESSEL DISEASE.
Ii23-phenylpentadecanoic acid (IPPA) is a radiolabeled free fatty acid that provides an index of myocardial flow and metabolism. Although 1-123 IPPA has an energy of 159 key, dosimetry necessitates the injection of less than 6 mCi yielding relatively count poor studies. To determine the affect of 180 ~ and 360 ~ reconstruction on IPPA image quality and calculation of defect magnitude (DM) we performed serial SPECT imaging with a triple head system. Imaging began 4 min post injection of IPPA (4.4mCi). Each tomogram (TOMe) was acquired for 2 min using a noncireular 360 ~ orbit. We compared early (4-8 min) TOMO (ET) DM with late (28:32 min) TOMe (LT) DM. All TOMOS were reconstructed utilizing both 180 ~ and 360 ~ of data using the same post 3-D low pass filter. Reconstructed slices were visually inspected and short axis slices quantitated using standard circumferential count profiles. DM was determined using a 60% threshold for the anterior, septal, inferior, and lateral regions. Qualitatively, the 180 ~ ToMes appeared sharper due to the increase in contrast and decrease in background activity. There was an excellent correlation of DM between 180 ~ and 360 ~ imaging for both ET (r=0.96) and LT (r=0.91). However, the DM for both sets of 360 ~ TOMES was smaller. While change in DM also correlated (r=0,83), a s m a l l e r change in DM was observed with the 360 ~ TOMO. Thus, 180 ~ reconstruction of IPPA SPECT images increases DM relative to 360 ~ and affects tenlooral changes in DM. The clinical importance of these differences are uncertain, but warrant further investigation.
S09-022 Beneficial Effect of [3-blockade on Hyperemic Myocardial Blood Flow and Vasodilatory Capacity in Humans Morten BOttcher, Johannes Czernin, Heinrich R. Schelbert UCLA School of Medicine Los Angeles CA. USA 13,-receptor blockade (M) reduees cardiac work and thereby lower myocardial blood flow (MBF) at rest. However, the effect of M on hyperemic MBF is unknown. To evaluate the effect of Metoprolol (specific [31-receptor antagonist), 50 mg p.o. 12 and 1 hour before the study on MBF at rest and during dipyridamole (DIP) induced hyperemia, 10 healthy volunteers (mean age 244-5 years, 8 males) were studied with N-13 Ammonia PET at control and after M. Resting rate pressure product (RPP) declined from 66214-555 at control to 51684-975 (p<0.05) during M. Similarlythe RPP declined from 101934-1330 during baseline DIP to 85754-1770 (p<0.05) during DIP+M. Resting MBF declined in proportion to cardiac work from 0.614-0.10 to 0.514-0.11 ml/g/min (p<0.05). Thus resting MBF normalized to RIP did not change after M 0.914-0.1 vs 0.994-0.19 p=NS). Hyperemic MBF increased from 1.864-0.28 to 2.404-0.70 aider M (p<0.05). The decrease in MBF at rest and the increase in hyperemic MBF resulted in an increase in the myocardial flow reserve from 3.164-0.80 to 4.74~0.73; p<0.01). Thus resting MBF decreases aider [31-receptor blockade while hyperemic MBF is increased possa'blydue to a reduction in extravascular compressive forces and/or an increase in the diastolic flow phase.
NP Sand, UH Eriksen, J Fr~kiaer, C FI~, JP Bagger, TF Nielsen, M Rehling. Skejby University Hospital, Aarhus, Denmark. We studied the impact of coronary collaterals (Co), originating from 'non-diseased coronary segments, on myocardial perfusion during exercise. Twenty-three patients (pts), 15 males and 8 females with a mean age of 56 years (40-69), with coronary stenoses suitable for PTCA, were included. Spontaneously visible and recruitable Co were graded according to the Rentrop-classification. Reversible perfusion defects (RPD) were assessed by sestamibi-SPEcT as areas of the left ventricle with a more than 20% reduction of activity during exercise estimated by comparisons of normalised rest and exercise maximal circumferential profiles. Fifteen pts had Co (Co+), while 8 pts did not (Co-). Eleven pts had prior myocardial infarction. Coronary stenoses were located to LAD (12), RCA (10) and CX (3). The degree of coronary stenosis was 98% for Co+ and 73% for Co- (p<0.05). Mean RID sizes were 25% for Co+ and 3% for Co- (p<0.05). The table compares pts with and without Co concerning the occurrence of RPD. Co+ Co+RPD 12 2 -RPD 3 6 p<0.05 In summary the occurrence of RPD is significant more frequent in pts with Co, and we conclude that Co afford insufficient protection against myocardial ischemia during exercise.
S09-024 USEFULLNESS OF INTRACORONARY DOPPLER FLOW MEASUREMENTS IN INTERMEDIATE CORONARY ARTERY STENOSIS (ICAS) : A COMPARATIVE STUDY WITH TL-201 MYOCARD PERFUSION IMAGING Tamer Atasever*. Sezai Orhan**, Gtilin Vural*, O~uz H. Caymaz**, Halls D0rtlemez**, Mustafa Onlti*. Gazi University Medical Faculty,Department of Nuclear Medicine* and Cardiology**, ANKARA / TURKEY. The aim of the study was to compare SPECT T1-201 myocard perfusion imaging (T1-MP) and intracoronary doppler flow ratio (IDFR) in patients with intermediate coronary artery stenosis ( 30 % - 70 % ) (ICAS). IDFR measurement and T1-MP were performed in 21 patients (pts). 25 Coronary artery territories demonstrating ICAS were interpreted. ICAS over 50 % ( 50 %-70 % ) , IDFR over 1.7 and hypoperfusion in T1-MP was considered as significant. ICAS below 50 % ( 30 % - 50 ), IDFR below 1.7 and normal T1-MP was considered as nonsignificant. Out of 25 Coronary artery lesion sites, angiography showed 17 (68 %) significant and g ( 32 % ) nonsignificant lesions. IDFR revealed 19 ( 76 % ) signficant and 6 (24 % ) nosignficant, T1-MP showed 16 ( 64 % ) significant and 9 ( 36 % ) nonsignificant lesions. According to angiography IDFR showed 94 % sensitivity, 7 1 % specificity and 88 % accuracy. T1-MP sensitivity, specificity and accuracy were 83 %, 7 1 % and 80 % respectively. Comparison of these diagnostic modalites using chi-square test did not show difference p>0.05. These results suggest that IDFR measurements in intermediate coronary artery stenosis agree with TI-MP.TI:MP imaging seems to be a valuable noninvasive alternative in evaluating intermediate coronary artery stenosis.
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Monday morning, April 24, 1995
S09-025
S09-027
ASSESSMENTS OF CORONARY ENDOTHELIAL FUNCTION: COMPARISON BETWEEN PET-PERFUSION AND CORONARY DOPPLER-FLOW VELOCITY TECHNIQUES
QUANTITATIVEEVALUATIONOFINTRACORONARYACETYLCHOLINE VERSUS BASAL 99mTc-MIBIUPTAKE TO ASSESS ENDOTHELIAL DYSFUNCTIONIN MICROVASCULAR ANGINA Giuseppe Rubini, Alessandro Bortone, Filippo Lauriero, Domenico Rubini, Giuseppe Di Giovine Luigi Sorgente, Mario Lepera, Paolo Rizzon, Angelo D'Addabbo. Nuclear Med. Dep. Bad University, Italy Intracoronary Acetylcholine (Ach) administration is useful in detecting endothelium-dependent vasodilation impairment.To date global vascular response to Ach test has been evaluated by coronary sinus flow (CSF).The aim of this study was to identify distrectual paradoxal vasocostriction induced by Ach and quantify the regional myocardial perfusion defects (RMPD) by 99mT-MIBI SPET.In 14 normotensive pts (4M,10F) with typical chest pain, negative stress test, no of ischaemic signs after iv ergono-vine and angiographically normal coronary arteries, Ach (10-4 M) was administered in the LMCA for 1.5 ml/min and the CSF assessed by thermodilution technique. After infusion 500 MBq of 99mTc-MIBI was injected and SPET performed 2 hours after.The day after, basal 99mTc-MIBI SPET was performed.In 7/14 Pts 99mTc-MIBI SPET showed reversible RMPD in the left coronary related area, affecting only part of the distribution area. Quantitative analysis performed by circumferential profiles (6 myocardial segments/slice) of apical, mid-ventricular and basal slices, considering RCA MS as reference, showed a significant regional perfusion reduction. CSF was not significantly reduced in all 7 pts. In the other 7 Pts no RMPD were detected and there was higher uptake in Ach 99mTc-MIBI SPET due to normal vasodilation induced by ach. 99mTc-MIBI SPET combined with intracoronary infusion of Ach is a useful method to detect pts and quantify RMPD due to endothelium-dependent vasodilation impairment.
Joan G. Meeder, Hans-Otto Peels, Eng S. Tan, Paul K. Blanksma, Jan Pruim, Willem Vaalburg, Kong I Lie. University Hospital Groningen, The Netherlands. Coronary endothelial function is generally studied by examining the response of epicardial coronary arteries to intracoronary administered acetylcholine (IAA) or cold pressor testing (CPTI. In order to develop a non-invasive technique, we compared parametric l~N-ammonia PET myocardial perfusion imaging with intracoronary doppler blood flow velocity measurements in both stenotic and non-stenotic coronary arteries ( n = 1 7 ) . Perfusion was examined at rest and during CPT. On the next day, flow velocity measurements were obtained at rest, during CPT and IAA. Perfusion and flow velocity reserves, stress/rest ratios, were compared between both tests and techniques. Positive correlations were found between: a) CPT PET-perfusion reserves and CPT doppler-flow velocity reserves (r = 0.51; p = 0.048); b) CPT PET-perfusion reserves and IAA doppler-flow velocity reserves (r = 0.60; p = 0.010); and c) CPT doppler-flow velocity reserves and IAA doppler-flow velocity reserves (r = 0.71; p = 0.001). Especially in areas supplied by nonstenotic coronary arteries fair correlations were found. Both CPT perfusion and CPT flow velocity reserve seems to mirror the response to IAA. Endothelial function testing with parametric PET-perfusion imaging might be a promising nonoinvasive alternative.
S09-026
S 10-028
P E T MEASUREMENT OF MAXIMAL MYO-
NEW RADIOLIGANDS FOR IMAGING OF CARDIAC A DRENOCEPTORS USING IODINATED RIVATIVES OF CGP12177 AND SPECT
CARDIAL BLOOD FLOW WITH ADENOSINE IDENTIFIES MODERATE/SEVERE CORONARY STENOSIS Hal A. Skopicki, Stephen A. Abraham, Hugo Castano, Gerasimos Zervos, Patrick T. O'Gara, Alan J. Fischman, Nathaniel M. Alpert, Robert E. Dinsmore, Henry Gewirtz, Massachusetts General Hospital, Boston, MA We tested the hypothesis that moderate-to-severe coronary artery stenosis (CAS) can be identified by PET (13NH3) measurement of maximal myocardial blood flow (MBF) response to adenosine (Ado-140 ug/Kg/min x 5 min). Computer assisted quantitative coronary angiography was obtained in 17 CAS patients (Pts). Moderate-to-severe CAS was defined as minimum lumen diameter (MLD; mm) <1.26 in proximal epicardial segments (reference diameter = 2.96+0.91 mm: Mean+SD). MBF response to Ado also was assessed in 9 controls (CNTLs). Rest MBF (ml/min/g) was 0.99+0.25 in CNTLs versus 0.62+0.26 in CAS Pts (P<0.01). In CNTLs all zones (n=23) had Ado MBF >1.65 (mean = 3.06+0.88). In CAS, 6/7 zones (4 Pts) with MBF >1.65 had mild or no CAS (MLD = 2.22+0.83) while 18/23 zones (15 Pts) distal to CAS with MLD <1.26 had Ado flow <1.65 (mean = 0.96+0.54; P<0.01 vs CNTLs). Heart rate (/min) and systolic pressure (mmHg) with Ado were similar in CAS (84+21; 127+19, respectively) and CNTLs (90+25; 128+17).Thus, for moderate-to-severe CAS positive predictive accuracy (PA)of PET Ado MBF
Eric A. Dubois, Jan C. van de Bos, Ton G.M. Janssen, Harry D. Batink, Martin P faffendorf, Eric A. van Royen, Pieter A. van Zwieten. Depts. of Nuclear Medicine, C a r d i o l o g y and P h a r m a c o t h e r a p y , U n i v e r s i t y of Amsterdam, Academic Medical Centre Amsterdam, Cygne B.V. Technical University Eindhoven, The Netherlands. In patients with congestive heart failure (CHF), plasma noradrenaline (NA) levels are known to be increased, tlaus leading to downregulation of cardiac B-adrenoceptors (BAR). I~ order to assess B-AR density in patients with CHF, we want to develop new radioligands for the imaging of gA R using SPECT. CGP l_217Tand nadolol are pqtent 15adrenoceptor antagonists. We tested the affinity ot ortho(C.YBL2BS), para-iodinated C G P 12177 and orthoiodinated nadolol for the B-AR in vitro, using displacement experiments with homogenates of left ventrlcluar tissue of New Zealand White rabbits, and[125I]-Iodoyanopindolol as the radioligand. We compared the affinity of the new compounds with the non-iodinated derivatives. The respective Ki-values are listed in the table. Ki(nanomol/1) Ki(nanomol/l) CGP12177 1.17+0.42 Nadolol 52.99+19.86 CYBL2A 28786+9255 CYBL1 1787+700 CYBL2BS I 1.06+2.08 (mean_+S.E.M., n=3-5) CYBL2BS, which can be readily synthesized, appears to display high affinity for the B-AR and may hence be developed as apotentlally radioligand for imagmg. CYBL1 and CYBL2A display a too low aIfinity in that respect.
$7
$8
Abstracts
JOURNAL OF NUCLEAR CARDIOLOGY
Monday morning, April 24, 1995
M O N D A Y P M A P R I L
March/April 1995, Part 2
S 10-029
S10-031
H E T E R O G E N E I T Y OF M Y O C A R D I A L M I B G DISTRIBUTION RELATES CARDIAC DENERVATION
Margot Jonas, W. Brandau, B. Vollet, M. Weyand, A. Fahrenkamp, F.-J. Gildehans, C. PuskAs, I. Seiuk, H. H, Schcld, W. Btcker, O. Schober University,Departmentof Nuclear Medicine, MOnster, Germany Simultaneous quantification of regional myocardial fatty acid metabolism (131I-PHIPA 3-10) and perfusion ~gmTr
Naoya Hattori, Nagara Tamaki, Tatsuya Hayash4 Izuru Masuda, Toshio Moritani, Takashi Kudoh, Yoshiharu Yonekura, KazuwaNakao, Junji Konishi. Kyoto University, Kyoto, Japan Both reduction of global MIBG uptake and heterogeneity of its distribution are reported in pathologically denervated hearts in diabetes mellitus. The goal of this study is to find out which factor - global or regional is important to evaluate the cardiac denervation, 19 normal coronary patients with diabetic neuropathy were studied. They underwent MIBG scintigraphy at 15 min (early: E) & 4 hrs (delayed: D) after injection and Power Spectral Analysis (PSA) of R-R intervals for identifying autonomic dysfunction within a week from the MIBG study. Following MIBG indexes were examined: heart/mediastinum count ratio (H/M), cardiac uptake ratio (UP), and washout rate (WR) as the global uptake index; inferior/anterior count ratio (I/A) and covariance value (CV) as the regional distribution index. Correlation coefficient (r) of logarithm of total power (TP) from PSA were: r
H/M(E) (D) 0.15 0.13
UR(E) (D) WR 0.33 0.30 0.30
I/A(E) (D) CV(E) (D) 0.63* 0,65* 0.70**0.24
E: Early data, D: Delayed data, * p < 0.01, ** p < 0.001 Correlation coefficients of the regional indexes were higher than those of the global indexes. In conclusion, autonomic dysfunction of the heart is related mainly with the heterogeneity of sympathetic nerve distribution rather than the global reduction of MIBG uptake.
Iodo-PHIPA 3-10, a phcnylene bridged long chain fatty acid, is accumulated in the myocardium with a long biological half life > 15 h, indicating a "metabolic trapping". During a heart transplantation a double nuclide study using t3II-PHIPA and 9~TcMIBI was performed. Scintigraphies of the explanted heart were compared to the preoperative scans, the activity of tissue samples and the corresponding histology, 13q-PI-llPA and 99mTe-MIBI were accumulated in hibernating or stunned myocardium in a ratio of 2 : 1 according to their percent I.D. In scares however, the accumulation ratio of PHIPA / MIBI reversed to 1 : 2. These results imply that residual viable myocardium can be more accurately differentiated from scares with PHIPA 3-10 than with MIBI. Furthermore the different biodistribution of PHIPA and MIBI in hibernating myocardium and scares indicates that not only the perfusion, but the metabolic state of the myocardium can be evaluated with PHIPA 3-10. As a metabolic marker of the heart PH1PA 3-10 has the potential to improve the assessment of myocardial viability with SPECT. So far 9 patients were investigated using mI-PHIPA 3-10 and the results were compared to 2~ and 99mTc'MIBI-studies. In 4 lesions no perfusion with MIBI was observed, but a significant uptake of PHIPA implicated residual viable myocardium.
S 10-030
S 10-032
DECREASED BMIPP UPTAKE SUGGESTS THE PRESENCE OF SEVERE ISCHEMIC MYOCARDIUM IN PATIENTS WITH UNSTABLE ANGINA.
Myocardial Fatty Acid Metabolism and Cardiac Sympathetic Nerve Function in Diabetes Mellitus : Analysis Using ~=I-BMIPP and '~I-MIBG Myocardial Scintigraphy Ohkuma Toshio, Ishiguro Motoyuki, Hashimoto Kazuaki, Goto Naoki, Torisawa Masanori, Inoue Kiyoaki, Minagawa Taro, Takada Nobuyuki, Hirano Takahiro, Matsuo HitoshiL Watanabe Sachiro" Department of Cardiology, Hirano General Hospital;Department of Cardiology, Oifu Prefectural Hospital" [ Objectives )The present study was undertaken to assess the feasibility of predicting cardiac events in patients with diabetes mellitus using '=I-BMIPP and ~=I-MIBG myocardial seintigraphy. [ Methods ) The subjects were 6 patients with diabetes mellitus (DM), 7 patients with diabetes mellitus complicated by renal failure (DM-CRF), 8 patients with non-diabetic renal failure (CRF) and 5 healthy volunteers (controls). The following parameters were measured and analyzed : (1) H / B ratio (the ratio of myocardial fatty acid metabolism, i.e, the ratio of myocardial count to ~vhole body count) (2) H / M ratio on '~I-MIBG myocardial scintigrams. (3) L F / H F ratio on power speetralt analysis, (4) left ventricular myocardial mass index (LVMI) as measured on ECG, and (5) ECG-CV value. ( R e s u l t s ) The H / B ratio in the DM group (5.65+-0.86) was significantly lower than that in the DM-CRF group (6.60• the CRF group (6.45-+0.49) and the control group (7.58~0.76). In the DM group, the H / B correlated positively with H / h i , L F / H F and CV, and it had a negative correlation with LVMI. When DM was complicated by renal failure, the H / M decreased while the H / B increased. Thus, the percentage of myocardial fatty acid metabolism in systemic fatty acid metabolism decreased in the presence of DM, and the H / 8 ratio was elevated when DM was complicated by renal failure. [ Conclusions ] In diabetic patients, the left ventricular myocardial mass is greater than normal, but myocardial fatty acid metabolism decreases.
Madoka Tateno, Nagara Tamaki, Masashi Yukihiro, Keigo Endo, Yasushi Suzuki, Takuji To yama, Tadashi Suzuki, Junji Konishi. Gunma and Kyoto Universities, JAPAN. Focally decreased uptake of 123I-g-rnethyl iodophenyl pentadecanoic acid (BMIPP) is often observed in patients with unstable angina at rest. To assess the clinical significance of decreased BMIPP uptake, BMIPP findings were compared with those of coronary arteriography, contrast ventriclography, exercise TI SPECT, and rest TI SPECT in 15 unstable angina patients without history of myocardial infarction. All patients revealed regional abnormality on BMIPP SPECT. Of 60 myocardial segments supplied with coronary stonosis (>75%), 41 segments (68%) had BMtPP abnormality, 25/44 (57%) had exercise TI abnormality, 19/54(35%) had resting T1 abnormality. Of 17 segments with abnormal wall motion on contrast ventriculography, 12 segments (71%) had abnormal BMIPP, 5/9 (56%) segments had abnormal exercise TI, and 8/15 (53%) had abnormal rest TI. Of 35 segments with abnormal exercise T1, 26 (74%) segments demonstrated abnormal on BMIPP at rest. There was 13/21 (92c;~,) BMIPP abnormality in the segments with severe hypopeffusion on exercise TI, while 13/21 (62%) BMIPP abnormality was seen in the segments with mild hypoperfusion on exercise TI. In conclusion, the abnormal BMIPP uptake at rest reflects severe myocardial ischemia on exercise T1 SPECT, which were often associated with regional wall motion abnormality.
JOURNAL OF NUCLEAI~CARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Monday morning, April 24, 1995
S 10-033
P01-035
W. Brandau, C. Pusk,~s, F.-J. Gildehaus, M. Jonas, B. Yollet, O. Sehober University, Department of Nuclear Medicine, Mtlnster, FRG
PHARMACOLOGICAL STRESS RADIONUCLIDE ANGIOGRAPHu (RNA) COMPARISON BETWEEN D O B U T A M I N E A N D DIPYRIDAMOLE. Gomez MV, Coma-Canetla I, Salazar ML, Terol I, Gallardo FG, Castro-Belras J M The purpose of this study was to stablish the diagnostic value o f dlpyridamole and d o b u t a m i n e - l n d u c e d transient wall motion alteration in the radlonuctide angiography (RNA) and to c o m p a r e the effect of tllese two p h a r m a c o l o g i c a l stress tests in coronary artery disease (CAD). Two projections basal, dobutamlne (up to 40Hg/kg/mlnfor 5 mln) and dlpyridamole (0.80 mg/kg for 6 rain) RNA were performed tn 30 patients with d o c u m e n t e d CAD who underwent both tests with 2 days interval. Global EF and regional motility in 180 segments were analyzed in each test Pharmacological-induced transient wall motion alteration was considered when there was either decrease or not increase of the regional EF RESULTS BASAL EF 42+_13 DIPIRYDAMOLE EF 45_+16 p < 0 , 0 1 EFA 3_+7 DOBUTAMINEEF 52.+_17 p<0,0001 EF610+-7 p<0,0001 When regional wall d a t a were analyzed, results were as
INFLUENCE OF MITOCHONDRIAL TRANSPORT ON THE MYOCARDIAL DISTRIBUTION OF 123I-PHIPA 3-10
A phenylene-bridged long chain fatty acid, 123I-PHIPA 3-10 has been discussed as a tracer for the investigation of myocardial metabolism. In the current study we compared the influence of Etumoxir as a specific inhibitor of palmitoyl-earnitine-transferase I (CPT 1) on the biodistribution of 123I-PHIPA 3-10. Animal studies were performed in non-fasted rats. While myocardial uptake was comparable to that in fasted animals, liver activity drops from 5% I.D./g (5 rain p.i.) to 0.6% I.D./g (4 h p.i.), in contrast to 3% I.D./g (4 h p.i.) retained in the liver of fasted rats. Treatment of non-fasted animals with Etomoxir (20 mg/kg) prior to injection of 123I-PHIPA 3-10 resulted in pronounced biokinetic differences. Myocardial activity accumulates significantly with time from 3.8% I.D./g (5 min p.i.) to 6.8% I.D./g (4 h p.i.) compared to 3.6% I.D./g (5 rain p.i.) and 3.2% I.D./g (4 h p.i.) for non-treated animals. In contrast the biokineties for blood, lung, liver etc. are not influenced, but the subcellular distribution changes evidently. In 4 volunteers basic biokinetic data were determined in planar and SPECT-studies up to 24 h p.i.. Myocardial accumulation was 2.1+1.1% I.D. with a heart/lung ratio of 1.95:0.2 30 min p.i. and a biological half life in the heart of about 27 h. The results from the animal experiments indicate that the retention of 123I-PHIPA 3-10 in myocardial tissue is influenced by mitochondrial transport, and that this tracer could serve as a metabolic marker in myocardial SPECT-investigations.
follows: DOBUTAMtNE: 25 (83%) of 30 patients had new walt motion alterations, In 54 segments there was either decrease or not Increase of contractility, DIPYR/DAMOLE: 29 (96%) of 30 patients had new wall motion alteration. In 95 segments there was either decrease or not Increase of contractility, (p<0.0001) Both agents produced an Increase In EF. However this increase was significantly lower when dlpyridamole was employed, Dipyrldamole RNAshowed higher sensitivity to d e t e c t CAD in this group of patients with known CAD
P01-034
P01-036
Tc - 99m SESTAMIBI STRESS/REST SPECT IN PATIENTS WITH STRESS PROVOCATED CHEST PAIN CORRELATION WITH ANG1OGRAPHIC FINDINGS.
MARKERS OF MYOCARDIAL ISCHEMIA WITH "VEX" (VASODILATOR-EXERCISE COMBINATION): DECISION-TREE INDUCTION AND LOGISTIC ANALYSIS.
Marek Ostrowski, Eugeniusz Dziuk, Wojciech Kwiatkowski, Leszek Kubik, Jaroslaw Wisniewski. Central Clinical Hospital WAM, Warsaw, Poland 63 consecutive patients with stress provocated chest pain were referred for treadmill exercise study according to the Bruce protocol, with simultaneous Tc-99m sestamibi myocardial SPECT. Post exercise SPECT acquisition was carried out 1 hour later and the rest study dndng 2-4 days after. The group consisted of 49 male and 14 female mean age 52 + 14 years. The accuracy of mdionuclide study was evaluated in comparison to coronary angiogmphy (CA). CA was performed up to 4 months post SPECT study. Stenoseswith > 50% luminal diameter reduction were considered significam. To compare stress/rest SPECT images short, vertical and horizontal long axes slices were used and qualitative evaluation was applied. 13 patients had single vessel stenosed and only one had 3 vessel disease (false negative SPECT study). 17 of the 20 patients with normal CA angiograms had negative and 40 of 43 with abnormal CA had positive mdionuclide study. The overall sensitivity and specifici~ for SPECT study was 93% and 85% respectively. Thus Tc-99m sestamibi SPECT accurately separate the patients with CAD from those referred for exercise study to diagnose stress provocated chest pain.
GA Hurwitz, DL Silver, ME Weingert. University of Western Ontario and Victoria Hospital, London, Canada. Vasodilation combined with symptom-limited exercise (VEX) may represent an optimal modality for stress scintigraphy in patients with reduced exercise capacity. To evaluate VEX, we compared clinical features, ST depression (consensus of 3 blinded observers) and scintigraphic markers with angiography in a referred population (n=503). Ergometry alone (ERG), dipyridamole infusion, or VEX was chosen for testing according to non-cardiac symptoms and current drug therapy. For each stress-mode, the presence of coronary artery disease was modeled by multiple logistic regression analysis, and by ID3, a machine-learning program for induction of decision-trees. Scintigraphic markers were discriminators for all dipyridamole-based tests with both methods of analysis. ST depression was contributory only with ERG. Reversing defects had greater diagnostic value with VEX than with ERG or dipyridamole. Thus VEX appears more helpful than single-mode tests in disclosing myocardial ischemia.
$9
$10
M O N D A Y P M A P R I L
Abstracts M o n d a y m o r n i n g , A p r i l 24, 1995
JOURNAL OF NUCLEAR CARDIOLOGY M a r c h / A p r i l 1995, P a r t 2
P01-037
P01-039
EFFECTS OF D O B U T A M I N E INFUSION ON LEFT VENTRICULAR SYSTOLIC AND DIASTOLIC FUNCTIONS IN PATIENTS WITH CORONARY ARTERY DISEASE: ASSESSMENT WITH RADIONUCLIDE VENTRICULOGRAPHY. ShiJa-Ping Yang, ~'Wei-Lian Chen, '~Cheng-Yi Cheng, Mason Shirtg Young, Dat~-Jiang Wang. Division of Cardiology, *Department of Nuclear Medicine, Tri-Servlce General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC. Thirteen patients (Group I, M 8, F 5, age 68+6 SD) with angiographically documented coronary artery disease (CAD) and 8 subjects (Group 2, M 5, F 3, age 64:i:7) with normal coronary artery underwent radionuclide angiography (RNV) during dobutamine infusion. Dobutamine infusion was started at the dose of 5/zg/kg/min with the increment of 5#g/kg/min every 10 minutes untll angina, high blood pressure (> 220 mm Hg) or maximum dose (20 /zg/kg/min) was achieved. Radionuclide ventriculography was performed before dobaramine infusion and at each level of infusion dose subsequently. During dobutamine infusion it revealed that 1) left ventricular peak ejection rate (PER) increased significantly in both groups of patients (group 1:3.2+0.6 to 4.4• group 2: 3.4• 5.4• end-diastolic volume/see, p<0.05); 2) left ventricular ejection fraction (LVEF) increased in group 2 patients (57• to 66+5%, p < 0.05) and remained unchanged in group 1 subjects (55 • 6 to 59 +7%, NS); 3) left ventricular peak fillingrate (PFR) increased significantly in group 2 patients (3.2• to 4.3 • end-diastolicvolume/sec, p <0.01) and tended to decline in group 1 patients (2.8+0.6 to 2.4• NS). In addition, 12 of the 13 patients in group 1 were found to have either newly developed regional wall motion abnormalities, corresponding to the coronary arterial lesions identified by coronary angiography, and/or failure of increase of LVEF during dobutamine infusion (sensitivity 93%). We conclude that dobutamine stress RNV is a safe and easily performed method in detecting CAD with appropriate accuracy. It also provides information about left ventrlcular functional reserve during stress in CAD patients,
EXERCISE SPET ~="3"c-MIB! IN THE DIAGNOSIS OF CORONARY ARTERY DISEASE IN PATIENTS WITH EQUIVOCAL ELECTROCARDIOGRAPHIC EXERCISE TESTING
P01-038 AND USEFULNESS OF SCINTIGRAPHY IN PATIENTS WITH ARTERY DISEASE SAFETY
M, Fraile, C. Bantana Boado. J. Candell Riera*, J. Caetell Conesa, A, Garcfa Burillo, J. Cortadellas*, J. Palet*, S. Aguad~ Bruix, D. Ortega-Alcalde, J. Soler-Soler*. Bervicio de Medlcina Nuclear. Servicio de Cardiologla " Hospital General Univereitari Vail d'Hebron Barcelona. Background: To assess the yield of exercise myocardial SPET with methoxy-isobutyl-isonitrile-technetium-99m (99mTc-MIBI) in the diagnosis of coronary artery disease. Methods: Seventy-two consecutive patients, without previous myocardial infarction end with coronary angiography, were investigated. All underwent a symptom-limited exercise test with intravenous injection of 15 mCi of ae"Tc-MIBI 30-60 seconds before the end of exercise. Detection of tomographic images was performed after one hour. Rest images were detected 2 4 hours later. Images with exercise perfusion defects which became normal at rest were considered as positive. Results: Sensitivity (84%), specificity (83%), global value (87%), positive predictive value (95%), and negative predictive value (79%) of 99mTc-MIBI were significantly higher than those of conventional exercise test (46%, 6 9 % , 55%, 69%, and 4 6 % , respectively). These values were lower when exercise test was insufficient (peak heart rate below 8 0 % in the absence of angina). The sensitivity values were similar for the diagnosis of one (81%), t w o (76%), and three (93%) vessel disease, The application of Bayes' theorem disclosed that the highest yield of MIBI was achieved with prevalences ranging between 3 0 % and 7 0 % . Conclusions: The efficacy of ~ SPET for the diagnosis of coronary artery disease was satisfactory, particularly when exercise was sufficient and with a prevalence of coronary artery disease ranging between 300/0 and 70%.
P01-040 ADENOSINE CORONARY
Maria G. Koutelou, El. Giatsitzoglou, S. Mavrogeni, V. Voudris, A. Manginas, A1. Karoussou, D.V. CokkinosOnassis Cardiac Surgery Center. Nuclear Medicine Department. 1st Department of Cardiology, Athens Greece. Adenosine is widely used for thallium (TI2~ scintigraphy (ATS) in patients (pts) with coronary artery disease (CAD). In this retrospective st'tdy we included 74 pts who underwent ATS, 58 male (78.3%) and 16 (21.7%) female. The mean age was 59~13 years old and 54 (72%) had history of myocardial infarction. Medication included b-blockers in 26 pts, calcium antagonists in 30 pts and nitrates in 18 pts. We used a continuous fixed intravenous adenosine infusion at a dose of 140 gamma/kg/min during six minutes with Tl 2~ being injected at the fourth minute. Results were obtained by comparison with coronary arteriography (CA) expressed in terms of sensitivity, specificity and extent of CAD. Systolic blood pressure (BP) dropped from 140-• mgHg to 132:t:22 mmHg. Heart rate increased from 66~-9 to 75• beats per minute. Twenty one had reversible defects and all had CAD and CA identified 36 diseased vessels (DV) with significant stenoses (>70%). Twenty seven had fixed defects; 26 had CAD and 40 DV. Nineteen pts had mixed defects (fixed and reversible), all of them had CAD and the CA identified 37 stenotic vessels INS). Seven pts had normal scans and CA revealed CAD in 4 pts. Overall the sensitivity and specificity were 98% and 50%. Five pts were in unstable angina. There was no preponderance of side effects, which were: chest pain (8 pts), transient hypotension (1) and headache (5 pts), while ST depression was seen in 2 cases. Thus ATS is useful in detecting ischemia and seems to be a suitable technique for pts in unstable angina.
SIMULTANEOUS DIPYRIDAMOLEIEXERCISE SPET m"Tc-MIBI IN THE DIAGNOSIS OF CORONARY ARTERY DISEASE IN PATIENTS WITH LOW PEAK HEART RATE, Ampere GarcIa-Bud((o, C~mar Santana Boado, Joan Castell, Jose Manuel Gonzfiiez, H Valenzuela, Jaume Cendell*, FM Domen~ch-Torn6. Servicio de Medicine Nuclear. Servlcio de Cardiologla* Hospital General Univeraitario Vail d'Hebron. Barcelona. Background: To assess the yield of simultaneous intravenous dipyridamo}e/exerr myocardial SPET with methoxyqsobutyl-ison}tritetechnetium-99m (~mTc-MIBI) in the diagnosis of coronary arery disease when an optimal heart rate was not achieved. Methods: 105 consecutive patients, without previous myocardial infarction and with coronary angiography, were allocated into 3 groups: - Group I: 45 patients with a satisfactory exercise test (heart rate > 8 0 % , angina or ST depression > 1ram). - Group I1:27 patients with a unsatisfactory exercise test. - Group Ill: 33 patients with e unsatisfactory exercise test with intravenous dipyridamole administration. Group I and II underwent a symptom-limited exercise test with intravenous injection of 15 mCi of 99"Tc-MIB130-60 seconds before the end of exercise. In group I~1, when an optimal heart rate is not achieved during the exercise test and ischaemic changes do not develop, a dosis of 0 . 2 8 - 0 . 5 6 mg/kg of dipyddamole over 2-4 minutes was injected while the patient keeps exercising. Detection of tomographie images was performed after one hour, Rest images were detected 24 hours later. Images with exercise perfusion defects which became normal at rest were consideredas positive. Results: SENSIT
SPEC
GL. V A L
POS PV
Gr I
91%
95 %
93 %
95 %
NEG PV 91%
Gr II
75 %
86 %
78 %
94 %
54 %
Gr Ill 85 % 85 % 85 % 89 % 78 % Conc ~sion: The efficacy of MIBI SPET for the diagnosis of coronary artery disease was satisfactory when exercise test was not maximal (heart rate < 8 0 % without angina or ST depression).
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Monday morning, April 24, 1995
P01-041
P01-043
THE IMPACT OF STRESS MYOCARDIAL PERFUSION TOMOGRAPHY ON THE SELECTION OF PATIENTS FOR CORONARY ANGIOGRAPHY
Automatic quantitativeanalysis of 99roTe $estamibi SPECT for the detection and assessment of extension of coronary artery disease (CAD). Multicentricprotocol. R.Campini, O.Zoccarato, F.Fringuelli, C.Marcassa, G. R,omolo, G.Cannizzaro*,G.Medolago~ E.Milan" Nucl. Med. and Cardio[. Opts Clinica del Lavoro Foundation IRCCS Veruno and Montescano*, Bergamo~ Palermo^ and Brescia ** Hosp. Aim of the study were : 1) evaluation of the predictive accuracy for CAD diagnosis of automatic quantitative polar map analysis of Sestamibt SPECT 2) correlation between extension oT permsion defects and location of coronary lesions (proximal 0r distal). We evaluated 112 pts (28F, 84M, age range 30-75) enrolled in 5 oilferenl institutions: 50 pls nao su]ferea ]rom prewous MI and 44 had not; 13 pts had a pre test probability lesser than 5%. Coronary angiogfaphy was performed within 2 months from.the exercise besmmJoi SPECT(2dayprotocol). 65 genaer matcnea pts constitued the normal database. Polar maps were evaluated for extension(EX) (n. of pixels with tracer uptake <2.5 SD o! the normal range), corrected for the geometrical distortion ol the hearth and severity(SV (EX multiplied for n. of SD below the normallimits). Sens. Spec. Ace. .78 1O0 ,80 EX all pts SV all pts .90 ,78 .89 EX without MI .65 100 .71 SV without MI .80 .88 .72 LAD EX .72 .82 .74 RCA+LCX EX .71 .81 .75 Normalcy rate = .92 No statistically significant difference was observed in EX between proximal or distal coronary lesion. We conclude that automatic polar map analysis is a reliable tool for CAD diagnosis. The apparent discrepancy between defect size and location of coronary lesions underlines the limitation of angiographic data to quantify the size 0r jeopardiseo myocaroium,
Habib Dakik, Kay Kimball, John J. Mahmarian, Mario S. Verani, Baylor College of Medicine, Houston, TX, USA Although myocardial perfusion SPECT is widely used in patients (pts) with suspected coronary artery disease, the impact of the test results on subsequent referral for coronary angiography (CA) is unclear. Accordingly, we analyzed all pts who underwent a stress (64% exercise, 36% pharmacologic) cardiac SPECT in our institution in 1993. Only 2.7% of pts with normal scans (n=1,892) subsequently underwent CA within 1 month of SPECT. In pts with abnormal scans (n=1,216), the odds for performing CA increased by 15 times (OR=I5.0 C[=I 1.1-20.3, p<0.0001) and 89% of those undergoing CA had significant coronary disease. The extent of perfusion defects and the presence of ischemia were strong predictors of subsequent CA: the odds of performing CA increased by 66b/o (OR=1.66, CI=1.551.79, p<0.0001) for every 10% increase in defect size, and it further increased to 450% when ischemia was present on the scans (OR=4.5, CI=3.48-5.89, p<0.0001). Thus, cardiac SPECT results have a powerful influence on the rate of subsequent CA.
P01-044
P01-042 REDUCED
SENSITIVITY
FOR INDIVIDUAL ARTERIAL THREE-VESSEL CORONARY ARTERY
STENOSES IN DISEASE PATIENTS USING SPECT PERFUSION IMAGING. K. A. Williams, K. P. Holdeman, and L. A. Taillon. The University of Chicago, Chicago, IL, USA. In patients (pts) with coronary artery disease (CAD), SPECT myocardial perfusion imaging is often used to diagnose, localize, and asses~ the physiologic significance of coronary stenoses. However, without absolute quantification of regional blood flow, relative tracer uptake may give "false negative" results in the arterial distribution of a vessel which is less diseased than contralateml vessels. Stress 99~Tc-sestamibi SPECT peffusion images and coronary arteriogmphic results of 33 pts, including 14 with one-vessel (1VD), 7 with two-vessel (2VD), and 12 with three-vessel CAD (3VD), were compared to determine the frequency of underdiagnosis of arterial stenoses due to the presence of contralateml CAD of greater severity (e.g., 80% left anterior descending and circumflex stenoses with an occluded right coronary artery). Results: There were 64 stenoses of >50% luminal diameter in the 33 pts. In pts with 1VD, the overall sensitivity of SPECT for CAD was 79%, compared with 95% in pt with 2VD or 3VD. However, in pts with 3VD, sensitivity for individual arterial stenoses was only 64%. Out of 36 diseased arteries in pts with 3VD, 20 were deemed at risk for underdiagnosis on SPECT due to contralateral disease; 11 of these 20 "predictable" territories (55%) were interpreted as normal on SPECT, vs. 2 of 16 (13%, p=.0234) other territories in 3VD pts, and 9 of 44 (20%, p=.0141) "unpredictable" CAD territories in all 33 pts. Conclusions: In the absence of absolute quantification of blood flow, the sensitivity of SPECT perfusion imaging for individual arterial stenoses is predictably reduced in pts with 3VD and contralateral ischemia, and may result in underestimation of CAD impact in these pts.
VISUAL ANALYSIS OF SPECT-TI 201 VERSUS SPECT-TI 201 QUANTIFIED IN THE DETECTION OF CORONARY ARTERY DISEASE
Fernando S~nchez-Navarro, Juan P, Gomoll6n, Angel Ascaso, Conccpci6n Ceballos, Maribr Mtravete, Luis J Placer. Hospital Mignel Server. Zaragoza Our aim was to evaluate the sensitivity of visual analysis versus computer-quantified polar maps in the single photon emission computed tomography with TL-201 (SPECT-TL) for coronary artery disease (CAD) detection. We realiced a SPECT-TL 5 min after exercise test using the Bruce protocol, and other three hours later in 52 patients with CAD without myocardial necrosis and significant stenosis ( _>50%) in the coronariography. Visual assesment of the tomographic slices was compared with the quantification using three computerized two-dimensional polar maps: stress, redistribution (Q) and slow-washout washin (W-W), Sensitivity Specificity Visual analysis 84% 82% Quantitative analysis W-W
65%
90%
96%
92%
In conclusion: quantitative thallitmi tomography improved the sensitivity in CAD detection using slow-washout washin polar maps. The sensitivity of polar maps is lower when used alone.
Sll
S12
M O N D A Y P M A P R I L
Abstracts Monday morning, April 24, 1995
JOURNAL OF NUCLEAR CARDIOLOGY March/April 1995, Part 2
P01-045
P01-047
DIPYRIDAMOLE THALLIUM PERFUSION PLUS RADIONUCLIDE VENTRICULOGRAPHY DETECT CORONARY DISEASE BETTER THAN EITHER TEST ALONE.
A COMPARISON of DOBUTAMINE INFUSION AND MAXIMAL EXERCISE DURING MYOCARDIAL PERFUSION SCINTIGRAPHY WITH Tc-99 m SESTAMIBI IMAG~qG FOR THE EVALUATION of CORONARY ARTERY DISEASE
MW Kronenberg, CH Lorenz, CU Cates, HW Collins, MP Sandier. Vanderbilt University, Nashville, TN. Abnormal myocardial perfusion and/or ventricular performance indicate coronary artery disease (CAD). With exercise this combination is more accurate than either test alone, but there are few data for vasodilator stress. Thus, we studied prospectively 25 patients (pts) with chest pain and no prior Q wave infarction using dipyridamole (D), TI-201 SPECT, and rest vs. D gated equilibrium radionuclide ventriculography (RVG). Eight pts had < 50% stenosis (classified normal) and 17 had >50% stenosis in > 1 major vessel (CAD). By quantitative T1 SPECT and receiver operating characteristic (ROC) analysis, D-T1 and RVG each had sensitivity 76% and specificity 88%. The TI and RVG results were concordant in 19/25 pts and discordant in 6r (25%), but with either test abnormal, sensitivity increased to 94% and specificity remained 88%. Results were similar using a70% stenosis for CAD. Thus, by combining tests of perfusion and performance using D, T1 and RVG, sensitivity improved and high specificity persisted. This useful combination of tests forms a standard of comparison for judging the results of firs t pass RVG and Tc-99m-based perfusion studies.
EAltmyay, H.Klsactk, MKIr, T.Kural, E.Ozalp, A.O~uzhan, A,Akin Ankara University Faculty of Medicine Department of Nuclear Medicine,Ankara, T~rkiye We have compared the inotropic drug dohutamine to maximal exercise as a means of inducing stress m myocardial perthsion studies. Sixty nine patients with "chest pain" syndrome underwent tomographic myocardial imaging, at rest, after maximal treadmill exercise, after dobutamine infusion ( maximum 40 Ixg/kg/min and augmented by the administration of atropine in required patients) Interpretation of all imaging results was performed by independent blinded physicians. All patients underwent coronary angiography. Luminal narrowing of 50% in a major coronary artery seen in 2 wiews was considered significant. Both dobutamine infusion and exercise test induced a significant increase of heart rate and blood pressure. But the rate of increase is significantly (p<0.05) higher with exercise test than dobutamine infusion. Concordance between the two studies fbr tdentification of perfusion status was observed in 1280 (90%) of the 1449 segments. Agreement on localization of the perfusion detect t o a specific vascular territory was 92% . In conclusion dobutamlne and exercise Tc-99m sestamibi SPECT imaging provide similar information in the diagnosis and localization of coronary artery diease.
P01-046
P01-048
IS DOBUTAMINE STRESS COMPARABLE TO THAT OF EXERCISE OR WHAT INTERVENTIONS/DRUGS SHOULD BE ADDED? Christoph Gr&del, Matthias Pfisterer, Peter Rickenbacher, Jan MUller-Brand. U n i v e r s i t y Hospital B a s e l / S w i t z e r l a n d
A Comparison of Hemodynamic Responses to Dobutamine Stress Testing and Semisupine Exercise Testing in Patients with Ischemle Heart Disease. SS Lele, DJ Macfarlane, FA Khafagi, MP Frenneaex. Department of Cardiology,Royal Brisbane Hospital,Brisbane,Australia
Dobutamine (D) has b e e n u s e d as alternative to exercise (EX) stress testing in different dosages and also combined w i t h atropine. To study possible differences of hemodynamics of D and EX, 8 patients with E X - i n d u c e d ischemia (pts)and 7 control subjects (ctr) with low l i k e l i h o o d of coronary artery disease and a normal EX test underwent D stress testing (5-40 ~g/kg/min) followed by supine bicycle EX. Changes in left v e n t r i c u l a r (LV) enddiastolic volume (EDV), LV e j e c t i o n fraction (EF) and heart rate ( H R ) were c o n t i n u o u s l y monitored using the VEST system. Results as m e a n differences (A) • SD from baseline to peak stress were: Dobutamine Exercise Pts Ctr Pts Ctr A HR +50"• +43"• +36*• +57"• A EF - 9 • +13 • -22*• + 5 • 6% A EDV - 8*• 6 - 7*• + 7*• + 5 • 9 SBP + 8 • +26"• +39*• +69*• *=p<0.05 for diff. from b a s e l i n e ; t = p < 0.05 for A between groups, SBP=systolic b l o o d pressure. While all patients showed a decrease of EF at EX this was seen only in 5/8 pts during D despite higher HR. Thus in contrast to EX D decreased LVEDV (preload) and only m i l d l y i n c r e a s e d BP causing less increase in myocardial oxygen demand despite even higher HR. This implies that additional interventions/drugs should not be aimed at increasing HR but increasing peripheral v a s c u l a r resistance and thus BP as could be a c c o m p l i s h e d w i t h low level EX.
Background. We comparedthe hemodynamiceffects of standard dobutamine and exercise protocols used for the provocation of cardiac ischenua, and assessedthe mechanismof paradoxical dobulamineinduced hypoteasion. Methods ~dRaults, 16 patients with coronaryaztery disease and objective evidence of ischcmia underwent radionuclidr ventriculography during a standard scmisupine exercise test followed 5 hours later by a standard dobutsmine infusion protocol(30-40 IZg/kg/min). Heart rate and blood pressure i n c r ~ more with exercise than with dobutamine (Rate-pressure product 202+54 vs 137+48 p<0,001). Mean left ventriculer ejection fraction did not change during exercise (46,8+11% at rest and 47.5+12.5% at peak exercise), but increased with dobutsmine (47%+15 to 59.5+13% p
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Monday morning, April 24, 1995
P01-049
P02-051
COST-EFFECTIVE MIBI PROTOCOL IN THE MANAGED HEALTH CARE ERA.
MECHANISMS OF PERFUSION DEFECTS DURING METABOLIC OR PHARMACOLOGIC VASODILATION.
Elisa Milan, Raffaele Giubbini, Giuseppe Gioia, Arturo Terzi, Joseph K Russell, Aurora Vaccari, Lina Facchetti, David Cassel, Jaekyeong Heo, Ami S Iskandrian. Philadelphia Heart Institute, Presbyterian Medical Center, Philadelphia, PA.
Gianmario Sambuceti, Assuero Giorgetti, Paolo Marzullo, Danilo Neglia, Lucio Fusani, Giacomo Puccini, Oberdan Parodi. CNR Institute of Clinical Physiology, Pisa, Italy.
The rest Mibi images may not be necessary in the stress-rest protocol provided that the stress images are unequivocally normal, thereby improving laboratory throughput and decreasing cost. This study examined this concept in 200 pts with no prior MI, CABG or PTCA. The stress (S) SPECT images were interpreted as soon as the images were processed without knowledge of the final interpretation based on stressrest (S-R) images. The S-R images were normal in 133 pts (Group 1) and abnormal in 67 pts (Group 2). In Group 1, the S images were considered normal in 107 pts (80%). In Group 2, the S images were interpreted as abnormal in 63 pts (94%). Thus, in 107 pts of the total group (54%), the rest study could have been eliminated at a considerable cost saving. The prevalence of unnecessary rest studies was 82% in men and 87% in women (p < 0.0001); 87% in low and 81% in high pretest probability of CAD (p < 0.0001) and, finally, it was 72% when the interpretation was done by technologists and 85% when done by physicians (p < 0.0001). Thus, to adapt to changes in health care, the stress-rest protocol is cost-effective if routine test studies are avoided. The use of gated stress images may further decrease the need of rest studies but more studies are needed.
Mechanisms of perfusion defects (PD) were evaluated in 24 noninfm'cted patients with single vessel coronary artery disease. Myocardial blood flow (MBF) was measured by positron emission tomography and 13N-ammonia, at rest, during atrial pacing tachycardia and after dipyridamole. A stenotic/control MBF ratio <0.8 (i.e. 2 standard deviations below mean normal value) was considered as PD. During pacing, 13/24 patients had PD: with respect to the remainders, these patients had lower MBF in stenotic m'eas (.77+.18 vs 1.10+.30 ml/min/g, p<.0l) but not in control regions (1.13+.33 vs 1.20+.49 ml/min/g, ns). After dipyridamole, 18/24 patients showed PD: these patients had similar MBF in stenotic areas (1.16+.38 vs 1.24+.20 ml/min/g, ns) but higher flow in control regions (1.95+.72 vs 1.22+.28 ml/min/g, p<.03) than those without PD. All these values were lower than those in 9 uormals during pacing (1.95+.64 ml/min/g) and after dipyridamole (3.59+.71 ml/min/g). Thus, PD during metabolic vasodilation directly reflect the impact of stenosis on MBF; dipyridamole PD are affected by an abnormal vasodilating capability of remote areas. In single vessel disease, a homogeneous MBF response to dipyridamole might indicate a global microvascutar disorder.
P02-050
P02-052
RE-EVALUATION OF NO~MAL CORONARY ANGIOGRAMS IN SYMPTCMATIC PATIENTS WITH ABNONMAL SPECT MYOCARDIAL PERF~SION Archibald A., Khan O., Henry R., Mejias S., Rahaman R., Maharaj P. Eric Williams Medical Sciences Complex Champs Fleurs, Trinidad W.I. Coni0arison between coronary angiography (CA) and SPECTmyocardial perfusion scintigraphy (MPS) using Tc-99m labelled ccmpounds in 26 patients (19 males, 7 females) yielded a sensitivity of 97% and a specificity of 80% for lesion detection. Angiographic analysis initially ascribed the scintigraphic defects in 8 patients (5 males, 3 re,hales) as falsely positive. Eleven (ii) coronary artery territories were involved; 8 within the LAD and 3 within the RCA. Patient symptc~ology, however, prc~npted angiographic review which revealed myocardial bridging of the LAD in i m a l e patient and differential perfusion of the lAD in 2 m a l e patients. DiaphranTnatic attenuation was felt to account for the false positives in the RCA. Critical re-evaluation of other pathophysiological abnormalities in the absence of vascular stenosis should thus be sought in patients with positive MPS to avoid unsuspecting patient morbidity.
S13
A COMPARISON OF ONE AND TWO DAY PROTOCOLS FOR PERFORMING Tc99mTETROFOSMINE MYOCARDIAL STUDIES SEM Clarke,K Au Yong,l Fogelman,MN Maisey Tc99mTetrofosmine is a new agent for myocardial perfusion imaging. Experience is limitedand this study has been performed to determine the best imaging protocol. A Tc99mTetrofosmins SPECT study was performed in 16 patients with angina.An exercise stress/4hr rest study and a rest/4hr stress study was performed on consecutive days.The stress study of Day 1 and the rest study of Day 2 were reported as a two day protocol. Results were compared with those of coronary angiography. There was no difference in sensitivity(100%v93%) specificity(100% in both) and accuracy(100%v93%) between the one-day stress/restand one-day rest/ stress protocols in diagnosing coronary artery disease.There was also no difference in individual aretry territories. The one-day and two-day protocols were not different in diagnosing overall reperfused segments (45/117 v 39/I07,p=0.3) and for individual artery territories.The one-day protocol showed more ischaemic segments overall(45/117 v 27/I07,p = 0.03)and for individual artery territories.The one day protocolshowed more ishaemic segments overall(p=0.03).In 36 studies,abdominal activity was seen which affected interpretation in 5.
S14
Abstracts Monday morning, April 24, 1995
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
P02-053 M O N D A Y P M A P R I L
P02-055
REPRODUCIBILITY OF M Y O C A R D I A L FLOW MEASUREMENT WITH PET
BLOOD
R Gistri, R Lorenzoni, F Cecchi, G Chiriatti, PA Salvadori and PG Camici. CNR Institute of Clinical Physiology, University of Pisa, Italy. PET allows the noninvasive measurement of absolute myocardial blood flow (MBF; ml/min/g) in man. To test whether PET provides reproducible measurements of MBF, 2 studies were performed in 16 pts (mean age 41+_12 years) with hypertrophic cardiomyopathy (HCM), using N13-ammonia and PET. In each study, MBF was measured at rest (R) and after iv dipyridamole (D, 0.56 mg/Kg, over 4 min). The second study was carried out after 2_+_0.5months in 9 pts (group A) and after 48-+3 months in 7 pts (Group B). R-MBF was corrected for the rate-pressure product [CR-MBF = (R-MBF/ratepressure product) x 10000]. Coronary vasodilator reserve (CVR) was calculated as: D-MBF/CR-MBF. Group A Group B
CR-MBF D-MBF CVR
1st study 1.19+-0.45 1.41_+0.65 1.21_+0.43
2nd study 1.01_+0.24 1.41+_0.58 1.44+_0.50
1st study 1.02~0,16 1.28+_0.24 1.28_+0.27
2nd study 1.15+_0.47 1.48_+0.79 1.38_+0.83
There were no statistically (ANOVA) significant differences in MBF and CVR values between the first and second study for both groups. In conclusion, the results of the present study show that PET allows accurate and reproducible noninvasive measurements of MBF in pts with HCM.
INTRACORONARYDOPPLER FLOWMEASUREMENTSAND TC99m MIBI UPTAKE IN THE ASSESSMENT OF INTERMEDIATE CORONARY ARTERY STENOSIS. Mustafa Unlii. O~uz H. Caymaz, Biilent Turgut, Mehmet L Alkan, Rldvan Yalgtn, SabahatInanir, H. Dfrtlemez. Gazi UniversityMedical Faculty, Departmentof Cardiology and Nuclear Medicine, Ankara / TURKEY. The physiologicalassessmentof angiographicallyintermediatecoronaryartery stenosis is a problematicin patient management. The aim of this study was to compare intracoronary Doppler flow measurementsand intracoronary administrated Tc-99mMIBIuptake (MIBI),usingSPECT, in the detection of intermediate-severity coronary artery lesions. 20 patients (mean age 54+6 years) with intermediate-severity coronary stenosis (30-70%, by visual assessment)were selectedduring coronaryangiography(CA). Mean percent diameter stenosiswas 48.5+14.6. Coronaryflow reserve (CFR) was studied in 14 LAD, 5 RCA, t LCX lesion with intracoronarypapaverine. After this procedure all patients received It0 MBq of Tc-99m MIBI, injected to the related coronaryarteryduringCA. SPECTimageswere performed3.5 hours after the intervention, whenthe patients werestabilized. For intracoronary Doppler measurements,proximat/dlstal flowratio (R) > t.7 and CFR < 2.0 were considered to be abnormal. Tc-99m MIBI SPECT was evaluated semiquantitatively accordingto the uptake as normal, diminishedor absent. Continuousvariablesweretested with Pearsoncorrelation, Fisher'sexacttest and kappa analysis. The correlationsbetween methodswere as follows:CA - R (r:.51,p:.02,k:.44), CA - CFR (r:-.52,p:.02,k:.32), CA - MIBI (r:.48,p:.03,k:. 17) R- CFR (r:.79,p< .001,k:.86) R- MIBI(r>.13,p:.57,k:.44), CFR - MIBI (r:.44,p:.05,k:.55). Doppler flow parameters showed a strong correlation. CFR and MIBIfindings were correctly correlated in 16 of 20 patients (80%, k:,55). In 4 patients who had < 50% stenosis, MIBIwere negative while CFR results were abnormal. In conclusion,Doppler flow measurements seem to be more sensitive in the detection of intermediate severity coronary artery stenosls, but prognostic importance of this phenomenonmustbe investigatedespeciallyin patientswith < 50% strenosis.
P02-054
P02-056
V A L I D I T Y O F 6 2 C u - P T S M IN Q U A N T I F Y I N G M Y O C A R D I A L B L O O D FLOW AT REST Eiji T a d a m u r a , N a g a r a Tamaki, Hidehiko Okazawa, Yasuhisa Fujibayashi, Takashi Kudoh, Yoshiharu Yonekura, Ryuji Nohara, Shigetake S a s a y a ~ a , Junji Konishi. Kyoto University, Kyoto, Japan 62Cu-PTSM is a generator produced PE.T tracer for assessing myocardial blood flow. In order to validate usefulness of 62Cu-PTSM PET studies using both 62CuPTSM and 13NH3 were performed at rest in 2 n o r m a l volunteers and 9 patients with coronary artery disease. Dynamic PET scans (10secX 12frame / 1 m i n X 8frame) were performed after injection of 62Cu-PTSM. After injection of I3NH3, dynamic PET scans were repeated. %uptake (2-10 rain) was calculated after normalization to the peak count in 11 segments of left myocardium. Based on the microsphere model regional blood flow (RBF) times extraction fraction(E) w a s calculated f r o m the myocardial counts and the integration of arterial input function in both t:acers, Input function was corrected by subtracting the metabolite. %uptake of 62Cu-F'TSM and 13NH3 correlated well with each other (y=15.7+0.8x, r=-0.85). (RMB)X(E) values did not differ from each other ( 0 5 6 + 0 . 1 3 , 0.54_+0.12, p = N . S . ) and correlated well (y=0.19+O,7x, r=0.71). This result s u g g e s t s extraction fraction of these tracers does not differ significantly at rest. 62Cu-PTSM PET permits a quantitative assessment of RBF comparable to 13NH3 PET.
IS REFERRAL TO CATHETERIZATION AIRIER NONI/qVASIVE TESTING BIASED WITH RESPECT TO AGE? Rory Hachamovitch, George Diamond, Hosen Kiat, Ishac Cohen, JA Cabico, J Gonzalez, C, Shufelt, JD Friedman, Daniel S. Berman. Cedars-Sinai Med Ctr, LA, USA. It is unknown whether referral to cardiac catheterization is biased with respect to age. Accordingly, we prospectively compared 1029 middle aged (MA: age 40-60) and 920 elderly (age270) who underwent rest Tl/exercise Tc-99m sestamibi dual isotope myocardial perfusion SPECT (DIMPS) and were followed for >1 year for referral to catheterization (oath) and revascularization (revasc) as well as events (/vii or cardiac death). DI/VlPS was visually scored in 20 segments using a 5 point scale (0--normal, 4=no uptake) and the sum of the scores of the stress segments was calculated for each patient (summed stress score, SSS). Elderly had greater rates of oath, revasc and events compared to MA (20% vs. 14%, 12% vs. 7%, and 4.1% vs. 2.4%, respectively, all p
8 27% 24% 0-3 0.5% 1.6% 4-8 5% 4% EVENTS >8 8% 9% Similar findings were noted for oath after 60 days and revase rates. Conclusion:= The difference in the rates of oath, revase and events allot nuclear testing can be explained by differences in the amount of abnormally perfused myocardium. No age-related bias in referral to catheterization or revaseularization after nuclear testing was found.
JOURNALO F NUCLEARCARDIOLOGY V o l u m e 2, N u m b e r 2, P a r t 2
Abstracts M o n d a y m o r n i n g , A p r i l 24, 1995
P02-057
P02-059
DIPYRIDAMOLE-INDUCED CORONARY BLOOD FLOW CHANGES: RELATIONSHIPWITHSPECT AND CORONARYANGIOGRAPY
ANOMALOUS CORONARY ARTERIES: CAUSE OF "FALSE POSITIVE" PLANAR THALLIUM MYOCARDIAL PERFUSION SCANS
G. Bisi, R. Sciagr~t, G.M. Santoro, P. Buonamici, P.F. Fazzini. Nuclear Medicine, University of Florence; Florence, Italy. Dipyridamole (D) induces coronary blood flow heterogeneity, while ischemia is supposed to be present in a minority of cases. The study aim was to estimate the D-induced flow changes in each coronary territory (Terr) and to correlate them with Tc-99m-sestamibi SPECT and coronary angiography. We studied 18 coronary artery disease (CAD) patients (pts) without prior infarction and 14 controls. Baseline (B) and D SPECT were performed 24-hour apart and Terrs classified as normal (N) or abnormal tAb). The study counts were normalised for dose and acquisition delay, compared and results expressed in % of B value. Dinduced changes were scored considering the prevalent value in each Terr from + 2 (> 40% increase) to - 3 (< 50% decrease). Controls were all N; 1 Terr had score 0, 11 +1 and 30 + 2. In the CAD pts, 18 Terrs without stenosis were all N, with score 0 in 3, +1 in 7 and + 2 in 8 (p = 0.05 vs. controls). In 36 steuotic Terrs, score was +I in 3 (3 N); 0 in 10 (2 Ab, 8 N); -1 in 10 (9 Ab, 1 N); -2 in 11 (11 Ab) and -3 in 2 (2 Ab). The Ab rate w~ts higher in Terrs with flow decrease (p < 0.00001). In the Terrs with score +1 or 0, a < 75% stenosis was always found. In 14/23 Terrs with score <1, a >- 90% stenosis was present (p < 0.0005). Thus, a high rate of CAD detection is observed in the Terrs with D-induced flow reduction. Most of these Terrs have -> 90% stenosis. The poorer CAD detection in the Terrs with < 90% stenosis could be also explained by the lower flow increase in the normal Terrs of the CAD pts compared to those of the controls.
Mil6inski M, Budihna N, Klan6i6 M, Zorman D*. Nuclear Medicine, *Cardiology, University Medical Centre, LJUBLJANA, SLOVENIA Aim of our study was to assess frequency of anomalous coronary arteries as a cause of "false positive" perfusion defects on planar thallium-201 myocardial perfusion scans. Method: results of 156 consecutive coronary angiograms and perfusion scans were analyzed and discordant studies were reevaluated. Results: 64% of 133 men and 48% of 23 women had concordant results of both studies. Five studies of all (3%) showed on reevaluation of coronarogramsanomalous CA- five in LAD and one of them in addition in RCA. Conclusion: "false positive" perfusion defects in pts without CA stenoses were found to be due to anomalous LAD in 3% of reevaluated studies.
P02-058
P02-060
C O R O N A R Y STENOSIS SEVERITY: COMPARISON OF Q U A N T I T A T I V E V A S O D I L A T O R TL-201 SPECT WITH Q U A N T I T A T I V E C O R O N A R Y ANGIOGRAPHY (QCA) IMPORTANCE OF VASCULAR TERRITORY.
INFLUENCE OF CORONARY COLLATERALS ON RESULTS OF MYOCARDIAL PERFUSION SCINTIGRAMS VS. CORONAROGRAMS Klan6i~ M, Mil~inski M, Budihna N, Zorman D*. Nuclear Medicine, *Cardiology, University Medical Centre, LJUBLJANA, SLOVENIA Aim of our study was to assess the agreement between coronary angiograms and planar thallium stress perfusion scans in patients with and without visible coronary collateral arteries. Method: results of coronary angiograms and stress-perfusion thallium-201 planar scintigrams were analyzed and concordance (c) of results for perfusion territories evaluated. In pts with discordant (d) results original films and scintigrams were reanalyzed. Results: c/d (%) MI (%) collaterals(%) M: 133 89/80 69/48* 59/40* W: 23 11/20 55/33 45/25 M-men, W-women, c/d (%)-concordant/discordant results in %, MI-previous myocardial infarction, *p<0.05. In conclusion, significantly more men than women w i t h concordant results of coronarograms and myocardial perfusion scans had previous MI and collaterals.
D. Moertl, G. Porenta, M. Gottsauner-Wolf, P. Prnbst, H. Sochnr. Depiutment of Ciu'dinlogy, University of Vienna, Austria. The purpose ol our study was to determine tile diagnostic value of quantitative TI-SPECT lor the assessment of stennsis severily in a given vasculm" territory. Methods: TI-SPECT wits perlk)nned after wtsodilator stress (adetmsiuc, dipyridlunolc). Extcnl tExt) and soverity (Sev) of perfusion deicers and a defect-score (Score = Ext*Sev) were calculated for the 3 wtscul~u"territories from polzu'maps (Cedlu'sSinai protocol). A QCA-percent diameter stem)sis > 50% wits defined ,'usIx)sitive and <50% as negative for the cldculatiou of sensitivity mid specifity of quantitative TI-SPECT (based on previous validation work). P a t i e n t s : 43 patients with 1-VD (29 LAD, 14 RCA), no previous MI. Results: LAD RCA Sensitivity Specifity Sensitivity Specifity Ext 94% (16/17)* 92% (11/12)* 57% (4/7) 86% (6/7) Sev 76% (13/!7)* 100% (12/12)* 71% (5/7):~ 86% (6/7):~ Scnre 94% (16/17)* 92% (11/|2)* 57% (4/7) 86% (6/7) * ..p<0.01, :~..p<0.05, Fisher's Test (vs _> 50%, diluneter steuosis). C o n c l u s i o n s : 1) For assessment of LAD-steuosis significance with quantitative T1-SPECT in patients with 1-VD Ext hits an excellent diagnostic value. Sev does not add diagnostic information. 2) In contrast, for tunctional evaluation of stenoses in the RCA-territory the diagnostic infi)rmatinn of Ext may be complemented by Sev. 3) Vasodilator SPECT con'elates well with QCA.
S15
S16
Abstracts Monday
M O N D A Y P M A P R I
L
J O U R N A L OF N U C L E A R C A R D I O L O G Y morning,
April
24, 1995
March/April
1995, Part
P02-061
P03-063
PET Myocardial Blood Flow and Coronary Doppler Flow Velocity Are Highly Correlated and Predict PostInfarction Perfuslon In Patients With TIMI 3 Flow Richard E. Stewart, Terry R. Bowers, Richard Ponto, William W. O'Neill, Cindy L. Grinas, Robed D. Safian, Jack E. Juni, D. Douglas Miller, William Beaumont Hospital, Royal Oak, Michigan & Saint Louis University Health Sciences Center, St. Louis, Missouri. The relationship of post-infarction TIMI flow to coronary Doppler flow velocity and quantitative PET myocardial blood flow (MBF) is unknown. Accordingly, 13 pts (61+12 yrs) with acute MI traated with direct angioplasty (LAD 6, RCA 2, LCX 5) with restoration of TIMI 3 flow and quantitative coronary angiography (QCA) and coronary flow velocity determ(nations (basal and adenosine-induced hyperemic flow) > 10 rain after successful intervention. Basal and adenosine (0.14 mg/kg/min x 6 min IV) nitrogen-13 ammonia positron emission tomographic (PET) quantitative MBF (ml/min/gm; 2-compartment model) were measured <36 hrs post-MI in all pts and repeated 7+4 days later in pts. Early Doppler flow and PET MBF responses are given below (~ basal y~, hyperamic states): Doppler Flow (ml/min) PET MBF (ml/gm/min) Basal Hvoeremic Basal Hvceremic Infarct Vessel 37:i:17 48+20** .56+A 6 .83• Non-infarct Vessel 70-J-48 127)-88 .91• 1.60)..44'* Doppler and PET coronary flow reserves (CFR) were highly correlated in infarct (r=0.57, p=o.05) and non-infarct (r=0.79, p=0.002) coronary beds. Early (<36 hrs) and 1-week post-angioplasty infarct zone PET CFR values demonstrated a trend toward improved myocardial peffusion reserve, from 1.6• to 2.4• (p=0.007). Conclusion: Acute restoration of TIMI 3 flow by angioplasty significantly improves hyperamic distal coronary Doppler volumetric flow and quantitative PET myocardial perfuslon in the infarct vessel, and predicts recovery of normal CFR by 1 weak following angioplasty for acute infarction.
AMPLITUDE ANALYSIS OF GATED SESTAMIBI: CORRELATION WITH WALL THICKENING IN INFARCTED AND CONTROL REGIONS. Assuero Giorgetti, Cebilia Marini, Gianmario Sambuceti, Paolo Marzullo. CNR Clinical Physiology, Pisa, Italy. Simultaneous evaluation of Sestamibi uptake (U) and wall tickening (T) was investigated in 13 patients (mean age 59+9 yrs) with previous myocardial infarction (4 anterior, 9 posterior) by gated planar Sestamibi scintigraphy. Ejection fraction averaged .49+.15. U and T were quantified, in infarct and contralateral segments, using normalized angular profiles of background-subtracted and amplitude images. Radioisotopic T was compared to echocardiographic T obtained from 2-D targeted M-mode studies in 13 infarcted and in 13 control segments. Infarct area
Sestamibi uptake Sestamibi T
61+17% 52+8%
Control
p<.01 p<.01
82+11% 84_+18%
Infarct areas showed a concordant reduction of Sestamibi U and T; furthermore, radioisotopic and echocardiographic T, despite obvious differences in absolute values, correlated well in infarct and in contralateral segments (r=.61, p<.001). Thus, a single gated Sestamibi study provides a reliable, quantitative evaluation of regional U and T; in areas of myocardial infarction this information is not hampered by the occurrence of perfusion defects.
P03-062
P03-064
SIMULTANEOUS EVALUATION OF THICKENING AND PERFUSION DOES NOT IMPROVE THE DETECTION OF VIABLE MYOCARDIUM IN MAN.
REST T H A L L I U M - S T R E S S MIBI DUAL PEHFUSION IMAGINe IN CORONARY ARTERY DISEASE, A PRACTICAL CHOICE. PRELIMINARY R E S U L T S IN S0 P A T I E N T S . M. Frnile, M.T. L u q u c ~ J. R i b s . D, P e r e f e r r e r , J, L u p o n a n d L, Serds Ho,~pit~d U n i v e r s i ~ a z ' i G e r m a n s T r i c e i P u j o l Badalona, Spain.
Assuero Giorgetti, Gianmario Sambuceti, Alessia Gimelli, Oberdan Parodi, Paolo Marzullo. CNR Inst. Clinical Physiology, Pisa, Italy. Planar Sestamibi (S) may underestimate tissue viability. To investigate whether gated S could improve the detection of residual viability we studied 18 patients (mean age 59i-_8 yrs) with previous myocardial infarction, before and following coronary revascularization. S uptake and wall thickening were expressed as normalized profiles obtained from planar and amplitude images, respectively. Normal limits (mean-2 SD) were obtained in 10 normals (mean age 54+10 yrs). Before revascularization, S uptake was abnormal in 29 segments (mean activity 43+9% of the peak) with resting echocardiographic hypo (6) or akinesis (23). Despite abnormal S uptake, 14/29 segments showed mantained wall thickening at amplitude analysis; after revascularization, I0 of these segments did not improve regional function. Of the 15/29 segments with S defects and abnormal wall thickening at gated S, 6 (40%) showed an improved wall motion after revascularization. Thus, the simultaneous assessment of S uptake and thickening did not improve the detection of tissue viability. Tethering or shine-trough could justify the detection of thickening in false positives; extreme wall thinning and partial volume effect could mask tissue viability in false negative studies.
AIM: t o a s s e s s t h e p r a < : t . i c a l i t y of d u a l p e r f u s i o n i m a g i n g in patients with suspected CAD a c c o r d i n g t o t h e p r o c e d u r e by B e r m a n e t a l (JACC 9 3 ; 2 2 : 1 4 S 5 - 6 4 ) ill t h e s e t t i n g e r a b u s y Nucl. Med. d e p a r t m e n t in a G e n e r a l H o s p i t a l METHODS: 50 c o n s e c u t i v e p a t i e n t s s u b m i t t e d f o r e v a l u a t i o n of ('AD w e r e e n t e r e d i n t o t h e p r o t o c o l . T h e r e w e r e 37 m e n , A g e r a n g e d f r o m 39 t o 74 ( m e a n = S t ) , T h a l l i u m (T1) S P E C T i m a g e s w e r e r e c o r d e d t e n t o 120 m i n u t e s a f t e r r e s t i n j e c t i o n I l l O MBq, 64 f r a m e s , 64x64,180o-). F o r p a t i e n t s w i t h k n o w n CAD a n d / o r h i s t o r y o f MI ( n = 3 3 ) , t h e m a x i l a u m delay" a n d s,1. n i t r o g l y c e r i n were used in order to a s s e s s v i a b i l i t y . I m m e d i a t e l y a f t e r r e s t TI a c q u i s i t i o n , p a t i e n t s w e r e t a k e n t o t h e t r e a d m i l l o r w e r e g i v e n D y p i r i d a m o l e (.56 m s / K s i n 4 rain) p l u s l o ~ - l e v e l e x e r c i s e ( n = 1 6 ) . MIBI S P E C T i m a g e s w e r e r e c o r d e d 30 t o 50 m i n u t e s a f t e r s t r e s s i n j e c t i o n (550 ~ B q } , T o m o g r a p h i c i m a g e s w e r e p r o c e s s e d a n d r e o r i e n t e d in a standard fashion, and bullseye maps were obtained. Two experienced observers determined the presence and r e v e r s i b i l i t y of a n y p e r f u s i o n d e f e c t . RESULTS: The new imaging protocol was adhered to very easily b y o u r n u r s i n g s t a f f . An a v e r a g e o n e h o u r w a s s a v e d p e r patient, thus increasing our throughput b y a t l e a s t a 20~ p e r session compared with the standard TI p r o c e d u r e . Based on rest-redistribution thallium images, the procedure also provided a good practical means of viability assessment in a s e l e c t e d p o p u l a t i o n a s o u r s ( v i a b i l i t y w a s a n i s s u e in 6 6 ~ of p a t i e n t s ) . B o t h T1 a n d MIBI p e r f u s i o n i m a g e s , a n d b u l l s e y e m a p s , w e r e c o m p a r a b l e ill q u a l i t y a n d die, g n o s t i c i n f o r m a t i o n , a s subjectively assessed by our NM experts. In t h e subset of p a t i e n t s with coronary an eiography (n=lG),sensitivity was 100% o v e r a l l a n d 77% p e r - v e s s e L Specificity was I00~ ( o v e r M I L a n d 94~ per vessel. Direct c l i n i c M i m p a c t w a s 36 % ( w h o l e s e r i e s ) . COMMENTS: Oue p r e l i m i n a r y experience with dual perfnsion i m ~ g i n g s e e m s p r o m i s i n g f o r p a t i e n t s w i t h CAD. It i s c o n v e n i e n t l'.)th for p a t i e n t s a n t i f o r t h e d a i l y routine of a b u s y N M d e l > ~ t r t I l l e n l , It m a y a l s o c o n t r i b u t e to o v e r c o m e t h e p r o b l e m s of practical viability assessment with other protocols,
2
Abstracts Monday morning, April 24, 1995
JOURNAL OF NUCLEAR CARDIOLOGY
Volume 2, Number 2, Part 2
S17
P03-065
P03-067
DIAGNOSTIC ACCURACY OF REST TI201/STRESS Tc-99m SESTAMIBI SEPARATE ACQUISITION DUAL ISOTOPE MYOCARDIAL P E R F U S I O N S P E C T IN T H E V E R Y E L D E R L Y Fan Ping Wang, Aman M. Amanullah, Hosen Kiat, Jinghui Lin, John D. Friedman, Daniel S. Berman. Cedars-Sinai Medical Center, Los Angeles, USA
DOBUTAMINE INFUSION IMPROVES THE SENSITIVITY OF MYOCARDIAL PERFUSION SPECT IN THE DETECTION OF CORONARY ARTERY DISEASE 1N PATIENTS WITH LOW EJECTION FRACTION RATES.
In the very elderly, accurate noninvasive assessment of coronary artery disease (CAD) is important to avoid unnecessary invasive testing. Thus, we studied 111 patients referred for evaluation with rest T1-201/exercise (ex) or pharmacologic (pharm) stress Tc-99m sestamibi separate acquisition dual isotope myocardial perfusion SPECT (DIMPS): 75 consecutive pts aged ->80 years (mean 83+2) with no known CAD who also had .coronary angiography and 36 pts with a relatively low likelihood (<20%) of CAD. Visual analysis used 20 SPECT segments and a 5 point scoring system (O=normal, 4--absent uptake). A SPECT study was considered abnormal if > 2 segments had a :stress score of 2 2 or >1 segment had a score o f > 3 . The overall sensitivity (Sn) and specificity (Sp) for detecting CAD with >70% :stenosis were: Sn Sp Normalcy, rate ex 95%(18/19) 80%(415) Pharm 95%(41/43) 75%(6/8) Overall 95%(59/62) 77%(10/13) ~3%(30/36) The Sn and Sp were 93% and 83% in pts with typical and atypical angina, and 97% and 71% in asymptomatic or nonanginal pts. Thus, ex or pharm DIMPS is highly accurate for the detection of CAD in the very elderly irrespective of symptoms. Pharm DIMPS appears to be an accurate alternative to ex in elderly pts who are unable to perform adequate exercise.
P03-066 REST TI-201/ADENOSINE Tc-99m SESTAMIBI SEPARATE ACQUISITION DUAL ISOTOPE M Y O C A R D I A L PERFUSION SPECT: DIAGNOSTIC EFFICACY IN DETECTION OF C O R O N A R Y ARTERY DISEASE tN WOMEN. Aman Amanullah, Hosen Kiat, Xingping Kang, John Friedman, Daniel S. Berman. Cedars-Sinai Med Ctr, Los Angeles, USA. Noninvasive tests have generally been considered to be less accurate in women than men. To assess the diagnostic efficacy of separate acquisition rest TI-201 (3mCi)/adenosine Tc-99m sestamibi (25mCi) dual isotope myocardial perfusion SPECT (DIMPS) in women, we studied 91 consecutive females (age 71+__10 yrs) who had DIMPS and catheterization. Visual analysis used 20 S P E C T segments(segs) and a 5 point scoring system (0=normal,4=absent uptake). DIMPS was considered abnl if ~ 2 segs had a stress score of>2 or >1 seg had a score of >3. The overall sensitivity (sens) , specificity(sp) and predictive accuracy(pre-acc) of DtMPS for detecting CAD (2:50% stenosis) were 9 7 % (64/66), 84% (21/25) and 93% (85/91), respectively, w ~ l e the corresponding results were, respectively, 97% (57/59), 66% (21/32), and 86% (78/91) for detecting >70% stenosis. In pts without prior MI (n=73), the sens, sp and pre-acc were 98% (47/48), 84% (21/25) and 93% (68/73), respectively for detecting > 5 0 % stenosis and 98% (41/42), 68% (21/31) and 85% 62/73), respectively for detecting >70% stenosis. The sens and sp for detecting individual diseased vessels (2.50% steno, is) were, respectively, 84% and 78% for LAD, 49% and 94% for LCx and 76% and 73% for R C A and the corresponding results for detecting >70% stenosis were, respectively, 88% and 73% for LAD, 57% and 92% for LCx and 76% and 72% for RCA. Thus, adenosine DIMPS is an efficient protocol with high diagnostic accuracy for detection o f significant C A D in women.
Mustafa Llnlti. Gtinsel Vural, Sabahat inantr, Serdar Gtinaydln, New ilgin, Nahide Gtk~ora, Levent GOkgtz. Gazi University Medical Faculty, Departments of Nuclear Medicine and Cardiovascular Surgery Ankara / TURKEY. The aim of the study was to compare the diagnostic efficiency of exercise test (ET) and dobutamine infusion (DI) in the detection o f coronary artery disease (CAD), in patients who had low ejection fraction rates (EFr). A separate dual isotope myocardial perfusion SPECT protocole was applied. 49 patients had T1 - 201 SPECT study at rest. Four days later, at the peak level of ET and two days after this following DI ( 5 m c g / k g / m i n . , up to 40 meg), 10 mCi of Tc99m MIBI was injected and stress SPECT data were acquired an hour later. According to coronary angiography results in the study group, 24 single vessel, 15 two vessel and 10 triple vessel disease were detected and mean EFr was 36 % + 6.7. In ET, patients had limited submaximaI exercise c 78.4 % + t2.3, PDP 185.1 + 46.3 ). Although, the main effect o f dobutamine is to increase myocardial oxygene demand, during DI patients had a significant increase heart rate t 10re DI : 73.2 + 13.6, post DI: 109 + 12.3. P<.005 ~. Overall sensitivity and specificities for ET and DI were 7 2 % . 91% and 80 % . 88 %. respectively. False positive and false negative rates were significantly lower in DI when compared to E T . Using DI, results were well corraleted with the degree of stenosis defined in coronary angiography, especially in the detection of intermediate lesions with 70 - 80 % coronary artery stenosis. (sensitivity : ET 75 %. DI: 90 %, x 2 : p < .05 I. Our data suggests that, DI stress test is more reliable to use in the detection of CAD in myocardial perfusion SPECT studies when compared to ET in patients with low EFr, who are unable to do maxim ~1 exercise.
P03-068 COMBINED ASSESSMENT OF MYOCARDIAL PERFUSION AND VIABILITY USING ONE DAY SEPARATE ACQUISITION REST THALLIUM-201/STRESS TEC'HNETIEM 99M SESTAMIBI DUALISOTOPE. INITIAL EXPERENCE IN MEXICO AND LATIN-AMERICA. Efick Alcxandersen, "victor Varguez, David Bialostozky. Instituto N~eional de Cardiologia"lgnacioChavez",Mexico City, Mexico. Rest-stress sestamibi single photon emission computed tomography(SPECT) has seusitivAy and specificitysimilar to those of thallium-201 SpECT for detectionof coronary ~ e ~ disease,ttowercer,sestamibiis not the ideal-qget~to study myocardial viability. There is not any publishedexperiencein Latin-Americausing dual isotope SPECT protocolto evaluate myoc~al perfusion and viabiliW. We studied 44 consecutive patiems with coronary artery disease, 37 of them with a previous myocardialirrthretion. Coronary angiographywas pertbrmedin all the patients. We used a 3mCirest T[.201 SPECT followedby stress and 25 mCi sestamibiinjection. Sestamibi SPECT was performed 30 minutes ,after excerciseor 1 hour after pharmar stress with dipyridamole, T,J validate pedhsion findings patients retunfingnext day for rest sestamibiinjection and SPECT. Scinti~'aphicdata were read by 2 blinded expertsusing 20 SPECT segmentanalysis and each segmentwas scored using 5 points scoring system(f)~,normal, 4=absentuptake), The seD'nental score agrcemem betweenrest thallium,201and rest sestamibiand the comparison or" defect reversibilitypergentage(R)~a~el non-reversibility(NR) l~ween bothprotocols R,e~stT1201 0 Rest MIBI
t
2
3
4
0 575 0 17 3 0 1 7 2~ 6 0 0 2 12 ,O t.~1 19 0 3 3 O 16 110 6 4 i '0 t 4 67
RestT~t Stress MIBI R NR
Rest/ :Stress R 77 0 MIBt NR 0 23* *32%ofthese segmems showedreversibility with late redistribntion TI images
Exact~greement:90.7O/o Cc~wlu3on: Separate acquisition dual-isotope myocardial perfilsion SPEL'T is ar162 lbr cororloryartery, disease evaluation. It showeda good agreementwith r~l,~ca'esssestamibi 8PECT for assessmentof:rest pedhsion defectsand reversibility. and it was a b~tar methodIo evaluatemyocardialviability
S18
M O N D A Y P M A P R I L 2 4
Abstracts Monday morning, April 24, 1995
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
P03-069
P03-071
EXERCISE MYOCARDIAL SCINTIGRAPHY WITH TI201/Tc-99m-MIBI DUAL ENERGY ACQUISITION USING TRIPLE-ENERGY WINDOW SCATrER CORRECTION.
I-Bi41PP( B-Z,iETHLIODOREEiYL PEiJTAJ:
Jun Hashimoto, Kayoko Nakamura, Koichi Ogawa, Atsushi Kubo. School of Medicine, Keio University, Tokyo, JAPAN
Kouichi ~(it~hsra.Sakakibara Heart Institute,Tokyo,Japan.
We carried out dual T1-201/Tc-99m-MIBI(TI/MIBI) imaging to reduce the time requked for exercise myocardial scimigraphy. Eight patients were involved in this study, and we investigated 4 different protocols. In protocol (A), 1] was injected at rest followed by the injection of M]B] at peak exercise. Dual SPECT images were obtained by T1-201/Tc-99m simultaneous acquisition. Protocol 03) means reverse either, in which MIBI was injected at rest followed by the administration of I ] at peak exercise. In protocol (C), exercise was performed first with MIBl-injection, and then 1] was injected a~ rest after one hour later, Simultaneous acquisition was also performed. In protocol (D), after the rest Tl-imaging, M]BI was injected at peak exercise, and then the MIBl-imaging was done. In protocol (A),(B) and (C), simultaneous acquisition was performed using Triple-Energy Window ("FEW) scatter correction. In 2 of 8 patients, underestimation or overestimation of ischemia due to crosstalk affected the interpretation of images. Thanks to using dual isotopes, all procedures could be completed within 1-2 hours, which was much shorter than the conventional myocardial perfusion imaging. Scatter correction was useful for accurate diagnoses, when the simultaneous imaging is performed.
]]yocar-.ial f~tty acid m e t a b o l i s m may disorderd by sichomia. ThJ.s <~ortion was i n v e s t i g ted by means of B~,IiPP / 21 du?,l isotope ,J:~ECT in 90 patients with h?il who had under~one successful reperfusion therapy. This procedure was performed 2-~ dDJs ~nd about 1 month after the onset of AMi. LV s~ort-axis images were divided into 2@ segments which were ~J_ven defect scores ranging O(mormal) to ](defect). The TI and I];~I2P defect scores were significantly decreased from 1].9 to 9.6 and 19. ~ to 17.0, respectively. in conclusion,nyoc~r<~ial metabolic impmirment m~/ occur in 1 rger are:as per fused by inf rct-related vessels rather tkan myoc r,Cial necrosis. Yurther:lore,the~/ m
P03-070
P03-072
COMPARISON OF REST Tl-201 MYOCARDIAL PERFUSION PATTERNS BEFORE AND AFTER EXERCISE: A PRELUDE TO THE VALIDATION OF SLMULTANEOUS REST Tt201/STRESS Tc-99m SESTAMIBI DUAL ISOTOPE SPECT Hosen Kiat, Guido Germano, Cindy Williams, Gerrard Silagan, Kenneth Van Train, John Friedman, Daniel S. Berman. CedarsSinai Medical Center, Los Angeles, California, U.S.A.
DUAL ISOTOPE (TI-201 and Tc-99m RED BLOOD CELLS) GATED SPECT TECHNIQUE FOR SIMULTANEOUS ASSESSMENT OF LEFT VENT1CULAR PERFUS1ON AND MOTION A.Constantinesco, L.Mertz, B.Bnmot, Mddecine Nucldaire. CHU Hautepierre. Strasbourg, France
While we have previously developed and validated separate acquisition rest T1-201/stress Tc-sestamibi SPECT (SEPDUAL), simultaneous acquisition (SIMDUAL) represents the more ideal approach to dual is3tope SPECT. With this approach, TI-201 is injected at rest just prior to exereise(ex) and stress sestamibi and rest T1-201 SPECT are performed simultaneously post-ex. An unresolved question of SIMDUAL is whether the rest TI-201 pattern obtained after ex is representative of true rest T1-201 distribution. Thus, we studied 10 patients who had demonstrable exercise induced reversible defects on SEPDUAL. The patients were then prospectively recruited to undergo rest TI-201 SPECT, followed immediately by treadmill ex. Fifteen minutes post ex T1201 SPECT was repeated. The pre- and post- ex TI-201 raw count polar maps were generated and compared. Results: Pre- and post- ex myocardial cts in the regions with SEPDUAL ischemia were: average cts: 169_+68 vs. 174+_53 cts/pixel; min cts: 142+64 vs. 147_+70; max cts: 203_+80 vs. 209+85. Pre- and post- ex T1-201 count ratios between ischemic and normal regions were: average cts: .77+.15 vs..78-+.15; min cts: .70+.22 vs..73-+.23, max cts:.86_+.08 vs..87_+.14. For all comparisons p=NS. Conclusions: Exercise does not appear to alter count distribution of rest T1-201 myocardial perfusion SPECT. This finding paves the way for the performance of SIMDUAL once effective correction for sestamibi photon crosstalk into "1"/-201 images is implemented.
For the assessment of myocardial viability, which requires the correlation of left vcntricular (LV) perfilsion to wall motion abnormalities, v,.e describe a dual G-SPECT isotope method using T1201 (I 11-130 MBq ) and Tc-991n Rcd Blood Cells (550 to 600MBq according to the patienl weight). A "three windows" acquisition is used to reduce significantly the "crosstalk" of activity from Tc-99m to TI-2t)I: window A with 20% centered at 70 keV for T1-201. window B a( 110 keV with 10% for Tc scatter and window C at 140 keV with 20% for Tc-991u. 16-framcs/R-R interval are recorded in G-SPECT mode for the Ihree windows (30 projections of 60 sec. 180~ rotation and body contour is used with a low energy high resolution collimator). TI-2(II SPECT peffasion inmges are reconstructed after subtraction of dam of windows A and B and addition of the 16 frames of each projection. The same geometrical parameters are then applied (o reconslnlct the G-SPECT images of the LV motion using data from the C window ensuring that pcrfi~sion slices correspond exactly to motion slices. Fourier analysis images and systolic/diastolic ROI's applied to LV motion slices are then superposcd to corresponding perfusion slices It analyse simultaneously myocardial perfusion/motion inmges correlations. The overall acquisition procedure lakes 3(I rain. Resuhs in normals and in a series of 20 patients a( rest. showing the feasabili(y and interest of this method. will bc prescnlcd :rod discussed
Abstracts Monday morning, April 24, 1995
JOURNAL OF NUCLEAR CARDIOLOGY
Volume 2, Number 2, Part 2
P03-073
P04-075
Withdrawn
DOES RESTING TL-201 IMAGING IMPROVE DETECTION OF VIABILITY IN RESTING Tc-99m-SESTAMIBI PERFUSION DEFECTS? G. Huan~. H.Y. ZHAO, K.J. CHEN Dept. Nuclear Medicine, Zhongshan Hospital, Shanghai Medical University, Shanghai 200032, CHINA.
S19
A comparison between T1-201 (T1) and Tc-99m-sestamibi (MIBI) in detecting myocardial viability has been reported. However, little information is available regarding the effect of the counts in left ventricular (LV) cavity (CLVC) on TI and MIBI imagings. SPECT with MIBI and T1 at rest were performed in 20 patients (17 males, 3 females, age=42-76 years) with myocardial infarction. LV was divided into 9 segments and regions of interest (ROI) were drawn on LV wall and LV cavity on short and long axis slices. The percentage (%) of LV maximum uptake was calculated by subtracting CLVC and no-subtracting CLVC. The results of segmental comparison were showed in table: No-subtracting CLVC Subtracting CLVC
Segmentalagreement betweenMIBI and TI
Segmentaldisagreement MIBI%>TI%MIBI%
129/180(72%)
16151(31%)35t51(69%) >PO.01 26/43{60%) 16/43(37%)
CLVC of MIBI imaging was significantly lower than that of T1 imaging (18+9% vs. 27+14%; p0.05).. Segmental TI uptake without subtracting CLVC was higher than MIBI uptake but that with subtracting CLVC was lower than MIBI uptake (p<0.01), especially in low uptake segments. Conclusion: A contrary result was found in the comparison between MIBI and TI imagings. Whether it is tree that resting T1 imaging could improve detection of viability in MIBI perfusion defects at rest remains a question.
P03-074
P04-076
QUANTITATIVE COMPARISON OF SI2XlGLE-ISOTOPE AND DUAL-ISOTOPE STRESS-REST SPECT IMAGING FOR DEFECT REVERSIBILITY. Hans-Marc J. Siebelinck, Donna Natale, Albert J. Sinusas, Frans J. Th. Wackers. Yale University School of Medicine, New Haven CT, USA.
MYOCARDIAL GLUCOSE UTILIZATION IN THE PATIENTS WITH TYPE II DIABETES AND CORONARY ARTERY DISEASE
Dual-isotope rest/stress (R/S) SPECT imaging is a timesaving imaging protocol. S radiotracer (RT) Tc-99m Sestamibi (MIBI) and R RT Thallium-201 (T1) have different physical properties. In patients with abnormal R image this difference may affect quantification of defect (D) size (S) and thus D reversibility (REV). Accordingly, we compared quantitatively DS and DREV by single-isotope (R/S-MIBI) and dual-isotope (S-MIBI / R-T1) SPECT. 39 patients with abnormal R image had S/R-MIBI and R-T1 SPECT. D were quantified using circumferential profiles and normal MIBI data base (DB). Of 22 patients, R-T1 was also processed with normal T1 DB (RT-specific DB). RMIBI DS was larger than R-T1 DS (21+17 vs 15+7; p<0.0001). DREV was larger using R-T1 than using RMIBI (12+10 vs 6+7; p<0.001).Using RT-specific DB RMIBI DS and R-T1 DS were not different (23+19 vs 21+16; p=ns). DREV was also not different using RT-specificDB (8+8 vs 5+6; p=ns). Thus, in patients with abnormal R image,quantitative DREV is larger with dual-isotope than with single-isotope imaging. Quantitative analysis of dual-isotope SPECT requires RTspecific normal DB.
Whole body insulin resistance characterizes the patients with non-insulin-dependent (Type II) diabetes. To study whether myocardial glucose uptake (MGU) is reduced in Type II diabetics, we studied 6 diabetic (D) and 7 matched non-diabetic (N) patients with 18-FDG PET during euglycemic hyperinsulinemic clamp. The patients had stable CAD but preserved left ventricular function. The MGU in the 'normal' myocardium and the whole body glucose uptake (WGU) were measured. The D patients had higher fasting plasma glucose (8.8+3.5 vs. 5.2.+_0.3 mM, p=0.05) and serum insulin concentrations (18+9 vs. 9+3 mU/I, p=0.04); otherwise no significant differences were found in the patients' characteristics. During PET study insulin (73+6 vs. 83+16 mU/I, ns.) and glucose (5.4+0.7 vs. 4.9+0.4 mM, ns.) were comparable. The WGU was significantly lower in D than N patients (18+6 vs. 32+10 mg/kg, p=0.011). However, no difference was detected in MGU between the groups (73+32 vs. 74+18 /~mol/100g/min, ns.). The WGU correlated significantly to BMI (r = -0.64, p=O.02) but not to MGU. The results of this study show that MGU is preserved in the patients with Type II diabetes and stable CAD, in contrast to decreased WGU. Thus, myocardial insulin resistance does not exist in the Type II diabetic patients.
Knuuti MJ, M&ki M, Nuutila P, H&rkSnen P, 8ergman J, Haaparanta M, Voipio-Pulkki L.M, Wegelius U. The Dept. of Nucl. Med. and Cyclotron-PET Center, Turku University Central Hospital, Turku, Finland.
S20
M O N D A Y P M A P R I L
Abstracts Monday morning, April 24, 1995
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
P04-077 Rest-Redistribution-reinjection
P04-079
TI-201 cardiac SPECT for assesment of myocardial viability.
E. Ferranti, L. Mango, L. Horena, G, Salerno, E. Procaccini, I-I. Ciancamerla, G. Ronga. II Clinica Hedica. University of Rome "La Sapienza". Italy.
ASSESSMENT OF MYOCARDIAL VIABILITY WITH LOW DOSE OF DOBUTAMINE STRESS RADIONUCL1DE VENTRICULOGRAPHY: COMPARISON W I T H R E I N J E C T I O N 201"1"1 MYOCARDIAL SPECT Li-Ping Zhang, Wen-gong Kou, Zuo-Xiang He, Rung-Fang Sift and ~Au-Jie Liu Cardiovascular Institute & Fu Wai Hospital, CAMS, Beijing, China
According to recent reports the rejection of TI-201 seems useful "tOol to recognized myocardial viability. We have studied 37 cases admitted in C.C.U. within 3 weeks from onset of acute myocardial infarction (AMI). Cardiac SPECT TI-201 was acqUired in basal condition (X), after 4h (R) and 20 minutes (J) and 20h (Z) from reinjection. 30 frames of 6 degree from -45o to +135o are perfomued by SPECT. The injected dose whas 2,5 mCi in basal condition and 1,5 mCi after 4h. For each acquisition, tomographic images were divided into 22 segments and each segment had a score from Grade 0 (< 30% maximal uptake) to Grade 3 (> 70% maximal uptake). The results are a score difference of +50 X vs R, +63 X vs J (p< 0,05) with 21% increment of score J vs X. The score difference X vs Z are not statistically significant, These preliminary dates seem demonstrate that performed TI-201 reinjection allows betteL- evaluation of myocardial viability even if compared with a rest and not stress examination.
To assess the possibility of low dose of dobutamine (Dob). stress radionuclide ventriculography (RNV) in identifying viable myocardium, 13 Pats with OMI were studied, RNV was performed with 99mTcRBC(in vivo) and Siemens T camera first on baseline,and during 10 ug.min.kg Dob infusion. In 1 week, 201T1 reinjection SPECT was done with Siemens multiSPECT.LV was divided into 6 segments. Results: 37/78 (47.4%) segments show abnormal wall motion (WM) under baseline, and 20/37 (54%) were improved with low dose Dob. 201TI SPECT showed: 11/37 (29.7%) segments demonstrated fixed and 26/37 (70%) reversible defects, Out of 26 segments with reversible defects, 18 (69.2%) showed improved W M with Dob. However, only 1/11 (9.1%) segments with fixed defect shows ilnp.roved WM. In conclusion: low dose of Dob RNV might be a noninvasive technique for assessing myocardial viability,
P04-078
P04-080
ASSESSMENT OF MYOCARDIAL VIABILITY BY LOW-DOSE DOBUTAMINE RADIONUCLIDE
QUANTITATIVE ANALYSIS VENTRICULAR FUNCTION
VENTRICULOGRAPHY:
OF
REGIONAL
LEFT
Ryuichi Ajisaka, Noriyuki Takeyasu, Shigeyuki Watanabe. Masahiro Toyama, Kazuhiko Sakamoto, Kazuhiko Eda, Tohru Takeda, Nobuyoshi Ishikawa, Yuji Itai, Yasuro Sugishita. University of Tsukuba, Tsukuba, JAPAN To assess myocardial viability, the response of regional left ventricuiar function to low-dose(Sug/kg/min)dobutamine(DOB)was evaluatedby quantitative radionuclide ventriculography(RNV)and comparedits response to the regional thallium uptake on redistribution images. Sixtythree patients with coronary artery disease were studied. Regionalthallium nptake Was ~aded as normal(N), low(L) and defect(D). Increase of regional ejection fraction(rEF)in response to DOB was significantly larger in N and L reNons (11+-5%, 11-+7%,respectively) than that in D region(4_+7%). Similarly, increase of I/3rEF in N and 1.,regions Was larger than that in D region. However, increases of rEF and l/3rE[: equivalent to those in L region were observed in some D regions. To assess viability in D region, positive response to DOB was defined as increase in rEF>5% and that in I/3rEF>2%, which corresponded to the mean increase minus 1 siandard deviation in L region Improved regional systolicfunction after successfldrevascularizatiOnWasobserved in 5 of 7 D regions with positive rEF response and 4 of 7 D regions with positive 1/3rEFresponse. In contrast, regions that Wereunresponsive to DOB showed no improvementof regional systolic fnnction despite successful revascularization. In conclusion, quantitative analysis of regional ventricular function with DOB-RNV is useful in assessing myocardial viability especially in persistent defect region in thallium images
UTILITY OF STIMULATIVE EFFECT OF NICOTINIC ACID DERIVATIVES ON FDG UPTAKE IN NORMAL SUBJECTS AND DIABETIC PATIENTS, Takashi Kudoh, Nagara Tamaki, Eiji Tadamura, Naoya Hattori, Madoka Tateno, Tatsuo Torizuka, Yoshiharu Yonekura, Junji Konishi. Kyoto University, Kyoto, Japan Nicotinic acid derivatives reduce plasma free fatty acid (FFA) and stimulate myocardial glucose utilization. The clinical utility of NAD on FDG uptake in normal and diabetic patients was evaluated. Six subjects without coronary artery disease and 5 diabetic patients were studied. Each subject took 250-500mg of nicotinic acid derivative (NAD) under at least 5 hrs fasting, and dynamic PET was taken 2 hrs after NAD administration. On a different day, FDG PET was repeated 1 hour after 75g oral glucose loading. K complex, standardized uptake value (SUV) and heart/blood count ratio (H/B ratio) was calculated, NORMAL DM
G}u.load
NAD
GIu,load
NAD
K complex 0.04_+0.01 0.03f0,0i 0.05_+0,04 0.07+0.03 SUV of heart 4.66_+0.44 7,07i-0.75* 5.42+1.71 7.62+1.75' SUV 0fbl0od 1.13_+0.15 2.58-+0.28' 2.01~,18 2.20t-0.19 H/B ratio 4,60-&_2.22 2.83_+0.68 3,12-+1,95 5.61+3.24 (*P
JOURNAL OF NUCLEAR CARDIOLOGY
Abstracts
Volume 2, Number 2, Part 2
Monday morning, April 24, t995
P04-081
P04-083
DIRECT COMPARISON BETWEEN CARDIAC FDG IMAGING WITH PET AND SPECT; RELATION WITH REGIONAL VENTRICULAR FUNCTION.
ASSESSMENT OF VIABLE M Y O C A R D I U M WITH NITRATES Tc-99m MIBI SPECT BEFORE AND AFTER CORONARY ARTERY BYPASS G1LS~FTING
Jeroen J. Bax, Frans C. Visser, Margreet A. Veening, Paul K. Blanksma, Eng S. Tan, Arthur van Lingen, Antoon T.M. Willemsen, Cees A. Visser. Free University Hospital Amsterdam, The Netherlands.
Sheng-Ting Li, Xiu-Jie Lin, Zong-Liang Lu, Rung-Fang Shi, 3"dao-Dong Zhu, Yun-Zhong Lin. Cardiovascular Institute & Fu Wai Hospital, CAMS, Beijing, China
The feasibility of imaging FDG with SPECT has been shown recently. In the present study we have compared FDG PET and FDG SPECTin 15 patients with coronary artery disease. Perfusion was evaluated with N-13 ammonia PET & early rest thallium SPECT. PET and SPECT studies were displayed as polar maps and divided in 13 segments. Based on PET and SPECT data, segments were scored as normal, viable or infarcted. Left ventricular function was evaluated using 2D echo, scoring each segment as normal (N), hypo(H), or akinetic (A). Results: 195 segments were analyzed; 116 (59%) segments ~ h e r normal or viable with PET and SPECT. Fifty (26%) segments were necrotic both with PET and SPECT. Twenty-nine (15%) segments were normal or viable with PET but infarcted with SPECT. Finally, 1 segment was infarcted with PET and viable with SPECT. Eighty percent of PET/SPECT infarct segments were A, 84% of PET/SPECT normal segments showed preserved function. PET normal/SPECT infarct segments showed in 70% preserved function. Thus, there is a good agreement between PET and SPECT to assess viability, although our data suggest that FDG SPECT may overestimate infarcted areas.
To evaluate the effect o f isosorbide dinitrate (ISDN) and Tc-99m MIBI in identit~ying myocardial viability, 13 pts. with previous myocardial infarction were studied with resting and during ISDN infusion MIBI SPECT before coronary artery bypass grafting (CABG) and resting MIBI SPECT after CABG. The images was analyzed with 9-segment scheme and 4-point scoring method. The wall motion (WM) were assessed before and after C A B G with radionuclide ventficulography. Results: Resting MIBI SPECT showed 57 segments (sts) with hypoperfusiun. In the 30 sts (52.6%) with improvement o f M I B I u~ptake during ISDN infusion, 25 sts (83.3%) showed a tmprovement of perfusion after CABG. In contrast, in the 27 sts with nitrates unchanged defect, 22 (81.5%) showed no improvement of perfusion after CABG. F r o m 26 sts with improvement of W M after CABG, 22(84.6%) had a increased MIBI uptake during ISDN infusion. Out of the 25 unchanged W M regions, 20 showed unchanged MIBI uptake vcith nitrates. In conclusion: This study suggested that nitrates Tc-99m MIBI SPECT may be a promising method for identifying viable myocardium.
P04-082
P04-084
CONCORDANCE BETWEEN THALLIUM-20I STRESSIMMEDIATE REINJECTION ]MAGING AND RESTREDISTRIBUTION IMAGING FOR THE IDENTIFICATION OF VIABLE MYOCARDIUM B.L.F. Van Eck-Smit, E.E. Van der Wall, L.H.B. Baur, A.H. Zwinderman, E.K.J. Pauwels, University Hospital, Leiden, The Netherlands
SESTAMIBI UPTAKE QUANTIFICATION PREDICTING RECOVERY OF SEVERE REGIONAL VENTRICULAR DYSFUNCTION J Castell, JM Gonz~lez, M Fraile, A Garofa-Burillo, S Aguad~, M Ysamat, J Candell. Hospital General Universitari Vail d'Hebron. Barcelona
The aim of our study was to determine whether thallium-201 (TI) stress immediate reinjection imaging provides adequate information regarding myocardial viability. In 23 patients (pts) with documented anterior wall infarction (> 3 months old) results of the immediate rcinjection proem.alumwere compared with 1) TI rest-redistribution images, and 2) left ventricular wall motion (LVWM) obtained with radionuclide angiography (RNA). RNA LVWM was used as reference standard for viability. For the reinjection procedure TI (75 MBq) was injected at maximal exercise (Ex) and reinjected (37 MBq) in'unediately post Ex imaging followed by imaging 60 min later. Rest imaging was performed on a separate day 60 min after injection of TI (75 MBq). In 13/23 pts additional redistribution images were acquired 3 h after rest imaging. The concordance between Ex-reinjection and Ex-rest was 181/184 segments (x=.97), and between Ex-reinjection and Ex-redistribution 102/104 segments 0r respectively. The sensitivity for assessing myocardial viability was 96% (CI 78-100%). We conclude that immediate TI stress reinjection imaging offers a time-saving protocol that 1) provides accurate information on myocardial viability comparable to rest and redistribution imaging, and 2) adequately identifies viability in dysfunctional regions in pts following myocardial infarction.
Rest 99mTc-SESTAMIBI uptake is reported to underestimate viability in asynergio myocardium. In this study we test the abiIity of quantitative assessment of SESTAMIBI myocardial uptake to predict potential reversibility of regional ventricular dysfunction. 22 patients, mean age 62.3 years (range 48-73), referred for coronary revasoularization, with impairment of regional contractility were studied. Three proiecctions radionuclide ventriculography for wail motion analysis and rest SESTAMIBI SPET was performed prs and post-revasoularization (4-6 months), The potential recovery criterion was > 4 0 % uptake in more than 5 0 % of regional extension defined in the rest polar map. 88 regions, 4 per patient, (antero-septal, inferior, lateral, apical) were analysed, 44 presented severe contraotll dysfunction, We excluded 3 non revascu[arizated territories and 8 regions without functional recovery end, subsequently, non-evidence of successfully revascularization (3 of this were non-viables in the polar map quantification). :33 out of 41 revascularizated territories were found to have functional improvement, 32 (97%) were defined as viable by quantitative SESTAMIBI uptake. There were not significant differences in mean EF pro (47% • 12) and post-revascularization (49% • 14), however global EF improved in 11 patients ( > 5 % ) , did not change in 7 and worsened in 4 ( < 5 % ) . Grade and extension S ESTAMIB[ myocardial quantitative analysis accurately identifies the dysfunctional regions in wich contractile function may be improved with revaseularization.
$21
$22
M O N D A Y A M A P R I L
Abstracts Monday morning, April 24, 1995
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
P04-085
P04-087
Clinical and Scintigraphie Factors Influencing the Decision to Perform Coronary Revascularization in Patients Undergoing Thallium-201 Myocardial Viability Studies
Comparison of F l u o r i n e - 1 8 - f l u o r o d e o x y g l u c o s e , 123-iodo-methyl-hexadecanoic acid (MIHA) and 201-thallium in prediction of left v e n t r i c u l a r recovery following revascularization after an a c u t e m y o c a r d i a l i n f a r c t i o n : Methodology
D. Douglas Miller, MD, Mulct T. Perez, MD, Leslee J. Shaw, phD, David L. Kemp, MD Sheila Byers, RN. Liwa T. Younis, MD, PhD. St. Louis Univ. Health Sciences Ctr. St. Louis, MO. Not all patients with evidence of myocardial viability on rest or reinjection thallium-201(T1-201) imaging undergo coronary revascularization. The decision thresholds for coronary revascularization were examined in 92 consecutive pts (age=59+12 yrs; 83% male) undergoing stress-reinjection (n=62) or rest-redistribution (n=31) T1-201 myocardial tomography. Pts were followed for 7+3 months or until coronary revascularization (bypass=22, angioplasty=10) or cardiac events (cardiac death=8, myocardial infarction=9, heart failure (CHF)/transplantation=3) occurred. Myocardial viability was defined as a >50% increase in segmental T1-201 activity in ~.2 post-stress fixed or resting defects. Clinical and scintigraphic variables are compared below: Revasc. No Revasc. x2_ v value Age (mean+SD) 59+11 57+13 1.2 NS Angina CCS class>160% 14% 13.5 0.001 NYHA class>2 60% 34% 7.2 0.03 CHF History 50% 31% 8.0 0.02 T1-201 Viability 97% 73% 7.7 0.02 Event rates did not differ between pts who did or did not have coronary revascularization (5/32=16% vs15/60=25%). In conclusion, patients undergoing TI-201 viability testing who do not proceed to coronary revascularization have less scintigraphic evidence of myocardial viability and fewer clinical indications (i.e. less angina and less severe CHF) for revascularization.
Vanzetto G, Janier M, Machecourt J, Fagret D, Noirclerc M, Comet M , Denis B - CHU - Grenoble and Lyon France FDG-PET, stress-redistribution-reinjection (Stress-RD-RI) T1 and rest-MIHA SPECT are used for the detection of viable myocardium. Uptake tresholds of these tracers have been proposed, but in miscellaneous populations or in chronic coronary heart disease. They however seem to be less accurate after MI. The aim of our study is to determine the best uptake thresholds of FDG, T1 and MIHA for an optimal prediction of LV recovery after revascularization following an acute MI. 25 pts undergo a FDG-PET, a stress-RD-RI-T1 SPECT and a rest-MIHA SPECT 15 to 20 days after a MI. Relative uptakes in each ROI are obtained from the Cedars Sinai program. Global and regional LV function is assessed by quantitative anglo before and 4 months after systematic revascularization (Centerline and Slager method). Receiver operating characteristic (ROC) curve analysis for predicting functionnal recovery will be derived from the measures of regional myocardial uptakes, with quantitative angiographies as a gold standart. The shape of the ROC curves and the areas under the curves will reflect the performance of each test in in this very population. Results will be presented.
P04-086
P04-088
LOW DOSE DIPYRIDAMOLE AND DOBUTAbllNE RADIONUCLIDE VENTRICULOGRAPHY FOR IDENTIFICATION OF MYOCARDIAL VIABILITY Z. Petrasinovic,M. Ostojic, V. Bosujaknvic,S. Pavlovic,B. Beleslin, R. Babic, M. Lekic, N. Kozarevic, S. Stojkovie, G. Stankovic, L Stepanovie, M. Nedeljkovic, A. Djordjevic-Dikic. Institute for CardiovascularDiseases,Belgrade, Yugoslavia Experimentaland clinicaleehoeardiogruphiestudyhave shownthat reversibilityof dysfunctionat rest on low dose dobutamine(DOB) and dipyridamole(DIP) infusioncould be a useful predictor of functional recoveryof viablemyoeardiumin the mediumterm followup. In order to establish the feasibility and diagnostic potential of low dose pharmacologicalradionuclideangiography (RNA) we studied 19 pts with previousQ-wavemyocardialinfarction(MI): 13 pts with anterior MI and 6 pts with inferior ML Patientswere studied before PTCA of infarct related artery (IRA), by RNA at rest, as well as during drug infusion. Low DOB dosewas 10 meg/kg/minover 5 rain and low DIP dose was 0.28 mg/kg over 2 rain. RNA was repeated at rest and 8 weeks at~er successful PTCA. Five percent increase of regional ejection fraction(REF) was used as criterion for functionalimprovement of infarctedregions induced by DOB and DIP, or spontaneously during followup. Out of 171 examined(19X9) segments,48 were in territorysuppliedby IRA, and they had abnormalREF (29 + 10%). Out of these 48 segments functional improvementwas documentedpre PTCA in 31 and 23 on DOB and DIP, respectively.That baseline functionalimprovementhad sensitivityfor functionalrecoveryafter 8 weeks follow up, 61% for DOB and 74% for DIP (p=ns). The specificitywas 23% and 48% for DOB and DIP respectively(p=ns). Conclusions:1) Regionalrecoveryassessedby RNA followinglow doseDOB and DIP identifieswith reasonableand comparableaccuracy myocardial viability. 2) This technique provides a widely available alternativeto echoeardiographyin patientswith poor acousticwindow or in settingswhere stress echo know -how is not available.
Q U A N T I T A T I V E A N A L Y S I S OF S E S T A M I B I U P T A K E AT REST FOR THE D E T E C T I O N OF HIBERNATING MYOCARDIUM. Jean-Michel Tarlet, lanusz Lipiecki, Francois Cellier, Charles-Eric Malka, Daniel Mestas, Bernard Citron, Jean Ponsonnaille, Annie Veyre, Jean Maublant. University Hospital, Clermont-Ferrand, F. Because sestamibi concentrates in the mitochondria of the living cells, some degree o f uptake could be expected in hibernating myoeardium. The myocardial distribution of rest injected sestamibi was assessed in a series of 21 patients presenting with hypokinesis, demonstrated by centerline analysis at contrast x,entriculography, in territories supplied by a stenoted artery but without infarction. Viability was detected on a contrast study performed after revascularisation. Wall motion analysis and sestamibi uptake were matched in 8 sectors repartited on a vertical long axis section. Overall, the mean sestamibi uptake was significantly diminished only in the necrotic areas (67+22% o f maximum uptake, vs 82+6% in the normal areas, m.-tsd, p<0.001). However, for the sectors b e l o n g i n g to the inferior wall, uptake was also significantly decreased if wall motion improvement was < 1.5 sd (71+11% vs 81+6%, p<0.001). Sestamibi uptake seems to be generally very low in not viable myocardium.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Monday afternoon, April 24, 1995
P04-089
P04-091
INTRACORONARY SESTAM]BI FOR THE DETECTION OF MYOCARDIAL VIABILITY. Carlo Trani, Alessandro Giordano, Antonella Lombardo, Roberto Patrizi, Michele Massaro, Maria L Calcagni, G Pelargonio, Attilio Maseri. Catholic University, Rome, Italy.
QUANTITATIVE SPECT Tc99mTETROFOSMIN FOR THE ASSESSMENT OF MYOCARDIAL VIABILITY IN PATIENTS WITH SEVERE LEFT VENTRICULAR DYSFUNCTION.
The poor local availability of perfusion tracers is the mare
limitation of myocardial scintigraphy in detecting viable myocardium in low-flow areas. We hypothesized that intracoronary administration could overcome such limitation. Rest/redistribution 201-Thallium SPET (TL) and eehocardiography (ECHO) were performed in a p t with previous anterior MI who underwent successful PTCA of infarct-related coronary artery. Immediately before the coronary dilation 74 MBq of 99m-Te-Sestamibi were intraeoronary injected proximal to the stenosis. SPET was performed 1 hour later (ieMIBI). Before PTCA anterior, septal and apical walls were akinetic at ECHO and nonviable at TL (uptake<50% max). In contrast, MIBI visualized the anterior and septal walls (TL/MIBI mismatch) while the apex was not (TL/MIBI match). The anterior and septal walls improved both wall motion and thallium uptake at ECHO and TL repeated 43 days after PTCA ("a posteriori" demonstration of viability). Therefore icMIBI resulted superior to TL in detecting hibernated myocardium suggesting a potential clinical application of this technique.
$23
A.R. Galassi, G Centamore, F. Liberti, A. Coppola, G. Palazzo, A. Di Primo, A. Fiscella, S. Mnsumeci, A. Galassi. Division of Cardiology, Catania, Italy. Tc99m Tetrofosmin (TF) is a new technetium labelled myocardial perfusion agent which has demonstrated favorable imaging characteristics in preliminary clinical trials. However, it is not certain whether TF as compared to Thallium-201 (T1), would underestimate myocardial viability in regions with profound left ventricular dysfunction. To this end 13 patients (mean age 52+7 years) with angiographically documented coronary artery disease and severe left ventricular dysfunction (ejection fraction 35+_9%) underwent both rest-redistribution TI and rest TF SPECT imaging. Regional tracer activity was assessed quantitatively using a 16 segments model. On rest-redistribution T1 protocol out of 208 total segments, 49 (23%) had normal T1 uptake, 39 (19%) showed reversible TI defects while the remaining 120 (58%) had irreversible T1 defects. Of the 120 segments with irreversible defects 68 (33%) had only mild to moderate reduction of T1 uptake (51-85% of normal) while the remaining 52 (25%) had severely reduced TI uptake (_<50% of normal). On TF protocol out of 208 total segments 57 (27%) had normal TF uptake; of the remaining 151 (73%) abnormal segments, 100 (48%) had only 51-85% of normal uptake while 51 (25%) _<50% of norroal uptake. Concordance between TI and TF regarding myocardial viability (>50% of normal uptake) was obtained in 190/208 segments (91%, K=0.74) leaving only 18 of 208 regions discordant (p=NS). These data show that when the severity of uptake was considered within abnormal segments a similar concordant amount of TI viable regions were observed by TF.
P04-090
Monday PM, April 24
THALLIUM-2(II, A SENSITIVE, BUT POORLY SPECIFIC INDICATOR OF VIABLE MYOCARDIUM Rcnata De Maria, Oberdan Parodi, Roberto Testa, Gianmario Sambuceti, Livia Ruffini, Roberto Sara, Eugenio Quaini, Edoardo Gronda, Alessandro Pellegrini, Giorgio Baroldi. Clinical Physiology Institute, Niguarda Hospital, Milan, Italy The morphologic correlates of Thallium-201 uptake (Tl%) in chronic pump dysfunction were studied in 11 transplant recipients by rest injection-4 h redistribution T1 SPECT and equilibrium radionuclide angiography (RNA) before surgery. 7 had ischemic heart disease (IHD) and 4 dilated cardiomyopathy (IDC); mean LVEF was 20+8%. Regional TI% was cxprcssed as % of peak activity; regional wall motion (WM) was normal (N) or abnormal (A: hypo, a or dyskinetic). Fibrosis was assessed in 15 segments from each excised heart, matching imaging data. Segments were classified as normal, dysfunctioning viable (DV), dysfunctioning scar (DS) according to TI% and WM. All IDC segments were DV. Results were as follows: TI % WM N. mean TI% RNA score Fibrosis% ->50 A 1DC 60 75-+14 1.7+0.8 2_+2 ->50 N N 7 85_+_14 0 IOL--12 >50 A DV 73 75+4 1.6+0.7 17+11 <50 A DS 25 37+8 2.0-+0.4 28_+19 p .0001"w .0001"w .0003&,^ *N vs IDC, DV, DS; w DS vs IDC, DV; & IDC vs N, DV, DS, ^DS vs N, DV. Thus, at similar Tl%, significant differences, indcpendent o1' regional WM, were found in the exlension of fibrosis, b] thor, TI% >50 detected <20% fibrosis with 92% sensitivity, 35% specificity, and 76% accuracy. TI% is a sensitive but poorly specific indicator of viable myocardium.
$16-092 to S21-111 and P05-112 to P07-171 S 16-092 THE PROGNOSTIC IMPACT OF PROGRESSIVE LEFT VENTRICULAR D I L A T A T I O N POST-AMI Niels Gadsboll, Claus Leth Petersen, C h r i s t i a n T o r p Pedersen. G l o s t r u p Hospital, U n i v e r s i t y af Copenhagen. METHODS: Radionuclide v e n t r i c u l o g r a p h y with determination of LVEF and LV volumes. DESIGN: 57 randomly selected patients with AMI were examined at hospital d i s c h a r g e and again 1 year Iater. None had a r e c u r r e n t AM1 between the f i r s t and the second i n v e s t i g a t i o n . All patients were followed up w i t h r e g a r d to death 7 years a f t e r d i s c h a r g e . RESULTS: 56% of the patients had an increase in LVEDV > 20% d u r i n g the f i r s t year p o s t - A M I . The cumulative m o r t a l i t y in these in the ensuing 6 y e a r s , i . a . , from year 1 to year 7 a f t e r AMI was 44% v s . 12% in the p a t i e n t s w i t h o u t f i r s t - y e a r d i l a t a t i o n (p < 0 . 0 5 ) . A l t h o u g h h i g h ly p r e d i c t i v e of e a r l y m o r t a l i t y none of the r a d i o n u e l i d e v a r i a b l e s determined at discharge or at the l - y e a r r e i n v e s t i g a t i o n were usefull in p r e d i c t i n g p r o g n o s i s from year 1 post-AMI and beyond. CONCLUSION: Late, spontaneous LV d i l a t a t i o n occurs in about half of hospital s u r v i v o r s of AMI and is the main d e t e r m i n a n t of Iongterm p r o g nosis a f t e r AMI.
S24
M O N D A Y A M A P R I L
JOURNAL o F NUCLEAR CARDIOLOGY March/April 1995, Part 2
Abstracts Monday afternoon, April 24, 1995
S16-093
S 16,095
MYOCARDIAL CONTRACTILITY AFTER MYOCARDIAL INFARCTION AND DETECTION O F MYOCARDIAL VIABILITY BY THALLIUM,201 SPECT. M. Scherrer-Crosbie, J. Rosso, J-L Monin, J. Garot, P, Dupouy~ A. Castaigne, J-L. Dubois-Rand6, H. Geschwind, P. Gu6ret, M. Meignan. CHU Henri Mondor, Cr&eil, 94000, France.
RADIO]~UCLIDE
Myocardial viability was assessedm hypokinetic and aklnetic-dyskinetic myocardium by stress-redistribution-reinjectionThallinm-201 SPECT in twenty one patients (pts) two weeks after acute myocardial infarction 0VII),Myocardial activity was assessedvisually (scale from 0 to 3) in 16 segments. Abnormal segments were considered viable if the defect improved (1 score)on redistribution or reinjection imagesor if Thallium uptake was moderately decreasedon all images. 58% of the abnormally contracting segments were viable as assessedby Thallium-201 SPECT. Viability was defined by the improvement in ecbographical segmental myocardial contractility three months after revascularization. Improvementin contractility was noted in 64% of hypoklnetie compared to 46% of akinetic-dyskinetlcsegments. Sensitivity and specificity of Thallium-201 SPECT in detecting contractility improvement were:
VE/VTRICULOGRAPHY
WITH
DOBUTAMIaSlE STRESS TESTING FOR RISK STRATIFICATION IN POST-INFARCTION PATIENTS.
Edoardo VERNA, Luca CERIAN1, Claudia CARELLA, Luea GIOVANELLA, Battistina CASTIGLIONI, Fabrizio MORANDt, Giuseppina RONCARI and Sergio REPETTO Ospedale Multizonale, Varese-Italy
Non viable Thallium-20lSPECT is a strong argument against viability of hypokinetic segments after MI. The underestimation of viability in akinetic-dyskineticsegmentsmight be due to myocardial thinning.
Ai._..~m: The purpose of this study was tO assess the value of radionuclide ventriculography (RNV) with stepwise dobutamine (D) infusion for risk stratification in postinfarction patients. Methods: RNV during D infusion was performend in 100 consecutive patients within two weeks from an uncomplicated acute myocardial infarction (AMI). Left ventricular ejection fraction CLVEF) was measured at baseline and at either low (5-10 mcg/Kg/min) and high dose ( 30-40 meg/Re/rain) D infusion. Follow-up data regarding major cardiac events (death, reinfarction, PTCA/CABG, and re-hospitalization for angina and heart failure) was obtained in 97 patients. Results: There were no major side effects durind D testing. Mean follow-up duration was 16+/-4 months post AML Adverse cardiac events occurred in 40 (41%) pts. By either univariate or multivariate analysis, multivessel coronary artery disease (p<0.01), failure to increase LVEF >10% at high dose D (p<0.02) ,a biphasic pattern of LVEF change during D (p<0.02) and a combination of the last two factors (p=0.05), were the most significant predictors of adverse outcome. Resting LVEF, infarct location and exercise ECG did not show sigruficant predictive values. Conclusions: RNV during stepwise D infusion is superior to resting RNV for predicting adverse outcome after uncomplicated AM/.
S 16-094
S 16-096
DIAGNOSTIC VALUE AND SAFETY OF EARLY ADENOSINE TL 201-SPECT TO PREDICT SEVERITY OF CAD IN PATIENTS WITH UNSTABLE ANGINA. J. H61ias, C. Cadiou, J.N. T r o c h u , R. Grosset~te, D. Crochet, J.F. Godin, CHU Nantes, F R A N C E . We have prospectively used early Adenosine-TI 201-SPECT (A-TS) to assess the extent o f coronary artery disease (CAD) in 100 patients (pts) hospitalized for unstable angina (UA), 3 to 7 days after onset o f symptoms, without discontinuation o f oral therapy.. All patients were also investigated b y c o r o n a r y a n g i o g r a p h y (CA) and results o b t a i n e d by comparison of these procedures following a double-blinded protocol. CA s h o w e d 53 pts with multi vessel disease ( M V D ) , 18 pts with one ( 1 V D ) and 28 pts without s i g n i f i c a n t coronary stenosis. Side e f f e c t s were frequent (85%), minor and short (37• see). T h e p r e s e n c e o f reversible d e f e c t s a l l o w e d c o r r e c t identification o f a significant CAD in 83/85 pts leading to a 92% positive predictive value (PPV) and a 80% negative predictive value (NPV). ATS with major and/or multiple defects detected 53/56 pts with M V D leading to a 95% sensitivity and a 77% specificity to diagnose severe CAD. Reversibility and/or extend of defects identify 67/70 pts n e e d i n g revascularization and the absence o f need for this therapy in 26/30 l e a d i n g to 9 4 % a n d 9 0 % P P V and N P V respectively.So, in patients with U A , early A T S is well tolerated, and allows a correct identification o f patients with scvcre and/or MVD, and those who need revascularization.
EXERCISE THALLIUM IMAGING PREDICTS ADVERSE CARDIAC EVENTS FOLLOWING ACUTE MYOCARDIAL INFARCTION WITH THROMBOLYSIS S Basu, B Sridhara, R Senior, U Rural, C Dote, C E Handler, E B Raftery, A Lahiri. Northwick Park Hospital, Harrow,
Global
Akinetic
Hypokmetic
Senskivky
79%
68%
100%
Specificity
68%
75%
43%
It is not clear whether post-discharge TI-201 studies have a prognostic value in patients (pts) with acute myocardial infarction (A/vII) in the thrombolytic era. We have prospectively studied 100 pts who underwent exercise, 4 hr redistribution and separate day rest (post nitroglycerine) planar TI-201 studies. The scans were performed 5-7 weeks after AM[ and the pts were followed-up for a mean of 19 (6-30) months and adverse cardiac events (death, reinfarction, unstable angina, heart failure and revascularisation) were documented. The planar Scans were converted to a polar image and read blindly by 2 investigators. Out of the 100 pts, 31 showed no reversible defects by exercise and separate day rest TI-201, of whom only 7(23%) had events. Of 69 pts with reversibility 34 (49"/0) had adverse cardiac events. By logistic regression analysis, reversibility between exercise and rest TI-201 predicted adverse events; p=0.05, odds ratio 3.33, 95% confidence interval 1.24-8.74. Redistribution imaging was not predictive of cardiac events. Rest injection of thallimn on a separate day following nitroglycerine therapy improved the detection of reversible ischaemia from 38% to 69% of these pts. These data suggest that even in the thrombolytic era, the detection of reversible myocardial ischaemia by thallium imaging is predictive of a significantly higher rate of adverse cardiac events.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Monday afternoon, April 24, 1995
S16-097
S 17-099
MYOCARDIAL STUNNING AND PERFUSION/ METABOLISM MISMATCH QUANTIFIED BY SPECT WITH THALLIUM AND FA'FFY ACID ANALOGUE
ASSESSMENT OF THE EFFECTS OF INHALED OXYGEN ON RVEF IN PATIENTS WITH CONGENITAL HEART DISEASE COMPLICATED BY PULMONARY HYPERTENSION
Tomoaki Nakata, Akiyoshi Hashimoto, Hiroshi Kobayashi, Kenjiro Miyamoto, Shigemichi Tanaka, Kenji Fujimori, Osamu Iimura. Sapporo Medical University, Sapporo, Japan.
Si-Jin Li, Xiu-Jie Liu, Kong-Fang Shi, Yun-Zhong Liu, Shi-Wei Pan, Jian, Fang Yu, Cardiovascular Institute & Fu Wai Hospital, CAMS, Beijing, China
In order to investigate the correlation of regional wall motion with myocardial perfusion and fatty acid metabolism, SPECT with thallium (T1) and fl-methyl-iodophenyl pentadecanoic acid (BMIPP) was performed in 60 patients with acute myocardial infarction; 39 patients received PTCA and 21 not received. Reduced TI and BMIPP uptakes were quantified as extent (EX) and severity (SV) scores by comparing with normal files and LV regional wall motion was evaluated by a centerline method. The mismatched uptake of TI and BMIPP (/XTI/BMIPP) was observed at acute and recovery stages because of a greater improvement of TI uptake compared to that of BMIPP. The area and grade of reduced wall motion well correlated with EX and SV of both tracers, respectively. Moreover, the improvement of regional wall motion during a 6-month period in the PTCA group significantly correlated with the extent and severity of/',T1/BMIPP at an acute stage. In conclusion, despite restored myocardial perfusion, fatty acid metabolism is persistently impaired and the degree of perfusion /metabolism mismatch closely correlated with reversible regional wall motion abnormality, suggesting one of the possible mechanisms of "myocardial stunning".
To determine RVEF in response to inhaled oxygen, 15 pts with CHD complicated by PH (mean age 10.8_+7.7 yrs) were studied with radionuclide ventriculography before and after inhaled oxygen. All the pts also underwent pulmonary perfusion scan and cardiac catheterization within 1 week. According to the increasing degree o f RVEF after inhaled oxygen, the 15 pts were divided into two groups: GI(10 pts), the RVEF increased > 5%; G2(5 pts), the RVEF increased <5%. After inhaled oxygen, the KVEF increased from 39.5_+6.2% to 47.0+7.5% in G1 (p<0.05) and from 38.4+10.3% to 38.6+10.6% in G2 (p>0.05). The lung perfusion scan showed the damage of the pulmonary vascular bed was mild and moderate in G1 and severe in G2. During cardiac catheterization, the pulmonary vascular resistence was reduced markedly during inhaling oxygen in G1 and there was no significant changes in G2. In conclusion: if the RVEF increased >5% after inhaling oxygen in pts with CHI) coml?licated by PH, it might indicate the PH would be reversible and good prognosis after corrective cardiac surgery.
S17-098
S17-100
M Y O C A R D I A L PERFUSION A N D SY~,TPATHETIC S Y S T E M IN C H A G A S ' H E A R T DISEASE - P R E L I M I N A R Y DATA.
E A R L Y A S S E S S M E N T OF D O X O R U B I C I N c A R D I O T O X I C I T Y W I T H 1 1 1 I N - R N T I M Y O S I N A N D 1 2 3 I - M I B G STUDIES. Ignasi Carri6, M o n t s e r r a t Estorch, Lluis Berne, Gustavo Torres. Hospital de Sant Pau, Barcelona.
M.C.P. Giorgi,F.H. tiironaka, B. [anni. E.L. Zanardo, R. Abe, .l.So~res Jr, M. Izaki, G. Cerri, J.C. Meneghtti.HeartInstitute - Sao Paulo School of Medicine- Brazil, Chagas' heart disease (CH) is characterized by autonomic denervation and myocardial fibrosis. In order to evaluate the extent of these lesions we've studied 10 CH patients (pts), 6 male, mean ago 51.9 _+10.6 years with M!BG-II23 SPECT (MG) performed 15 minutes and 3 hours atter injection of 240 MBq of the tracer. Eight pts were also submitted to M1BI SPECT peffusion imaging (MI) within one week. Polar maps were obtained for each pt and mean percentage area defect was calculated for MI and MG images. Perfusion defects were observed in 3 apical, 2 inferior, 1 anterior and 1 postero-lateral regions. MG diffuse decreased uptake was observed in 5 pts and f~al defects were present in 6 inferior, 3 apical, 2 anterior and 1 postero-lateral regions. Mean percentage area detbcts were similar in MI (20.07 _+13.75%) and the 15 rim1 MG (19.67_+14.75%), p=0.80; and was more extensive i~ the 3 hour MG imaging (32.37 _+18.06%), p-~,01. In conclusion, besides bemg a diffuse cardiomyopathy, CH pts showed localized MIBI peffusion and M1BG 15 rain defers. MIBG 3 h images suggest more severe neuronal derangement than cardiac muscle involvement.
Detection of m y o c y t e cell d a m a g e w i t h m i n antimyosin (AMI and detection of impairment of adrenergic neuron function w i t h IDI-MIBG during doxorubicin a d m i n i s t r a t i o n m a y p r o v i d e early identification of patients at risk of significant cardiotoxicity. We s t u d i e d 50 cancer patients treated with c h e m o t h e r a p y including doxorubicin. M I B G scans, A M scans and ejection fraction (EF) m e a s u r e m e n t s were p e r f o r m e d before chemotherapy, at intermediate c u m u l a t i v e doses and at maximal cumulative doses of doxorubicin. M I B G uptake was q u a n t i f i e d by ~ m e d i a s t i n u m to heart ratio and A M uptake was q u a n t i f i e d by a heart to lung ratio. All p a t i e n t s had absent AM uptake (mean ratio 1.40• w i t h normal MIBG uptake (ratio 1.85• b e f o r e chemotherapy: EF was 61• At 240-300 m g / m 2 of doxorubicin, an increase in A M uptake was o b s e r v e d w i t h a ratio of 1.85• (p<0.01), w h e r e a s a similar degree of ~ MIBG uptake was o b s e r v e d (mean ratio of 1.80• p=NSl; EF w a s 58• p=NS. At 420-600 m g / m 2 increased A M uptake was o b s e r v e d with a ratio of 2.02• (p<0.01), w h e r e a s a decrease in MIBG uptake was o b s e r v e d (mean ratio of 1.76• p<0.05); EF was 52• (p<0.05). A M studies are more sensitive t h a n M I B G studies and than EF m e a s u r e m e n t s to detect c a r d i o t o x i c i t y at intermediate c u m u l a t i v e doses. At m a x i m a l doses, A M and MIBG studies may be abnormal with decreased or m a i n t a i n e d EF.
$25
$26
Abstracts Monday afternoon, April 24, 1995
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
$17-101 M O N D A Y P M A P R I L
$17-103
SILENT MYOCARDIAL ISCHAEMtA IS A C O M M O N FINDING IN PATIENTS WITH CONGESTIVE HEART FAILURE DUE TO CORONARY ARTERY DISEASE Roxy Senior, Sanjiv Kaul, Usha Raval and Avijit Lahiri. Northwick Park Hospital, Harrow, UK. Recent studies have shown that patients (pts) with cardiac failure (CHF) due to coronary artery disease (CAD) have evidence of hibernating myocardium, but it is not clear whether they also have effort induced myocardial ischaemia, since the detection of this may have important therapeutic implications. We have prospectively studied 34 pts with symptomatic CHF due to CAD with a mean ejection fraction (SD) of 26 (11%o)presenting to our clinic. Rest and stress Tc-99m sestamibi SPECT (MIBI) was performed on 2 days and 2D echocardiogram was used to assess wall motion abnormality (WMA). All data were read by 2 blinded observers and ischaemia was considered present when a MIBI score changed by a grade of 0.5 in 2 o r m o r e segments in a 12 segment model (0 = normal and 4 = absent uptake): Out of a total of 40g segments IS0 (44%) were defined as ischaemic in 23' (79%) pts. Of these, 20 (58%) had exercise induced ST-segment depression and only 8(24%) had angina on effort. Out of 180 ischaemic segments, 172 (96%) haed resting WMA These data suggest that pts with CHF due to CAD demonstrate a significant degree of reversible ischaemia in the absence of stress induced angina or ST-segment change. This data may be of therapeutic importance when considering revascularisation.
$17-102 CANDIOTOXICITY INDUCED BY EPIRL~ICIN SHOIK~ HE MONITORED BY ANTIMYOSIN ~ I N T I G R A P I I Y
A. Ferraironi, R. Sciuto, A. Tofani, P. vici, M. Lopez and C.L. Maini "Regina Elena" Natl. Cancer Inst., NDme, Italy Cardiotoxicity induced by high dose rate (140160 mg/sqm) epirubicin (EPI) was evaluated in 48 pts. by angiocardioscintigraphy (ACS) and by antimyosin inlnunoscintigraphy (IS) using the heart lung ratio (HLR). Clinical follow-up was Over 24 months. group A group B EPI (mg/sqn) -488 + 65 LVEF (%) 66 + 7 64 _+ 7 HLR 1.45 +.2 1.98 +.3 ~ p ( 0 . 0 5 ~ or 0.001 ~176by t test
group C 942 _+ 113 58 + 8 2.3 +.4 ~
Sensitivity for cardiomiopathy was 92% in gr.B and 100% in gr.C for HLR while pump disfunction by ACS was found only in 35% of gr.c pts. ACS should be used only in selected patients with cardiac risk factors while IS is clearly n~re sensitive to detect and to monitor the cardiomyopathy; the issue m a y b e clinical relevant to prevent late heart failure in long survivors
THE ROLE OF Tc-99m HMPAO LUNG CLEARENCE IN STAGING OF PULMONARY HYPERTENSION IN CONGENITAL HEART DISEASE: A COMPARATIVE STUDY WITH CARDIAC CATHETERIZATION Ali Yener, Mustafa Unlti, Serdar Gtinaydm, Sabahat inamr, Gtinsel Vural, Rana Olgunttirk. Gazi University Medical Faculty, D e p a r t m e n t s of N u c l e a r M e d i c i n e , Pediatric Cardiology and Cardiovascular Surgery. Ankara / TURKEY. Pulmonary hypertension (PHT) especially in pediatric patients is a common problem in surgical decision and outcome. In order to determine a non-invasive method for the staging of PHT, 21 cases (mean age: 6.2+ 4.2) with congenital cardiac anomalies (4; ASD+VSD, 8;VSD, 2 PDA, 7; TOF) underwent Tc-99m HMPAO lung imaging and the results were compared with cardiac catheterization (CC) and pathological evaluation of the lung tissue samples obtained during surgery.Tc-99m HMPAO having lipophylic charecteristics which may reflect accurate lung clearance and retention had been chosen as scintigraphic agent.2 dynamic data sets (1 sec./150and 60 sec/ 10 frames) were obtained after IV injection of 0.3 mCi / kg dose of Tc-99m HMPAO. Time activity curves were generated and clearance times were calculated as t 1/2. Pulmonary artery pressures were measured with CC in all patients. Lung tissue preperations obtained in surgery were evaluated with respect to the degree of PHT in 3 grades; 1-2, 3,4, histopathologically. According to pathological grading, very well correlated results were obtained between t 1/2 values and pulmonary artery presures ( G I - 2 : 8 . 3 7 _+.90, 21.86 _+ 1.75, r:.83, G 3 : 2 1 . 5 4 _+ 7.65, 42.86 -+11.13, r:.85. G 4 : 3 8 . 9 6 -+ 7.59, 72.86 _+ 15.77, r:.88 ). There were also statistically significant differences in Tc-99m HMPAO lung clearence results between G1-2, G3 and G4,(Anova- p< .001). Considering the results obtained in the study, it is concluded that Tc-99m HMPAO lung clearance may be a useful parameter for the non-invasive evaluation and monitoring of PHT especially in pediatric patients.
$20-104 THE EFFECT OF HYPERBARIC OXYGEN TREATMENT ON LEFT VENTRICULAR FUNCTION IN PATIENTS WITH CORONARY ARTERY DISEASE I.Vassiliadis, A. Fountos, B.Zachariadis. Cardiac Nuclear Medicine a n d H y p e r b a r i c Medicine Depts., A t h e n s Navy Hospital, Greece. H y p e r b a r i c oxygen treatment(HBO)in ischemic h e a r t disease is a c h a l l e n g i n g dilemma f o r e x p e r i m e n t a l a n d clinical r e s e a r c h . Real time m o n i t o r i n g of LV f u n c t i o n d u r i n g HBO c a n b e a c h e i v e d b y a p o r t a b l e r a d i o n u c l i d e device (VEST). Eight p a t i e n t s , with d o c u m e n t e d CAD, a n d 8 c o n t r o l s were e v a l u a t e d b y a) VEST d u r i n g HBO e x p o s u r e at 2 atm a b s o l u t e ATA. b) c o n t i n u o u s a r t e r i a l BP m o n i t o r i n g a n d c)PO2measurement.Results(*p<0.051: CONTROLS PATIENTS Rest HBO Rest HBO Heart.Rate 78• 63• 78• 69• E j . F r a c t i o n 52• 44• 52• 45• EndDiastVol 89• 85• 77• 77• EndSystVol 40• 45• 37• 40• C a r d . o u t p u t 3.8 2.4* 3.1 2.5 BPsyst 118• 114• t14• 136• BPdiast 74• 74• 81• 89• PO2 88• 1076• 75• 1296• We s u g g e s t t h a t t h e ischemic p a t t e r n of LV d y s f u n c t i o n in r e s p o n s e to HBO can be a t t r i b u t e d to a r e d u c t i o n in s t r o k e volume r a t h e r , t h a n in b r a d y c a r d i a . This could be explained in c o n t r o l s b y d e c r e a s i n g c i r c u l a t o r y volume a n d v e n o u s r e t u r n a n d in CAD p a t i e n t s b y a f u r t h e r r e s t r i c t i o n of myocardial blood flow d u e to t h e v a s o c o n s t r i c t i o n of t h e a l r e a d y a f f e c t e d c o r o n a r i e s .
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, N u m b e r 2, Part 2
Abstracts Monday afternoon, April 24, 1995
$20-105
$20-107
DIABETIC AUTONOMIC DYSFUNCTION - RELATIONSHIP OF MYOCARDIAL MIBG AND HEART RATE VARIABILITY Michael R. Freeman, Paul W. Armstrong, Anatoly Langer. St. Michael's Hospital, Toronto, Canada
EJECTION FRACTION FALL DURING MENTAL STRESS IN CORONARY ARTERY DISEASE: IS IT DUE TO PERIPHERAL EFFECTS OR CONTRACTILE DYSFUNCTION? Sherif Shaker, Diwakar Jain, Matthew Burg, Frans J Th Wackers, Robert Soufer, Barry L Zaret. Yale Universl'ty, New Haven CT. Mental stress (MS), like exercise ( Ex ), decreases left ventricular ejection fraction (EF) and induces wall motion abnormalities in a significant proportion of coronary artery disease (CAD) patients (Pts). The relationship of these changes to altered ventricular contractility vs. afterload is not clear. Consequently, 21 Pts (17 men, 4 women ), age 56+11 yrs, with CAD underwent MS by mental arithmetic & anger recall followed by supine bicycle Ex. EF, LV peak power (PP), an afterload independent index of LV contractility, cardiac output (CO) & peripheral vascular resistance (PVR) were derived noninvasively from radionuclide anglocardiography and central aortic pressure obtained during MS & Ex. 9 Pts (Gp I) showed >5% decrease in EF on MS, while 12 Pts (Gp II) did not. Changes (A) in heart rate (HR), systolic blood pressure (SBP), CO, PVR and PP are as follows: *=p <.05 AHR ASBP ACO APVR APP ~___~pll 6-+4 15-+7-0.4+0.8 252_+205 0i-_1 MS I 9i-_7 9i-_10 0.7+0.8" -22+224" 0i-_1 ~pl 42+28 15+25 2.3+3.4 -331+591 0.7+2.2 Ex II 57+36 29+18 5.7+4.6* -691+354 3.2+2.4* PV responses differ between pts with (Gpl) and without (Gp II) MS induced LV dysfunction, while contractility is unchanged. PVR increases during MS and falls to a lesser extent on Ex in Gp I Pts. In contrast, HR and SBP changes are similar in both Gps. Thus, abnormal PV responses appear to be important factors in MS induced LV dysfunction. Whether similar response occurs in the coronary vasculature is currently unknown.
Autonomic dysfunction(AD) in diabetic pts is assessed with 5 indirect bedside maneuvers (5STD). To assess directly cardiac AD in 65 asymptomatic diabetic pts we performed the 5STD tests(>2 tests abnormal=AD), ECG for QTc interval, 48 hr Holtor monitoring for heart rate variability(HRV) measured as the area under ~ e curve of the low frequency band, and I"~'metaiodobenzylguanidine(MIBG) and rest sestaMIBI SPECT imaging. MIBG and MIBI images 4 hrs and I hr after injection respectively, were graded visually and the MIBG score was corrected (c) by not counting MIBG defects (DEF) in areas with MIBI DEF. MIBG-MIBI mismatch was quantitatively (QT) derived by comparison to a normal data base. The results are: QTc HRV MIBG(c) MIBG(QT) No AD(n=19).42• 5.9• 10• 4• AD (n=46) .43• 5.1• 19• 17• p 0.11 0.005 0.0001 0.0001 MIBG(QT) c o r r e l a t e d w i t h HRV(r=0.39, p = 0 . 0 0 6 ) , and both by multiple regression analysis independently predict AD . Thus, MIBG imaging and heart rate variability can objectively and directly assess cardiac sympathetic function.
S20-106
$21-108
REGIONAL BRAIN A C T I V A T I O N C O M P A R E D IN SILENT AND PAINFUL M Y O C A R D I A L ISCHAEMIA
Preliminary Findings Using In Vivo Imaging with Radiolabeled Monoclonal Antibody to ICAM-1 and MHC Class II Antigen in Cardiac AIIograft Rejection.
SD Rosen, E Paulesu, P Nihoyannopoulos and PG Camici. MRC Clinical Sciences Centre, RPMS, Hammersmith Hospital, London, UK. Why myocardial ischemia can be silent (ie painless) is unclear. Using positron emission tomography (PET) with H2150, we measured regional cerebral blood flow (rCBF) changes as an index of neuronal activation during painful and silent myocardial ischaemia (M-ISC). Two groups were studied: A - 9 patients [7 male, age 61(7) years, mean(SD)] with angina, M-ISC on exercise ECG and angiographic coronary artery disease (CAD); and B - 9 patients [all male, age 62(7) years] with a positive stress echocardiogram (echo) and angiographic CAD, but no angina during M-ISC. No patient had diabetes. M-ISC was induced with iv dobutamine (D) until angina + ST depression on ECG in Group A or until painless MISC (confirmed by ECG and echo) in Group B. Similar doses of D were infused in group A and B which elicited comparable ratepressure products and ST depression, rCBF changes during M-ISC were compared to baseline conditions and to placebo. PET images were transformed into a standard stereotactic space and comparisons made across conditions by Statistical Parametric Mapping. During M-ISC, there were rCBF increases bilaterally in the thalamus, basal frontal and prefrontal and anterior cingulate cortices in Group A and in the thalamus and basal frontal cortex in Group B. Thus, in silent ischemia the thalamus is activated and may act as a gate to afferent pain signals. Abnormal central processing of afferent pain messages may have an aetiological role in silent myocardial ischaemia.
A. lain McGhie, Branislav Radovancevic, Warren Moore, Pavel Capek, Fred Clubb, Mike Cloy, Leela Kasi, Lamk Lamki, O. Howard Frazier, James T. Willerson. UT-Houston Health Science Center and Texas Heart Institute (THI)/St. Luke's Episcopal Hospital, Houston, TX. Increased expression of ICAM-1 and MHC Class II antigen (MHC-2) occurs during cardiac allograft rejection (CAR). We hypothesized that CAR could be detected non-invasively using radiolabeled monoclonal antibody (MoAb) to ICAM-1 and MHC-2. Six beagles, receiving cervical cardiac allografts from outbred puppy donors, were studied serially over 51 __+20 days by percutaneous myocardial biopsy and imaging with radioiodinated MoAb to ICAM-1 (n =3) and canine MHC-2 (n =3). Labeled MoAb uptake by the donor heart was expressed in cts/pixel/mCi. Two of 3 animals studied developed severe CAR which was associated with a progressive increase in MHC-2 MoAb uptake by the donor hearts from 16.2 __+4.3 to 99.1 _+39.1 cts/px/mCi. In the remaining animal which did not develop significant CAR no increase in MoAb uptake was observed (24.3 vs. 13.0 cts/px/mCi|. No correlation between uptake of labeled ICAM1 MoAb and CAR was discernible. In conclusion, uptake of radiolabeled MHC-2 MoAb by the donor heart appears to be related to the degree of CAR and may allow the non-invasive detection of CAR.
$27
$28
Abstracts
JOURNALOF NUCLEARCARDIOLOGN
Monday afternoon, April 24, 1995
M O N D A
Y P M A P R I
L
March/April 1995, Part 2
$21-109
$21-111
THE INFLUENCE OF AGE ON MYOCARDIAL 1231-MIBG U P T A K E . I g n a s i Capri6, M o n t s e r r a t Estorch, Jos~
DUAL ISUIDPE IMAGINGOF Tc-99mBMS-194796and I]201IN DOG O3RONARY ARTERY STEN(~IS MODEL
L6pez-Pousa, Lluis Berne, G u s t a v o Tortes. Hospital de Sant Pau, Barcelona. Fifty-two cancer patients, e n r o l l e d in a study to assess the effect of doxorubicin a d m i n i s t r a t i o n o n a d r e n e r g i c n e u r o n function, underwent b a s e l i n e studies w i t h I~I-MIBG before chemotherapy. N o n e of the p a t i e n t s had a history of previous cardiac disease. M I B G uptake was quantified by a m e d i a s t i n u m t o h e a r t ratio (MHR) 4 hrs after i.v. a d m i n i s t r a t i o n of 5 mCi of 'DIMIBG. Mean age of p a t i e n t s was 36 years, ranging from 16 to 75. Nine p a t i e n t s w e r e below 20 years, 12 p a t i e n t s were b e t w e e n 20 and 40 years, 14 patients were between 40 and 60 years and 17 ~atients were over 60 y e a r s of age. Myocardial I-MIBG uptake was o b s e r v e d in all patients w i t h a m e a n M H R of 1.85• range 1.31 to 2.62. MHR correlated to age (r=-0.6264, p60 years was 1.55. The best separation was o b s e r v e d c o m p a r i n g patients w h o w e r e > 6 0 years (mean M H R of 1.55• range 1.31-1.78) w i t h p a t i e n t s w h o w e r e <60 years (mean MHR of 1.95~0.26, range 1.45-2.62, p=0.003); mean EF in both groups w a s similar: 56• and 60• p=NS. We conclude that intensity of m y o c a r d i a l '~I-MIBG uptake relates to age. A d e c r e a s e in M I B G u p t a k e is observed with aging, specially in p a t i e n t s over 60 years.
$21-110 COMPARISON OF TC-99M-LABELED SYNTHETIC PEPTIDE FRAGMENTS FOR IMAGING OF ATHEROSCLEROTIC PLAQUES Lu P, Zanzonico P, Lister-James J, Herrold E, Lees RS, Lees AM, Dean RT and Borer JS Cornell Medical Center, New York, NY, USA We have previously shown that 1-123-1abeled-SP4 (2 kD), a synthetic peptide fragment, identifies aortic atherosclerosis in a hyperlipidemic rabbit model by external gamma camera imaging. Because Tc-99m is preferable to 1-123 for imaging, we have studied three Tc-99m-labeled SP4-derived peptides (P352, P380, P302), injecting each into normal (NL) or cholesterolfed (CF) New Zealand White rabbits and sacrificing 1530 min (6 NL;6 CF) or 2 hr (11 NL;15 CF) later, En face gamma camera imagin.g demonstrated that all 3 Tc99m-peptides localized m grossly visible aortic atherosclerotic plaques but not plaque-free portions of the aorta. Although not achieving statistical significance, the activity concentrations (% ID/gm) at 30 rain were uniformly higher in CF than in NL rabbits in all aortic segments, with CF-to-NL activity concentration ratios of 1.2 to 2.2. However, the relative difference in aortic %ID/gm between NL and CF rabbits increased from 30 min to 2 hr for P380 only. The ratios of CF to NL in upper, middle and lower aortic segments were 2,3, 2.6 and 4.3 (P<,05, CF vs NL). Tc-99m-P380 shows important potential for clinical imaging,
B~ K IJn.der,B Patel, S ~ P Wedeking,N Raju, K Ramalingam,AD Nunn,Brax~ ResearchUSA,Princeton,NJ, USA The purpose of the present study was to compare the distribution of BMS-194796 (Tc-796) a new Tc-99m-5oxa-amine-oxime nitroimidazole complex that preferentially localizes in tissue with low POz, to that of T1-201 in a canine stenosis model. The left anterior descending coronary artery (LAD) was partially occluded to yield downstream PO2 levels of 2-6 Torr. At 10-20 rain. stenosis, ~2 mCi of T1-201 was co-injected with 30 mCi Tc-796, followed by SPECT imaging (2-3 dual-isotope acquisitions from 40-120 min. post injection). Ischemic tissue lesions were well visualized with Tc-796 throhghout this time, Analysis of excised heart planar images (106-132 min. residence) showed a lesion to normal tissue ratio of 2.71_+0.76 (n=3) for Tc-796. The T1-201 ex vivo images resulted in a normal to lesion ratio of 1.23+0.13 (n=3). This redistributed T1-201 in the myocardial lesion suggests cardiac viability at sacrifice time. The extent of the jeopardized region is far more easily delineated with Tc-796 than with T1-201,
P05-112 IS Tc-99m GLUCARATE A GLUCOSE-LIKE MARKER OF DIFFUSE MYOCARDIAL INJURY? Khaw BA, Vural I, Petrov A, Pak CYK, Narula J. Northeastern University, Boston, MA, USA. Whether Tc-99m glucarate (Tc-G) uptake in dif~se myocardial injury by subcutaneous isoproterenol (ISP)(85 mg/kg) can be affected by glucose levels, 21 Wistar rats,divided into 4 ISP groups [ISP-fasted (F, n =4), F-glucose loaded (GluL)(n =3), non-fasted (NF, n =3) or NF GIuL (n = 3)] and 2 control (CF and CNF) groups (11 ffi 4 each) were studied. After ISP injection (1/2 h), Tc-G (I 12,5 mBq ) was injected iv and 2 h later, the ~ s were killed, the hearts excised, imaged, then counted in a gamma scintillation counter. I-fighest uptake was in ISP-F hearts (1.34 4-0.59, meaa %ID/g4-SD). Uptake in ISP-FGIuL (0.45 + o. 12), ISP-NF (0.32 4-0.17) and ISP-NF-GIuL (0.24 4-0.14) hearts was lower than ISP-F hearts (9 < 0.03) but greater than CF (o.0254-0.o03) and CNT (0.039 4-0.o09) hearts (9 < 0,03). Similar to the response in the necrotic myocardium, fasting or non-fasting status, and glucose loading also affected the liver activity. Although, Tc-G may function as a glucose like analogue, its medmrdsm of infarct uptake is most probably different from that of glUcoSe.
JOURNAL OF NUCLEAR CARDIOLOGY V o l u m e 2, N u m b e r 2, P a r t 2
Abstracts M o n d a y a f t e r n o o n , A p r i l 24, 1995
P05-113
P05-115
EVALUATION OF MYOCARDIAL VIABILITY USING 2~ TI SCINTIGRAPHY FOLLOWING ADMINISTRATION OF CoQ10.
DIAGNOSIS AND FOLLOW-UP OF VASOSPASTIC ANGINA WITH 1-123 BMIPP SPECT STUDY
K. Tamura, T. Endo, H. Iguchi, T. Nishiuch, A. Shiragami and S. Saito, Health Insurance Naruto Hospital, Muyacho, Naruto, Tokushima, Japan Coenzyme Qla(CoQ10) was administered to enhance ~~ redistribution in a shorter time than by conventional 20l TI myocardial seintigraphic imaging. The studies were p e r f o r m e d on 35 patients who had sustained an acute myocardial infarction 1 month or longer prior. The bicycle ergometer exercise test was performed using a multi-step incremental workload protoeol prior to 1 week and following the administration of 90mg/day of CoQ~0. SPECT images were acquired immediately after exercise, and then again at 3 and 24 hr after exercise. The myocardium was divided into five regions, anterior, septum, apex, inferior and lateral wall. The images obtained in these regions were then classified as having complete redistribution (CR), incomplete redistribution (IR), and persistent defect (PD). Immediately after exercise, reduced blood flow was observed in 65 segments. On the 3 hr scan, each of 4 , 2 2 , and 39 segments demonstrated CR, IR, and PD, respectively. On the conventional 24 hr scan, 26, 17, and 22 segments demonstrated CR, IR, and PD respectively. On the 3 hr scan following the administration of CoQ~o ,21, 19, and 25segments demonstrated CR, IR, and PD, respectively. Z~aT1 images obtained" 3 br with CoQ~0 were comparable to the conventional 2~ images delayed by 24 hr. Since z0J T1 imaging with CoQl0 has the advantage of allowing accurate measurement within the same day, and it provides useful and rapid testing for the evaluation of myocardial viability.
Kenichi Nakajima, Kuniyoshi Shimizu*, Junichi Taki, Yoshihisa Uetani*, Shota Konishi, Norihisa Tonami and Kinichi Hisada. Dept. of Nuclear Medicine, Kanazawa Univ. Hospital, Kanazawa, and *Dept. of Internal Medicine, Kaga Chuo Hospital, Kaga, Japan The purpose of this study is to detect myocardial damage caused by vasospastic angina (VSA) with 1-123 labeled methyl-branched fatty acid (BMIPP), and to use BMIPP in the follow-up study after medical treatment. Study group comprised 31 patients (pts) (M/F: 23/8) with VSA without history of infarction, in whom coronary arteriography was performed and significant spasm was induced by Acetylcholine or Ergonovine. Resting BMIPP and exercise Tc-99m MIBI myocardial SPECT studies were performed. Abnormal findings were observed in 12 of 31 (39%) p~s with MIBI study, while 27 of 31 (87%) showed abnormality with BMIPP study. Complete or partial agreement between SPECT abnormality and coronary territory was seen in 28 pts. After medical treatment (ave. 199 days later), BMIPP SPECT study was repeated. Of 11 pts who showed improvement of angina 10 showed improvement in BMIPP uptake, whereas only 4 of 11 with persistent angina attack showed BMIPP improvement (p<0.05). Thus, BMIPP SPECT can sensitively detect the injured myocardium, and may be used as a marker for improvement.
P05-114
PO5 - 116
123I-IPPA SPECT IMAGING IN NORMAL S U B J E C T S : M Y O C A R D I A L D I S T R I B U T I O N AND R E L A TIVE UPTAKE ANALYSIS. R.Taillefer, G.Bavaria,
EFFECTS OF SUMATRIPTANON MYOCARDIALPERFUSION USING 13NH3 PET SF Barrington, PJ Lewis, LD Lewis and P Marsden Guys and St Thomas's Clinical PET Centre, London, UK
C.Benjamin, S.Lacombe, A.Gagnon, A.Iskandrian.Nnclear Medicine DepLrtment, HoteI-Dieu de Montreal, Canada. The use of 123I-IPPA myocardial imaging has been the subject of recent studies, specially in the assessment of myocardial viability. The purpose of this study was to evaluate the normal regional myocardial distribution (RMD) and relative uptake (RU) of 123-I I P P A . Thirthy normal volunteers (19M,11F, mean age 48) with a likelihood of CAD of less than 5% were injected with 4.9mCi of 123I-IPPA. SPECT imaging was performed with a dual-headed gamma camera at 4, 20~ and30 minutes post i.v. using 32 angles (20 sec/view for the first two studies and 30 sec/view for the last acquisition), Polar map displays were reconstructed for each acquisition and divided into 13 segments and then into 3 regions corresponding to each major coronary territory. RMD and RU were determined. The uptake at 4 min. was used as a reference (100% uptake). In women, the RU at 20 and 30 rain. was 97.3 _+ 9.5% and 65.2 -+ 4.5% respectively while in men it was 99.3 + 5.7% and 68.0 + 4.1%. The analysis of RMD demonstrated that the anterior wall shows the lowest uptake (83%) in women while in men it is the inferior wall (81%). In conclusion, the gender-related RMD of 123I-IPPA is similar to other perfusion imaging agents. Imaging should be completed within 3045 minutes due to its rapid myocardial washout. These data obtained in normal subjects can be used as a normal data base for quantification of myocardial SPECT imaging with 123I-IPPA.
$29
Sumatriptan is a 5HT agonist available for the treatment of migraine. It is known to cause cerebral vasoconstriction during migraine attacks but reports of chest pain in users has led to concern that it may also cause coronary vasoconstriction. We have investigated the effects of sumatriptan on myocardial blood flow (MBF) in 19 healthy female migraineurs, using positron emission tomography (PET) and 13N ammonia. Volunteers aged 33 to 62 (mean 48) were screened to exclude any with cardiac risk factors or taking cardioactive medication. Each attended on two occasions, with a baseline scan performed to measure MBF,at rest, followed by a repeat scan !0 minutes after sumatripta,16mg or placebo given subcutaneously. Volunteers and supervising doctors were blinded to the treatment. Pulse, blood pressure and ECG were recorded at baseline and every 2 minutes after injection. Regional MBF was quantified using the Patlak method in 5 ROIs, applied to short axis slices. No significant change in HR, BP or ECG following sumatriptan was recorded. Statistical analysis was performed on a regional basis using paired T tests. We found no significant change in regional or global MBF in this patient population, between placebo and sumatriptan, mean (sd), 9.51(18.04)% versus 6.63 (18.75)%. The intraindividual change in rMBF in our study is similar to other published data. Our findings suggest that sumatriptan does not cause significant coronary vasoconstriction in users without coronary arteryd~.,~ease
M O N D A Y A M A P R I L 2 4
$30
Abstracts
JOURNAL OF NUCLEAR CARDIOLOGY
Monday afternoon, April 24, 1995
M O N D A Y P M A P R I L
March/April 1995, Part 2
P05-117
P05-119
OPTIMIZATION OF 1-123 IPPA MYOCARDIAL SPECT IMAGES: WHAT IS THE RIGHT FILTER?
t~,sCI'S OF N I T N O G L ~
ZX He, G Guidry, JJ Mahmarian, R Taillefer, A Iskandrian, G. Heller, MS Verani for the IPPA Multicenter Trial. Baylor College of Medicine, Houston, TX, USA
G Zuin, M Sicolo, F Di Pede, G Turisno, P Pucci, G Bisi, PF Fazzini, E Piccolo. Divisicn of Cardiology aqd Nuclear Medicine Service of Meslre-Venice and Florence - Italy.
1-123 iodophenyl pentadecanoic acid (IPPA) has been recently used for evaluation of myocardial metabolism This study assessed which filters are optimal for IPPA SPECT. Myocardial SPECT was performed at rest on 15 pts with coronary artery disease, 4' and 30' following intravenous administration of IPPA (4-5 rnCi). On a first step, SPECT images reconstructed with Hamming, Parzen, Ramp, Gaussian and Butterworth filters were compared for quality of myocardial and cavity delineation, ease of defect identification and separation from adjacent structures The best filter (Butterworth) was then selected for further analysis using combinations of cutoff frequencie s (035, 045, 055 Nyquist) and orders (5, 10). The reconstructed images were then displayed simultaneously and evaluated by consensus of two experts. Best images were obtained with a CF=0.45 and order=10. Thus, optimization of IPPA myocardial SPECT, which is critical for enhancing image analysis, can be achieved using widely available filters.
(m~)
ON MYOCAF~IAL DEFECT SIZE IN AO3PE MYOCARDIAL IAFAFLTION.
The
effects of lOmg/24h iransdermal nitroglycerin after acute ~
( ~ m m t R) ~ m s ~
i n f a r c t i c ~ , an l e f t v e n t r i c u l a r defect s i z e , was assessed i n 65 p t s who underwent 99mTo-MIBI (44 pts) or 201T1 (21 pts) myocardial s c i n t ~ a t r e s t and a f t e r bicycle exercise (30W/~n') at 2 weeks snd at 6 mondos. P l a n m images were acquired mad scored visually (O=normoperOasicn, l=mild asd 2=moderate kg/poperfusion, ~-absence of
perfusien). Results: (mean values of total score are reported) NID (31 pto) Placebo (34 pts) rest stress rest stress 2 we~gs I0,3 12,2 8.3 10.8 6 months 8,7 10.9 7.4 9.1 % - i~ - 11% - 11% - 16~ Ccnclusians: NTG gre~o s&ows s greater decrease of rest total score (2 weeks vs 6 mcnths) and a lesse~ decrease of stress total score; this ms~ be due to a favorable effect of NIG on the viable myecardium recovery.
P05-118
P05-120
DETECTION OF SEPTAL ISCHEMIA ~ I T H IODINE 123PHENYLPENTADECANOIC ACID (p-IPPA) IN PATIENTS WITH LEFT BUNDLE BRANCH BLOCK.
Tc99m-TETROFOSMIN FOR DIPYRIDAMOLE STRESS MYOCARDIAL SPECT. INTRA-INDIVIDUAL COMPARISON WITH TC99m-SESTAMIBL P. Flamen, M. Rosseel, H. Everaert, A. Bossuyt, P.R. Franken. Department of Nuclear Medicine, University Hospital, Free University of Brussels (AZ VUB),Brussels, Belgium.
R.G.E.J.Groutars. J,F.Verzijlbergen, C.A.P.L. Aseoop. St.Antonius Hospital, Nieuwegein, the Netherlands, In this study, we tested the hypothesis that in symptomatic patients with a left bundle branch block(LBBB) exercise induced septal myocardial ischemia occurs independent of coronary artery disease(CAD),due to asynchronic septal contraction. Regional myocardial ischemia can be detected with delayed clearance of p-IPPA, We examined 13 patients with and 6 without LBBB by p-IPPA exercise scintigraphy and coronary arteriography, There was no CAD. Dynamic images (I frame/minute) were acquired in a 40~ projection during 60 minutes. The mean apicalseptal p-IPPA washout rate in patients with LBBB during the first 20 minutes was 2 • 3% compared with 11 • 3% in the apical-lateral segment (p
The aim of this work was to determine whether tetrofosmin could be more suitable than sestamibi for pharmacological stress testing in a one-day protocol. Methods: Thirty patients underwent two similar one-day, rest and dipyridamole stress imaging protocols, one using tetrofosmin, the other using sestamibi. SPECT was performed 60 minutes after tracer administration. Images were analyzed both visually and quantitatively. Results: Heart-to-liver activity ratios were higher for tetrofosmin than for sestamibi, both in the resting (1.19i-0.39 vs 0.96!4).45; I><0.05) as in the stress studies (1.37:t:0.37 vs 1.055:0.42; p<0.05). Heart-to-lung ratios were similar for both tracers. In segments showing abnormal uptake during stress, the perfusion indexes were similar with tetrofosmin and sestamibi, as well at rest (66.8%+17.2 vs 66.7%:1:16.4) as at stress (60.5%5:15.7 vs 59.7%+16.6). The degree of'reversibility of these segments was also similar for both tracers (6.3%+7.7 vs 6.9%:~-9.3). The extent, intensity and severity of the perfusion defects were similar in both tracer studies, Conclusions: Our study results indicate that tetrofosmin offers a more optimal biodistribution than sestamibi when used in a one-day, rest and dipyridamole stress imaging setting. However, no difference in quality nor in the diagnostic interpretation of the images could be demonstrated.
JOURNAL OF NUCLEAR CARDIOLOGY V o l u m e 2, N u m b e r 2, P a r t 2
Abstracts
P05-121
P05-123
Comparison of 18FTHA= and 18FDG-PET in Regions with Reduced Perfusion in 99mTC-MIBI-SPECT G. Schulz, J. v.Dahl, U. Cremerius, L. Banneitz, G. St0cklin', U. Buell. University of Aachen and "Research Center J0dich, Germany
14(R,S)-ISF-fiuoro-6-thiaheptadecanoic acid (FrI-IA) had been proposed as P E T - t ~ r of the B-oxidation pathway. To investigateits diagnostic value as a viabilitymarker we studie~I 13 patients with angiogmphically proved advanced coronary heart disease. All patientsunderwent PET with 250 M B q F T H A and 150 M B q 2JSFfiuom-2-dcoxygiucos~ (FDG) (in the first hour past injection) preceded by SPECT with 400 IVlBq 9~mTc-2-Methoxy-Isobutyl-Isonitril (MIBI) for pcffnsion asscssmcnt. All tl~ree methods were quantitativelyevaluated in 25 polar leftventricular regions per paticnt,Regional uptake of MIBI, F D G and FTHA was normalized to the region with highest MIBI uptake (100%)..Among 325 regions we extracted three groups for FTHA evaluation: MIBI- and FDGUptake > 70% (normal), MIBI- and FDG-Uptake < 50% (scar), MIBI-Uptake < 50% and F D G - U )take> 7 0 % (iscl~=..mia), ~'oup MIBI (%} F D O (%} F T H A (%) normal (n=141) 88 • 105 + 3 0 89 scar (n=27) 37 +8 29 +2 44 iischemia(n=17) 39 +8 89 +7* 47 mean • standard deviation, */* significant for p<0,001,
+21 +17 + • *+ +/+ not s.
In regions identified as scar or ischemia by FDG-PET, FTHA.uptake was not different. This and the proximity to MIBI-uptake suggest that reduced B-oxidation combined with decreased perfnsion limit clinical FTHA employment in distinction between ischemia and scar.
EVALUATION OF THE EFFICACY OF NISOLDIPINE IN PATIENTS WITHISCHEWICHEARTDISEASE--BY USINGEXERCISETI-201 ~0CARDIAL SPECTTakesM Yorishita, Juniehi Yamazaki, Hisa~o Yamushina, Shujl Nan~ou, Shouhei yamashina, Katsuhiko Naitou, Takehi ko Munakata, Chie Su-ganami, Ha~ime Nakano, Yoshimasa Yab e. 0hmori Hospital, TOH0 Univ. School of Med,,Tokyo, JAPAN The effect of nisoldipine(N) on myocardial perfusion in ischemic heart disease was studied using exerciseload Ti-201 myocardial SPECT (Ex-SPECT), Ex-SPECT was carried out in 7 patients with previous myocardial infarction(0Ml) and 6 with angina pectoris (AP) before and after administration of N I0 mg/day, for 2 or 4 months; extent score(ES), severity score(SS), ~Tl-uptake(~Tl} snd ~ashout rete (NR} in ische~ic areus ~ere calculated from short uxial images using the Bu11's eye method. ES and SS in the LV improved significantly before and after N, ~TI in the ischemic areas on the stress images improved significantly before and after N. The relative-WR in the ischemic areas improved. It is concluded that normal dosages of N have effects of increasing the myocardial perfusionin in the ischemic areas on stress, improving the distribution of myocardial perfusion. Ex-SPECT was indispensable in the diagnosis and assessment of therapeutic effect,
P05-124
P05-122 T[TUL:]:
D_S.3~j!!.~!;s o~.is!~.,'_4~.!t"rjs.L e ' ~': ADt!!IJK!'~'~;rJ; ~,}' .!.?.V !llTb;!1 sHs r:&tHL~l,~@,5's.ls 9LJS3'.lt~i,r' ,.
...... ~ " ~_,,~t:.:o,~
:-N'FHOI!~.:,t,II,:',AYF~-'.OBHI'.AS, ',l,',, ;~) EZ. H,L.
~,%,W2,, F,(i.
(;kLLARDO.
Earlier Visualization of Experimental Atheroselerotic Lesions with High Specific Radioactivity/Low Antibody Dose Negative Charge Modified Chimeric Z2D3 F(ab')3.
{,,i~!tl;,-g;dlELbA.
H,::SFIF,% (;ARLOS if! HA[2D.
Utility ~ kTP admi)list, ere:i I': ill TL-2t}ISF'ECT in the diagnoaia ~f ',:'~:i:. Thirtp:ne patients~ith di:ulgo~is of ,,~,i,.~r: disease after clinical an~or and cat}leterism. Sixteen of them Md <:ooardiai infarction {HI). age: 58,a-+9 ~ During a 5 mia. IV infusion of KFF a+ a dose on 0.I8 mK,'K~/~in, TL201 was inyected at the 3rd minute. '_atoad presure and Hg~ :~ez'e !'ecor:k.d at onset mud aft<' kTP infustot~, SHCT a a ~ s using the "buil-<~e"technique ~ere recorded at ense) and after 4 hours, 'Phi= Tt,-::)l was rein?'ected and ne~ lla3g~$ ;&'[S :, !i ! aia,~,:!, :;{':"':;: [luring stress, Uie cuantifield total p~!d'usi,,a & f e u I ~as :'.;;,2-+ I?~ harange:10,2-74~ after reinfection, ,~ean the defect was 2~1.5-~1{..q (p:O,OOO,1}, In the {r,)up of lfi 9atLe~ta ~itMut 9resi,m~ ':}t,[,, the stress u)gal perfusion de['~ct was 2~'k,q+-8,;; ~hile the defect after re ye.:qion ~as 27,6+- I? :p:O.0!HJl]. All p>~eedures uere ~ell tolented and rio m~,~aairable e~mp!ieations ~ere observed, "HTLN:7;V~;I~: Ti-21)l SHI',T-ATP is a sellsibla ~afe and *ze[I r, .:nl~) ~ethod, very useful in tile diagnosis of myocardial i>ff~eaia. i:7:~Ji-:_b"~--i 'J;:
S31
Monday afternoon, April 24, 1995
Narala J, Petrov A, Ditlow, Chen F, Torchilin VP, K h a w BA. Northeastern University and Massachusetts General Hospital, Boston, MA. Scotgen Biopharm. Inc., Menlo Park, CA. A mouse/human chimeric antibody Z2D3 specific for proliferating smooth muscle cells of human athemma cross-reacted with rabbit experimental lesions in vitro. Z2D3 F(ab')2 was modified with negatively-charged (NC) chelating (DTPA) polymers ~ 10kD) at 1:1 molar ratios, to improve target organ activity and to provide vexy high specificradioactivitylabeling with In-Ill. Rabbits (n =22) with
experimental athernsclerotic lesions (abdominal aortic deendothellalizationand hyperlipidemlc dietfor 12 weeks) were used: SampleL*mm~ Ab ~ Activity (u) DurationTargets target/ %IDLE faw'~ fmCTt Studvfmv l s ~ laver Z2D3 Pro. 0J~0.75 0.66 4 4a 4/4 0.49t0.05 0.104_+0.03 N-SIt. Pro. 0.~0,75 0.65 4 48 0/4 0.34+0.010.03_090.01 Z2D3 NeE. 0.025-0.05 0.~ 4 48 4/4 0.40-~.02 e.o8_~yO.Ol N-Sp. NeE. 0.02S-OJ~ 0.65 3 48 0/3 0.1_8~.03 0,02_0~.0| Z2D3 Net. 0.025-0.05 0.65 4 24 4/4 0.4_~.05 0.08_0+0.01 N-SD. NeE. 0.025-0.05 0.65 3 24 0/3 0.16+0.100.025+0,01 N-Sp.= ram-specificF(ab')-=,Pot = oonv=nfionalZ2D3,NeE = NC-polymermodified. Unequivocal lesion visualiz~ljon In all 8 rabbits was possibie by 24 H with NC- Z2D3. The conventional Z2D3 showed biood pool activity at 24 H. Biood clearance was faster with NC- Z2D3. Target to Liver ratios and mean % IDlE in the lesions were similar. The kidney activity with NC-Z2D3 was significantly lower (p-~.001). Thus atherosclcrotic lesions can be visualized earlier, with 15-20 times iess Z2D3 with charge modification
M O N D A Y A M A P R I L 2 4
$32
Abstracts Monday
M O N D A Y A M A P R I L
J O U R N A L OF N U C L E A R C A R D I O L O G Y afternoon,
April
24, 1995
March/April
1995, Part
P05-125
P05-127
REST-STRESS ONE DAY TETROFOS?vlIN MYOCAR1)IAL PERFUSION SINGLE-PHOTON EMISSION ( O M P U I ED T O M O G R A P H Y , A CLINI(~AI, VALII)ATION STUDY. Erick Alexanderson, Humberto Rodriguez, :Meiandro Lechuga,David Bialostozku hlstituto Nacinnal de Cardiologia "lgnacin Chavez', Mexico (. itv..klcxico.
EVALUATION OF 99mTc-TETROFOSMIN SPET FOR DIAGNOSIS OF CORONARY ARTERY DISEASE. M Pajares, JM Freire, E Otero, R Arana. Puerta del Mar University Hospital, Cadiz Spain
feclmetium-99m-tetrofosmin is a new nwocardial perfusion a~en~ with an ideal energy Ifbr gemuna camera imaging. I heir rapid back g~'ound clearance fiom liwacould represent one advantaar over Sesla MIBI imaging. There is not published experience in Latin-America on tetrofosmin. We studied 46 ~onsecutive patients with coronary artery disease. 26 of them with a previ.us myocardial infarclinn. Coronary a~lgiography was performed in all the paliems. We did a 7 mCi rest tetrofosmin SPECT starting acquisitinn 30 rain after rest iniection, followed by same day" 21 mCi tetrofosmin stress iniection. Stress SPECT was perfomled 30 ,fin ',filer exercise or 45 nfinutes after phannacoio~cal stress with dipvridamole. To validate perfiminn findings we did a ne~ study using rest-stress one day tedmetinm-99 m Sesta MtBI SPECq a/ler 3-b days of tetrofomfin imaging.Scintigraphic data were read l:,v 2 blinded experts using 20 SPECY segmeta analysis and each segment w:!s scored using 5 points scoring system (0=normal, 4-absent uptake). The segmental score a~eement between Sll-ess letrofosmin arid stress sestamibi ;rod the comparison of defect leversibilitv percentage (R) and non-reversibiiiw (NR} were: Stress tctrofosmin tctrolosmin 0 ~ 2 3 4 R NR 0
554
g
21
12
2
MIB1 R
16
6
Stress 1 14 21 11 4 0 NR 6 72 MIBI 2 18 15 110 29 0 3 I~) 5 19 76 30 4 2 0 I 16 S6 Exact a~eeme~t: 7g 8%, Sensitivity (%) fh, idenlilication of disease in individual c~ronary arteries were tbr tetrofi)smin and M1BI respectively: 0.AI): 92,80 I,CX: 60,60 RCA: 94,95) Specificfly (%0 was similar in both (LAD: 80 I,CX: 72 RCA: 77) Conclusi~w,s: Rest, Stress one day tetrofosmin SPECT myocardial periilsion protocol is accurate for coronary artery disease evaluathnl. It showed a good agreement with rest-stress tree day sesta-mibi SPt-CT study.
Tetrofosmin (MYOVIEW) is a new technetium labelled lipophilic cation evaluated for use as a myocardial perfusion tracer. The aim of this study was to establish the clinical value for the detection of coronary artery disease (CAD). SPET 99mTc-Tetrofosmin (TETRO), one-day imaging protocol, were performed in 18 patients (pts) with chest pain referred for diagnostic coronary angiography. There were 3 pts with no CAD, 5 pts with one-vessel ( 7 0 % ) , 7 pts with 2-vessel and 3 pts with 3-vessel disease. The left ventricie was divided into five regions and blindly evaluated by two independent observers. The sensitivity for CAD detection were 100% (15/i5) and for significant stenosis identification were 85% (24/28) by TETRO. Concerning localization of individual coronary artery stenosis the following values were obtaining: LAD LCX RCA SENSITIVITY 100%(11/11) 75%(6/8) 78%(--~/9) SPECIFICITY 71% (5/7) 100%(10/10) 89%(8/9) Theses findings suggets that TETRO is clinically useful for CAD, with results comparable to another perfusion myocardial imaging agents
P05-126
P05-128
LEFT BUNDLE B R A N C H B L O C K (LBBB) AND CORONARY ARTERY DISEASE (CAD): A C C U R A C Y OF D I P Y R I D A M O L E IN CASE OF POSITIVE STRESS THALLIUM-201 SPECT
REST Tc-99m TETROFOSMIN SPECT IMAGING IN MEN WITH SEVERE CORONARY ARTERY DISEASE IN ABSENCE OF PREVIOUS MYOCARDIAL INFARCTION
N-E Lebtahi, *J.C Stauffer, A Bischof-Delaloye, *L Kappenberger, B Delaloye. Depts. of Nuclear medicine and *Cardiology, University Hospital, Lausanne, Switzerland. It has been suggested that pharmacologic vasodilatation is more accurate than stress to evaluate left anterior descending (LAD) disease iu patients with LBBB. Seventeen patients (14 men and 3 women) aged 37 to 77 years (mean 58), with LBB. 13 and antero-septal (AS) perfusion defects on stress thallium-201 SPECT, underwent dipyridamole (0,56mg/kg/4mn) thallium-20l SPECT (DP). Eight patients had normal AS perfusion with DP, 3 had a moderate AS defect, 6 had a severe AS defect. Twelve patients underwent coronary angiography (CA). Three had a significant(>50%) LAD stenosis, all 3 positive with DP (2 moderate, t severe AS defect). The 9 patients with no significant LAD stenosis had normal AS perfusion in 6 and a severe AS defect in 3 with DP. In presence of strictly normal DP, CAD can reasonably be excluded, but with a moderate or severe AS perfusion defect, CA is neccssary to identify CAD, a major prognostic factor in patients with LBBB.
A.Pappalardo*, M.P.Risa, A.P.lesi, M.G.Tassone, N.M.Uthurralt. S.Filippo Neri H., *Policlinico Casilino, Rome, Italy. Tc-99m Tetrofosmin (TcT), a newly developed myocardial perfusion agent with stable myocardial retention, correctly identifies pts with coronary artery disease (CAD). No clinical studies about the specificity of TcT rest imaging in the diagnosis of myocardial viability are available. Then we evaluated rest TcT spect imaging in 15 men with angiographic evidence of severe CAD ( at least 1 totally occluded vessel) and no anamnestic and clinical evidence of previous myocardial infarction. In different days, rest images were aquired after injection of mean doses of 10 mCi of TcT and 3 mCi of TI. TcT images showed defects in 9 pts (specificity 40%) while only 1 T1 defect ( trivial septal defect) was observed in a pt with proximal LAD occlusion (specificity = 93%)( p = 0.007). Spect territories with TcT defects were: anterior (n=4); septal (n=3); apical (n= 8); lateral (n=l); inferior (n=7). We can conclude that in pts without a previous myocardial infarction and severe CAD, TcT imaging frequently shows rest defects probably due to a conspicuous flow reduction. Thus rest TcT had a poor specificity in the identification of myocardial viability.
2
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Monday afternoon, April 24, 1995
P05-129
P05-131
RAPID CORONARY DISEASE DETECTION WITH D I P Y R I D A M O L E T E B O R O X I M E W A S H O U T IMAGING M.Merhige, D.Phillips, R. Henneman, B.D'Arcy, SUNYAB, Buffalo, NY, U S A
REINJECTION THALLIUM, REST THALLIUM OR REST SESTAMISI: WHICH IS BEST TO ASSESS VIABILITY AFTER MYOCARDIAL INFARCTION?
Since 99m-TC Teboroxime (TEB) washout is delayed in post stenotic myocardium, we studied 102 patients with early/late phase d i p y r i d a m o l e (DIP) SPECT imaging using a single injection of TEB. Five, sequential, 2 m i n . i m a g e s were obtained 5 min. after 0.56 mg/kg. DIP, 1 min. after TEB injection. The first two and last three scans were summed to create early (S) and late (W/O) images. Rest (R) imaging was also performed. Of 38 DIP induced defects, 14 were fixed and 24 reversible at R. W/O imaging p r e d i c t e d r e v e r s i b i l i t y in 20/24 segments; none of the 14 fixed defects improved at W/O. 4 r e v e r s i b l e defects, failed to improve at W/O. Quantitative analysis confirmed these results. Conclusion: coronary disease can be diagnosed with a i0 min. image sequence when defect r e v e r s i b i l i t y occurs at W/O. If no improvement occurs at W/O, a separate R study is necessary.
V Gil, J Ferreira, J Calqueiro, M Trabulo, M Almeida, A Ventosa, R Seabra-Gomes. Hospital de Santa Cruz, Carnaxide, Portugal The aim of this study was to evaluate the relative value of reinjection of thallium(Ri-T), rest thallium (R-T) and rest sestamibi(R-M) for the diagnosis of viability after myocardial infarction (MI). In 12 patients (pt) previously studied with stress-reinjection thallium SPECT, rest scintigrams were repeated with same-day separate injections of thallium and sestamibi. Pt were 56.58+ 7.6 years and 3 were female. Angina was present in 8 pt. MI was anterior in 10 pt and inferior in 2 pt. For stress studies dipyridamol was used in 9 pt and exercise in 3 pt. A perfusion score of 0-4 points was used in each of 13 segments. Concordance was excellent between the three methods. Ri-T R-T R-M Reversible PD. 34% 34% 33% NS PD: perfusiondefects Conclusion: The methods showed excellent concordance for the assessment of viability. The choice of one method should rely on logistical conditions or on individual patient characteristics.
P05-130
P06-132
SINGLE AND SEPARATE DAY STRESS-REST SPECT WITH 9 9 m T c - T E T R O F O S M I N : A N A L Y S I S OF ACCURACY AND AGREEMENT IN CAD DETECTION
The ImageeFeature Of Exercise 9 9 m T c - M I B I MyotardiolPerfusion 8 P E C T In Healthy People W uhe-P en g ; P u d e - Z hen; g ahui-J in ; Y il i-L iu Nanfang Hospitcd, GuanuZheu, Chima. ~ healthy people(mode 19,female #) cam firmed by clinical evaluation and coronary arterography underwenta submazimal( ) 8 0 ~ of age predicted heart rate) m u l t i ~ g e bicycle ergometer test according to the Bruce Prototal. A dose of 925-1110MBq 9 9 m T c - M I B I was injected intravenously at peak exercise, TosPdbo G C A 90IA/BA 8 P g C T with a Lower gnerg Hi#he Resolution Collemator( L E H R ) was used to record imagesafter stress and l.5-2,0 h~urs a f t e r # g m T c - M I B I injection. The 8 P g C T images showed that local perfusion d e f e r s r be seen in 76,21~ of normals at anterior or inferior wall with short-azio view and apical area with horizontal long-axis view.Unec~enimages often appear in inferior part of vertical long-axis view.Loe~ dark areas with gray scale decrease could be detected at septal and inferior region of Bull's eye display. Recognize these fea|ures in healthy persons are important for evuluating C A D with 8 P g C T .
GM Sacchetti, M Rudoni, A Baroli, F Loria, F Aina, E Pittaluga, M Brambilla, E Inglese. Depts. of Nucl. Med. and Cardiol'~gy, Ospedale Maggiore, Novara, Italy. The aims of this study were 1) to compare 99mTctetrofosmin Spect perfusion images with coronary angiography; 2) to assess the agreement between rest images acquired in the same or in a separate day with respect to stress images. Tomographic studies were obtained in 12 patients (5 previous MI) with single (9) or double (3) vessels CAD (lesions > 75%). Studies were read visually by 3 blinded investigators and quantitated by means of maximum pixel circumferential profiles of 3 short axis and the mid long axis slices. Visual analysis identified stress defects in 81 myocardial segments: 29 sites were in disagreement with coronary lesions and/or previous MI. Among them, 26 belonged to the inferior wall. Quantitative analysis showed an high agreement (Kw=.88) between rest studies performed in the same or in a different day with respect to stress imaging. In conclusion, quantitative analysis of stress tomograms with a normality data bank seems necessary to overcome the problem of unexpected defects in inferior walls; no significant differences were found between rest studies performed in the same or in a separate day with respect to stress imaging.
$33
$34
Abstracts Monday afternoon, April 24, 1995
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
P06-133
P06-135
M O N D A Y
COMBINED BULL'S EYE DISPLAY OF REST, STRESS AND VIABILITY IMAGING IN CORONARY ARTERY DISEASE.
BEDSIDE TOMOGRAPHIC
P M
The anatomical correlation among different baseline, stress and viability nuclear images is complex but critical in the clinical decision making. To overcome this limit, we applied the same bull's eye display to 20 patients with coronary artery disease who underwent nuclear imaging examinations. In these patients, 30 Thallium studies and 30 radionuclide angiographies related to baseline, exercise stress test and viability, achieved by low-dose dobutamine in wall motion studies or by Thallium reinjection, were analized. Two independent observers transferred the individual clinical report of each examination in a format based on 11 standard bull's eye segments using a score ranging from 1 (normal) to 4 (severely abnormal). Patient's stress, rest and viability images were represented in different shades of color containing also information on transient cavity dilation. Overall inter- and intraobserver variability was 13% and 7%; in particular, Thallium reports showed a lower variability (10%) when compared to wall motion studies (13%). No loss of information was found in the reverse process. In conclusion, the bull's eye plot may represent a valid reproducible display able to integrate rest, stress and viability nuclear studies.
A P R I L
Michele Emdin, Manila Niccolai, Alessandro Taddei, Alessia Gimelli, Paolo Marzullo. CNR Institute of Clinical Physiology, Pisa, Italy.
MYOCARDIAL
P E R F U S I O N IMAG'ING"
IN THE INTENSIVE CARE UNIT USING A MOBILE GAMMA CAMERA SYSTEM
S Dale, D Bone, LA Brodin, C Lindstr6m, H Elmqvist, T Ribbe, L Jorfeldt. Department of medical engineering, Karolinska institute, Stockholm, Sweden. The objective of a mobile tomographic gamma camera system is to enable bedside determination &myocardial perfusion in the critically ill. A direct and non-invasivemethod will provide evaluation of heart infarction treatment during the acute phase of an infarction. A first prototype of such a system based on the tomographic principle of Ectomography has been developed and built within our departments. Since December 1993 more than 150 studies have been performed. In a comparative study, 19 patients were imaged with both Ectomography and SPECT using Tc99~ Cardiolite| A blind evaluation confirmed the clinical usefulness of Ectomography for myocardial imaging. Two further research projects have been completed: a comparative study to follow the dynamic properties of myocardial perfusion after coronary artery bypass graft (CABG) and an animal study for determination of myocardial damage and myocardium at risk after ischemia or infarction. Currently, a second prototype is being developed which will be no heavier or larger than a modem mobile x-ray cart.
P06-134
P06-136
REGIONAL MYOCARDIAL GLUCOSE U T I L I Z A T I O N AND IMAGE QUALITY ASSESSMENT USING A SIMPLIFIED PROTOCDL AND PATLAK ANALYSIS WITH POSITRON EMISSION TOMOGRAPHY.
CORRELATION BETWEEN HYDROGEN PEROXIDE PLASMA LEVEL AND MYOCARDIAL ISCHEMIA EVALUATED BY SPECT.
P. Alagona, Jr., B. Kaul, R. Cacciatore, D. Jordan, E. A. Eikman. St. Joseph's Positron Center, Tampa, Florida. . Qu.ata.titative measurement of regional myocardial glucose utilization, rMGlu (umole/gmTmin), and image quality assessment were performed with PET-FDG subsequent to oral glucose (OG) .and OG-insuhn (OGI:) loading. 9 healthy voluntecrs underwent study using 10 mCi FDG, 13eripheral venuus blood glucose sampEng, loading conditions described (OG, OGI), LV cavity ROI input function, 57 min dynamic acquisition andPatlak analysis with dephospho.rylation rate constant (k4) = 0. ROrs were placed over tlie septum, anterior, lateral .-,ad inferior segments using a mid-chamber short axis slice. rMGlu of each ROI were r.btained post-OG and OGI ,rid mean segment values + SD for all studies calculated ksee below). "Individual qualitative image assessment pre =nd post Patlak applicatton were pertormeo. SEP ANT LAT INF OG- 0.29+0.07 0.33~:0l l 0.31• 0.28• rMGlu OGI- 0.29+0.07 0,29+0.r 0.30• 0.20• 0.07 rMGlu This simplified protocol failed to reveal sign.ificant rMGlu differences between OG and C,GI loading but results were reproducible for both inter anO intra patient segment comparison. Substantizlly improved image quality due to enhanced image density and contrast 0iscrimmation as a result of Patlak application is illustrated. "
M.Ka,~mierezak, A.Wykr~towicz, H.Wysocki, A.Minczykowski, J.Smielecki, K.Bielski, M.Ruchala, J.Sowinski, M.Gembicki. Academy of Medicine, Poenafi, Poland. In our recent studies we have demonstrated that hydrogen peroxide (H202) plasma level is increased during exercise test in patients with coronary artery disease (CAD). Currently we addressed the question if there is correlation between severity of induced myocardial ischemia end increase in H202 production. 10 patients (age 28-67, mean 52+13) were subjected to two provocative tests. First was performed with the use of dipyridamole (Persantin, Boehringer Ingelheim, Germany) and the second one with the use of dobutamine (Dobutrex, Lilly, France). lschemia was followed by sestamibi-Tc99m (25 mCu) SPECT. The severity of ischemia was defined by 5 point scale (0-0.5-1.0-1.5-2.0) in 9 segments of left ventricle (before and after pharmacological provocation), Hydrogen peroxide plasma level was determined by spectrophotometric method of Frew et al. Blood for H202 determination was obtained before test, directly after dobutamine infusion or 5 minutes after dipyridamole injection. The mean score in patients before provocation was 15.54"1,1 pts. and diminished to 13.3+-3.8 pts. (9=0.05) after dipyridamole injection or to 14.64.2.0 pts. (p=0.04) after dobutamine infusion. Hydrogen peroxide plasma level increased from 16.64.2.8 ~mol/1 to 34.3_+10.3 Ixmol/1 after dipyridamole provocation (9-0.04) or to 37.3+11 grnol/1 after dobutamine (9=0.06), We have noticed the positive correlation between the decrease in radiotracer accumulation in myocardial tissue after dipyridamole injection and H202 plasma level (r=0.915; p<0.001). Similar correlation (r 0.712; p<0,05) was demonstrated between the decrease of radiotracer accumulation after dobutamine provocation and hydrogen peroxide plasma level. Thus we concluded that increased H202 plasma level induced during provocative myoc~cdial isehemia correlates with area of transient myocardial ischemia detected by SPELT
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Monday afternoon, April 24, 1995
P06-137
PO6-139
PAPER VERSUS FILM FOR HARD COPY OF MYOCARDIAL PERFUSION TOMOGRAPHY: RECEIVER OPERATING CHARACTERISTIC (ROC) ANALYSIS.
RESOLUTION IMPROVEMENTS IN MYOCARDIAL SPECT WITH DOUBLE-HEADED SPECT SYSTEM. Y. Petegnief, A. Mure, R. Lebtahi, M. Faraggi, L. Sarda, D. Le Guludec. Bichat Hospital; Paris - France.
G A Hurwitz, P Slomka, RL Vandierendonck, JP O'Donoghue, DC Wilson, CL Willems, SK Ghali. University of Western Ontario, London, Canada. Rapid availability of high-quality copies of myocardial perfusion tomograms might facilitate (i)feedback in performing reconstruction, (ii) clinical review in patients experiencing symptoms, and(ill)communication by FAX. We assessed 48 rest/stress sestamibi studies performed and hard-copied during the first month after introduction of a new technique; at the time of reconstruction by technologists, reference views and mid-ventricular slices in 3 projections were printed on 1 l"x8" paper using a conventional 600 dpi laser printer. Studies archived on paper were blinded and read for presence and nature of defects by 4 nuclear medicine residents, and compared using ROC methods to standardized film copies formatted by one physician-author. Paper was similar to film in inter- and intra-observer variation, and in diagnostic accuracy. Subsequent routine use of paper prints has reduced costs and improved clinical service.
Double-headed SPECT systems with cameras at right angles offer a twofold gain in sensitivity for 180" myocardial SPECT. SophyCamera DST allows a myocardial dedicated orbit with heart centered on the axis of rotation (by adjusting bed height and gantry translation each step). We investigated the respective role of collimator and orbit selection on resolution improvements. A cardiac phantom containing 2O1TIand a 3 cm3cold defect was imaged with 3 collimators: high sensitivity, general purpose and high resolution (HR). Defect to normal contrast, calculated on short-axis slices (Hann filter, fc=0.5 cycles/cm) was respectively 0.44, 0.49, 0.55 and relative number of counts 2, 1.3, 1. This enabled the choice of HR collimators, combining two heads sensitivity and gain in resolution. For a 75 mm left off-axis 9~nTc line source and HR, transaxial full width half medium (FWHM) was 14.7mm in both radial and tangential directions when source is centered and 15.7 mm radial FWHM and 12.2 mm tangential FWHM Without centered acquisition. Thus, symetry of spatial resolution over the myocardium was obtained with heart-centered setting without loss of resolution due to the complexity of system motion. Optimal clinical acquisition parameters derived from 10 normal patients exercise data (111MBq of 2~ were 50 sec/view giving a total time of acquisition of 14 rain and 2.45 Mcounts.
P06-138
PO6-140
LOWER SPECIFICITY OF 201TL-MYOCARDIAL-STRESS SCINTIGRAPHY - WHY IT IS: A RESULT OF ROUTINE QUALITY-CONTROL IN NUCLEAR-CARDIOLOGY. L.Fridrich, M.Chamieh, V,Mtihlberger, N.Moes, G.Friedrich, G.Riceabona. Univ.Clinic of Nuclear Medicin and Departement of Invasive Cardiology University Innsbruek, AUSTRIA Out of 2252 patiens(pts) investigated by planar 201TIMyocardial-Stress-Sc.(MSC) - in 22% of pts also coronary angiography(CA) was performed. To introduce quality control in routine nuclear cardiology a random sample initally judged by an experienced nuclear cardiologist has been retrospectively compared to the results of CA by an invasive cardiologist not involved in performance or judgement of MSC or CA. Results: For individual patients CAD detection Sensitivity(SENS) and Speeificity(SPEC) was 100 and 18% respectively ; according to individual coronary artery regions SENS and SPEC was for LAD 83 and 42%, for RCA 94 and 44%, for RCX 55 and 94% respectively. In the 14 pts without SCAS but pos MSC 10 had arterial hypertension with diffuse calcified coronary sclerosis in 7 pts, another patient had inducable coronary spasm and two pts were judged equivocal by MSC. Conclusions: pts with CAD and number of diseased vessels were detected with good sensitivity by MSC, however pts without SCAS revealed other pathophysiologic correlates explaining detected perfusion abnormalities and thus low specificity.
QUANTITATION OF SPECTCARDIAC PERFUSION IMAGES : VALIDATION OF A NEW ,AUTOMATED ANALYSIS SOFTWARE BASED ON RADIAL SLICES. Th. Benoit, D. Vivegnis, M.P. Larock, J. Foulon, P. Rigo. CHU SART-T~LMAN,Liege, Belgium. We have developed a new automated software using a 360~ elliptical sampling of radial slices, circumferential profiles and a polar summarj display for myocardial SPECT perfusion imaging quantitative analysis. Partial volume effects are homogeneoulsy distributed in all orientations and data are corrected pixel by pixel for surface distortion resulting from planar projection. Threshold for abnormality is fixed pixel by pixel as normal mean (NM) - 2.5 SD. Defect severity is defined as NM - patient value (pt) over NM - pt background in abnormal regions. An ischemic size index (ISI) (defect surface x defect severity) is calculated to eliminate the surface overestimation and severity underestimation effects of diffusion. The ISI reproducibility is 3.5% for pts studies while RSD reaches 6% for cardiac phantom studies because of a geometrical discrepancy between the ellipsoid model used and the phantom cylindrical shape. Linear regression between phantom defects of various known sizes and corresponding calculated ISI demonstrates excellent correlation (r: 0.992) with only a slight overestimation of very small size defects.
$35
$36
Abstracts Monday afternoon, April 24, 1995
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
P06-141
P06-143
M O N D A Y
A UNIFORM STANDARDIZED PROTOCOL FOR SCINTIGRAPHu OF THE MYOCARDIUM WITH 201-TL IN AUSTRIA.
DIRECT GENERATION OF MYOCARDIAL IMAGES FROM DYNAMIC HI~O SCANS.
P M
19851 heart studies were performed in Austria in 1993. In the 42 departments of Nuclear Medicine in Austria multiple protocols a r e in use. To avoid confusion because of different sensitivity and specifity of techniques, unnecessary repetitions of myocardial scintigraphies, radiation burden and at last costs a uniform standardized protocol for 201-TI scintigraphy of the myocardium was established.
A P R I L
H.Fritzsche*, H.B~rgmann, L.Fridrich, H.KShn, P.Lind, J.Mlczoch, A.Mostbeck, G.Porrenta. *Landeskrankenhaus Feldkirch
34 of 42 Nuclear Medicine departments will use this protocol, starting January ist, 1995. This protocol describes indication for myocardialscintigraphy, bicycle and pharmacological stress-testing and vasodilatation techniques, acquisition and processing of planar and SPECTstudies. Also quality control procedures are included. Variation of the protocol is possible, buthas to be mentioned separately by the user.
TISSUE
Flemming Hermansen, Stuart D. Rosen, John Ashburner, Peter M. Bloomfield, Paolo G. Camici, and Adriaan A. Lammertsma. MRC Cyclotron Unit, Hammersmith Hospital, London, U.K. Myocardial blood flow (MBF) can be measured quantitatively using H2150 and PET. However, a myocardial tissue image is needed to define regions of interest (ROIs). This image is normally created by subtracting a C1~O (blood pool) image from a transmission (tissue density) image. Disadvantages of this approach are: need to produce C~50; increased radiation dose; increase in study duration; sensitivity to patient movement; and difficulty in detecting small movements between the C~50 and H2~50 scans. Using factor analysis, myocardial images can be generated directly from the H2~50 scan without using the C150 scan, although it is difficult to remove the blood activity simultaneously from the left and right sides of the heart. In this presentation a modification is described, which circumvents this problem. A statistical model has been developed to describe the dynamic images as a function of the factor images. The equations have been solved in order to find the myocardial image solution with minimum noise. The solution does not use principal component analysis, which is usually used in factor analysis. The modified method can consistently generate myocardial images, with optimal statistical properties.
P06-142
P06-144
ARE AGE AND SEX OF IMPORTANTANCE IN MYOCARDIAL BULL'S EYE REFERENCE FILES WITH Tc-99m MIBI?
AUTOMATIC DETERMINATION OF RECONSTRUCTION LIMITS FROM PROJECTION IMAGES IN MYOCARDIAL PERFUSION SPECT. Guido Germano, Johnny Chen, Paul Kavanagh, Hsiao-Te Su, Kenneth Van Train, Hosen Kiat and Daniel Berrnan, CedarsSinai Medical Center, Los Angeles. We have developed an algorithm that determines the upper and lower boundaries of the LV myocardium from projection images, using 2-D feature extraction techniques. The "best" 3:5 projections (based on acquisition and camera specifics) ere identified and summed, and the resulting image Io convolved with a feature detector, the double derivative of a 2-D Gaussien with variable standard deviation. This process yields several points Pi, candidates to represent the LV center. Io is now processed by template convolution followed by local maxima extraction. Continuous rings of maximal pixels surrounding Pi are identified by breadth-first search and iterative directional pixel dilation, and the ring most likely to represent the LV chosen using size/shape/location heuristics. The software was developed on a Sun SPARC5 computer and requires approximately 1 sec/study. The algorithm was applied to 530 patient studies acquired on a triple detector (Picker Prism 3000, 193 studies), a 90 ~ dual detector (ADAC Vertex, 200 studies) and a single detector camera (Siemens Orbiter, 137 studies). Myocardial boundaries were correctly determined in 96.4% of the patients (187/193+193/200+131/137). If integrated with filtering, reconstruction and automatic reorientation of the transsxial images (Germano et aL, J Nucl Med 1995), our approach may achieve complete operator-independence in the processing of myocardial poffuaion SPECT data.
J e n s Tort, B i r g e r H e s s e . R i g s h o s p i t a l e t , C o p e n h a g e n , Denmark. Reference files, separate for men (m) and women (f) are useful adjuncts in the evaluation of myocardial perfusion SPECT. The purpose of this investigation was to study the influence of age and sex on myocardial distribution of sestamibi uptake at rest (R) and during exercise (Ex) in normal subjects: 136 healthy subjects (18-39 y: 19 m, 6 f; 40-59 y: 21 m, 20 f; 60-79 y: 41 m, 26 f) with a less than 5% likelihood of IHD, drawn from the Copenhagen City Heart Study, underwent a 2-day R and Ex (max HR --- 10%) SPECT study (GE camera, elliptical orbit, 180~ Bull's eye tracer distribution was divided in four 90~ zones: ANT, LAT, INF, SEPT. Activity distribution, expressed in % of max zone, was equal in 3 zones in m and f (mean values for Ex/R, m-f): ANT: 92/93-90/90; EAT: 99/100-99/100; SEPT: 91/89-91/89. But INF wall differed: 85/84-91/90, p< .001 both for Ex and R. SD values were generally slightly higher in women. Age differences were found only for m in ANT wall: 18-39 y: 90/90 vs 60-79 y: 93/95 (p<.001 both for Ex and R). For m 40-59 y: 92/92 (ns). Conclusion: In 136 healthy subjects AN~I" wall activity varied nearly as much with age in m e n as INF wall activity with sex. LAT and SEPT wall activities were independent of age and sex.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Monday afternoon, April 24, 1995
P06-145
P06-147
THREE-DIMENSIONAL DEMARCATION OF CORONARY ARTERY PERFUSION ZONES: TOWARDS AUTOMATED INTERPRETATION OF MYOCARDIAL TOMOGRAPHY
REPRODUCIBILITY OF AN AUTOMATIC QUANTIFICATION OF THE DEFECT SIZE AND SECTORIAL ACTIVITY IN MYOCARDIAL TOMOGRAPHY.
PJ Slomka, GA Hurwitz, G St.Clement, JA Stephenson University of Western Ontario, London, Canada.
Fran~oise Wieczorek, Didier Scellier, Jean-Christophe Cauvin, Jean-Yves Boire, Jean-Ren6 Lusson, Jean Cassagnes, Annie Veyre, Jean Maublant. Centre Jean Pen-in, Clermont-Ferrand, F.
Automated localization of myocardial perfusion defects could result in more objective interpretation of images. In this study, three-dimensional (3-D) maps of specific coronary artery zones were created to provide a reference for automated characterization of defects. Tc-99m sestamibi images of 168 angiographically-correlated normal and single-vessel disease patients were aligned and sized to the same 3-D orientation using an auto-mated image registration technique (PERFIT). Hypoperfusion zones and normal templates were derived by combining images in distinct angiographic groups. A regiongrowing algorithm identified defect-voxels by comparison to the voxels in the normal templates; defects were marked directly on tomographic slices and quantified with respect to volume, location, and severity. Defects ~_2% of myocardial volume positioned within perfusion zones were detected in 105/119 abnormal and in 3/49 normal patients. Maps of myocardial peffusion can be used for automated localization of myocardial perfusion defects. Template-based region-growing is a robust technique for volumetric defect demarcation.
The intraobserver reproducibility of an automatic method for the measurement of the defect size (DS) and of the relative sectorial activity in myocardial SPECT was evaluated in a series of 30 patients (pts). Fifteen pts with a myocardial infarction underwent rest TI-201 and sestamibi studies, and 15 other pts with coronary artery disease underwent stress-rest studies. After the manual positionning of a spherical ROI around the myocardium (myoc.), an entirely automatic processing involving methods of mathematical morphology resulted in the delineation of the defect area for calculation of the DS, and the division of the myoc. into 20 sectors. Overall, reproducibility of DS measurement was 0.966 and 0.972 with T1-201 and sestamibi, respectively, and for sector analysis 0.971 and 0.958, respectively. The correlation between the DS with T1-201 and sestamibi was also excellent (r=0.928). The findings were similar in the subgroups. It is concluded that this method allows a highly reproducible quantitative analysis of T1-201 and sestamibi tomograms.
P06-146
P06-148
THALLIUM-201 REST REVERSIBILITY AND CORONARY ANATOMY. SD Newman, MW Kronenberg, DH Freeman, Jr., ML Nusynowitz. University of Texas, Galveston, TX.
Inter and Intra observer variability of lVIyocardial Blood Flow Measurements using Positron Emission Tomography 3/L. BOttcher, J. Czernin, K. Sun, G. Porenta, M. Dicarti, D. Buxton and H. R. Schelbert, UCLA Sch. of Med L.A. CA. USA Quantification of myocardial blood flow (MBF) with N-13 ammonia and dynamic PET involves subjective decisions, e.g., reorientation into short axis cuts and placement of regions of interest which could render resulting MBF estimates observer dependent. We examined the inter observer variability (IOV) of MBF measurements in 8 normals (age 56+5) and 15 patients (ase 54+4) with CAD (N=8) or ischetrfic/ idiopathic car&omyopathy (N=7). Subjects were stu'died at rest or during dipyridamole hyperemia. Using a validated software routine (2 compt. model), 6 observers independently and blinded of patient history quantified MBF in the territories of the 3 coronary arteries in each subject Coefficient of variance (CV) of mean MBF values averaged 8• % and 12+8% for regional values. Analysis of variance failed to show any differences between observers Agreater regional IOV was found in patients with perfusion defects and cardiomyopatby compared to normals. (16• and 12• vs 8• (p<0.05). No differences were found in the CV of the 3 vascular territories but the CV was greater in absolute but not in relative terms for hyperemic than for resting myocardial blood flows (0.10• vs. 0.27• ml/ g/man; p<0.05 vs. 17• vs. 23• p=NS).Thus, estimation of MBF using PET yield stable results with low IOV. The variability is most pronounced in patients with perfusion defects and it is concluded that IOV can be reduced by using strict criteria for assigning ROI and by careful selection of the arterial input functions.
Enhanced T1-201 uptake at rest implies myocardial viability and predicts functional recovery after revascularization. To study reversibility we reviewed a consecutive series of T1-201 stress tests, and evaluated 19 stable patients with fixed defects who had restreinjection on a separate day and cardiac catheterization. SPECT images were graded for relative T1-201 uptake in 4 representative regions/pt (n=76) immediately and 4 hours after injection using a 10 color scale (units). Results were compared to ECG's, coronary stenoses (%), collaterals and LV wall motion. 58/76 regions were abnormal: 32 had persistent defects (avg. decrease 0.2 • 0.6 units) and 26 of 58 (45%) had reversible defects (avg. increase 1.6 5 : 0 . 5 units), implying myocardial viability. The presence of T1-201 rest reversibility was not related to initial T1-201 uptake, wall motion, collaterals, previous MI or severity of coronary stenosis. Thus, standard clinical and anatomical information was inadequate to detect scintigraphically viable myocardium. The scintigraphic diagnosis of viability may be related to preserved cellular TI-201 extraction and low TI-201 washout rates in the abnormal (but viable) regions.
$37
$38
Abstracts
JOURNAL OF NUCLEAR CARDIOLOGY
Monday afternoon, April 24, 1995
M O N D A Y P M A P R I L
March/April 1995, Part 2
P06-149
P06-151
DOSE Tc-99m-TETROFOSMIN MYOCARDIAL SPECT REPRESENT REDISTRIBUTION AT REST AND EXERCISE ? H Kobayashi, T Oka, N Matsumoto, Y Ikkatai, K Kusakabe, S Hosoda, Tokyo Women's Medical College,Tokyo, Japan
EVALUATION OF HYPOPERFUSION AT LATERAL WALL IN HYPERTENSIVE PATIENTS WITH TL201 and Tc 99m SESTAMIBI STUDIES E. Ozalp, N.O. Ktiq~ik, EAltmyay, K.M. Ktr, G. Aras, G Erbay Ankara University Faculty of Medicine, Deptartment of Nuclear Medicine, 06100 ANKARA/TIORK|YE
To assess the existence of redistribution after the injection of 99mTc-Tetrofosmin at rest and exercise, 20 patients with old myocardial infarction (MI) at rest and 20 patients with angina pectoris (AP) at exercise were studied 99mTc-Tetrofosmin myocaridal scintigraphy. M e t h o d : SPECT images were obtained 30 minutes and 3 hours after the injection of 99mTc-Tetrofosmin. Results: Redistribution findings were not observed both in the rest and exercise delayed SPECT image. Although, mild reverse redistribution findings were observed in 4 of 20 MI patients and 7 of 20 AP patients. These reverse redistribution findings were frequently observed in the ischemic myocardial territories. Myocardial washout rate in the rest 99mTc-Tetrofosmin images were 5 to 35%, and patients variability were significant. Conclusion: Redistribution findings were not observed both in the rest and exercise 99mTcTetrofosmin images. Reverse redistribution were occasionally observed, and delayed image at rest is not suitable for evaluating myocardial viability.
The relative hypoperfusion at lateral wall due to septal hypertrophy on Tt201 myocardial pert~sion sca,~s (NIPS) have been previously reported in patients (pts) with hypertension The aim of the study was to investigate the frequency and degree of lateral hypoperfusion in pts with hypertensive (HT). While T1201 SPECT was pertbrmed in 33 HT pts and 27 normotensive (NT) pts, Tc99m Sestamibi SPECT was performed 18 HT pts and 10 NT pts. All of the pts have normal coronary angiograms. The images were evaluated quantitative method and lateral-to-septal (L/S) count density ratios were calculated from both stress and delay images. L/S ratios were found as in tbllowing table: Stress Rest TI201 HT (n:33) !.02+0.09 1.01+0.08(p<0.01) NT(n:27) I. I I_+0.09 1.09-+0.08(p<0.0 I) MIBI l-{T(n:lS) I 03_+009 I 05+007(p<0001) NT(n:10) 116_+006 I 18-+0.08(p<0001) The ratios of t,/S in HT pts were found significantly lower than NT pts in boti~ T1201 and Tc99m Sestamibi studies. Lateral fixed hypoperfusion which may mimic myocardial infarction may be seen , and physic,ans on TI20 l and also Tc 99m Sestamibi SPECT stud'es interpreting myocardial per'fusion scans should kept in mind this alteration.
P06-150
P06-152
SEMI-QUANTITATIVE RELATION B E T W E E N RESTING THALLIUM SPECT AND FDG SPECT IN NORMALS.
EVALUATIONOF THE LEFTVENTRICULARFUNCTION(LV} USING 3-DIMENS[ONAL(3-D) MYOCARDIALSPECT
Jeroen J. Bax, Frans C. Visser, A.B.Johan Groeneveld, Gerrit J.J. Teule, Arthur van Lingen, C.A. Visser. Free University Hospital Amsterdam, The Netherlands. Recently the feasibility of FDG and thallium-201 (2~ in combination with SPECT has been demonstrated. However, since differences in attenuation and photon energies exist for these tracers, this may cause a problem in the inferoseptal region, which is most susceptible to attenuation. Therefore, the relation between 20,T1 and FDG SPECT was studied in normal volunteers. Nine male subjects (43• yrs) underwent FDG SPECT during hvperinsulinemic glucose clamping and 201T1 SPECT. Three 20r~ Tl and FDG short-axis slices (apical, mid and basal) were analyzed using circumferential profiles (60 segments). Activities were normalized to the maximum counts in the slice. The segments were grouped into 4 regions: anterior (ANT), lateral (LAT), inferior (INF) and septal (SEPT). Pooled data showed a linear relation (p<.0001) between 2~ and FDG: FDG=0.762~ (r=0.70). Although individual tracer uptake varied significantly between the 4 regions, no difference was observed between 2~ and FDG within regions: SEPT ANT LAT INF 201TI 0,91• 1.04+0.07 1.08_+0.07 0.97_+0.09 FDG 0.90• 1.05_+0.09 1.08_+0.07 0.98_+0.08 In conclusion, no differences between ~~ and FDG uptake were found; these data can be used as a normal reference for patient studies.
Hisayo Yamashina, Jun-lchi yamazaki, Takeshi Merishita, Masaaki Takano, Katio Kosakai, l)Jun-ichi Sugita The Ist department of internal medicine, Toho univer sity school of medicine, l)Kubota co, jp, Tokyo, Japan We have developed the new program for quantitative analysis of the LV function from gated myocardial SPEC T by Application Visualization System {AVS), 3-D myocardial SPECT with ~9=Tc-MIBI was performed in myocardial phantom, We obtained the myocardial muscle volume from the number of voxels on the basis of the phantom we had already known, and determined the threshold of RI counts, After injection of ~=Tc-MIBI(740MBq}, myocardial gated SPECT was performed in 5 normal controls. The threshold in normal cases were determined(40--.45~} based on the phantom study(5S%) and visual findings, The myocardial volume and total counts of the endodiasto]ic(ED) and endosystolic(ES) phases were obtained by AVS, The contraction fraction(CF) was calculated accordingto the following formula, (ES(counts/volumelc/ v}-ED(c/v)}/EDIc/v ), The CF{0,57.--0,61) was correlated well to LVEF(0,54--~0,6) from R[ ventriculography with ~mTc-HSAD, The CF was considered to be a usuful index for evaluating LV function,
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Monday afternoon, April 24, 1995
P07-153
P07-155
REST-REDISTRIBUTION THALLIUM AND DOBUTAMINE ECHOCARDIOGRAPHY FOR THE PREDICTION OF RECOVERY OF FUNCTION AFTER ACUTE MYOCARDIAL INFARCTION A Elhendy, G Trocino, A Salustri, JH Cornel, EP Krenning, PM Fioretti. Thoraxcenter and Department of Nuclear Medicine, Erasmus University, Rotterdam, The Netherlands.
SIMULTANEOUS DOBUTAMINE STRESS SESTAMIBI MYOCARDIAL SCINTIGRAPHY AND ECHOCARDIOGRAPHY IN PATIENTS WITH MYOCARDIAL INFARCTION J~inos Mester, Tam~s Forster, Mild6s Csan~dy, L~szl6 Csernay. Albert Szent-Gy6rgyi Medical University, Szeged, International Medical Centre, Szeged, Hungary
Aims: 1) to assess the spontaneous recovery of wall motion (WM) and thallium (TL) uptake at 3 months after acute myocardial infarction (MI); 2) to compare the value of restredistribution (RR) TL SPECT and low-dose dobutamine echo (LDDE) to predict the late spontaneous recovery of WM. Methods: 23 consecutive patients were studied with RR TL SPECT and LDDE at discharge and with RR TL SPECT and rest echo at 3 months. A 16-segment matched analysis was done. Viability was judged as absent if TL uptake was < 50% of peak activity and/or there was no improvement in WM during LDDE. Results: 31/89 dyssynergic segments at discharge recovered function at 3 months. TL uptake slightly improved from 48% (95% CI 44-53) to 43% (95% CI 39-47). Prediction of WM recovery based on the presence of viability was: Sens Spec PPV NPV RR TL 71 43 40 53 LDDE 84 86 76 91 Conclusions: 1) a spontaneous recovery of regional WM 3 months after MI occurs in 1/3 of dyssynergic regions, parallel to a slight improvement of "I'L uptake; 2) LDDE, but not TL SPECT, is an accurate predictor of regional WM recovery.
The noninvasive identification of coronary lesions in patients with myocardial infarction is a difficult problem. We investigated 23 patients with myocardial infarction and significant narrowing on 40 coronary arteries. Symptom and heart rate limited dobutamine (DOB) stress was performed (5-10-20-30-40-40 ~g/kg/min, 4x0.25 mg atropine if necessary). SESTAMIBI myocardial perfusion SPECT (SESTAMIBI) was performed according to a one-day protocol (200 MBq at stress, 750 MBq at rest). Echocardiography was evaluated by simultaneous cineloop projection of the views each at baseline, low dose and maximum dose. SPECT study was evaluated under combined consideration of the slices and the quantitative bull's eye. In the identification of individual lesions, echocardiography had a sensitivity of 26/40=65%, and a specificity of 23/29=79%. The values for SESTAMIBI were 33/40=83% and 20/29=69%. In conclusion in patients with myocardial infarction DOB stress echocardiography has higher specificity and SESTAMIBI has higher sensitivity for detection of individual coronary lesions.
P07-154
P07-156
Withdrawn
COMPARATIVE INVESTIGATION OF LEFT VENTRICULAR WALL MOTION AND REGIONAL WALL THICKENING WITH CINE MRI AND GATED SPECT IN PATIENTS WITH MYOCARDIAL INFARCTION Jfinos Mester, Tam,is Forster, E6rs M~tt6, l.~szl6 Csernay. Albert Szent-Gy6rgyi Medical University, Szeged, International Medical Center, Szeged, Hungary Cine MRI and gated blood pool SPECT (GASPECT) were performed in 17 patients with myocardial infarction and in 4 controls. MRI was performed on a 0.5T device (FA=50 ~ TR=40ms, TE=7ms, 16, 5mm thick midventricular short axis images per cardiac cycle). Enddiastolic (ED) and end-systolic wall thicknesses (WT) were measured manually. Fourier phase and amplitude values of GASPECT were displayed in bull's eye format and wall motion was classified as normal, hypokinetic, akinetic or paradox. The ED WT was between l l . 6 + 3 . 0 m m (for normal segments) and 13.6+3.9mm (for akinetic segments) without a significant difference between groups. The systolic wall thickening in abnormal segments was reduced (5.8+3.3mm vs. 0.5+3.9mm, p<0.001), with a further reduction in paradox areas as compared with akinetic segments ( 0 . 1 5 + l . l m m vs. -1.7+2.5mm, p<0.01). The combined use of cine MRI and GASPECT provides detailed information on regional myocardial kinetics and may be especially useful when the quality of 2D-echocardio~raphy is suboptimal.
$39
$40
Abstracts M o n d a y a f t e r n o o n , A p r i l 24, 1995
JOURNAL OF NUCLEAR CARDIOLOGY M a r c h / A p r i l 1995, Part 2
P07-159
P07-157 M O N D A Y P M A P R I L
Myocardial ~,gmentuff Cardiomyopoth?
Viability
Patterns
in
Patients
with
Is(heroic
MYOCARDIAL ISCHAEMIA DETECTION: 99mTc-SESTAM1BI ECHOCARDIOGRAPNHYDURINGDOBUTAMINESTRESS.
VERSUS
O, Masoli, N. Perez Balifio, A~ Merette, A. Di Leva, F Otero, D, (ragnolino. Hospi.~.l Argerich Universidad de BuenosAires - BuenosAires, Argentina
G. Cantlnho, A. Perelrloba, A.I. Santos, M. Flliza, L. Olivelra, E. Dlas, M.G. Lopes, F. Godlnho. Institute de Medlclna Nuclear and UCIM/Med IV, LA3 CCUL Hospital de Santa Maria, Llsbea -Portugal
Objeaires: IdentiGc~un of normal, [schemic, stunned, hibernated, ,~, necratic 'segmenter/ ~rns', i~ ~ent~ ~ith ~siti~ or rmga~ve LVEF responseto Amm,~n~ (~,md. Metbadr: 20 ~tients (~) with CAO and previous myocardial infarctions and LVEF < 40 %, were oras~ly enrolled. Planar Thallium 201 e~cersisestresspeffosion images (S TI),4 h(s redistdb~on, and reinje~on (Ri) protocol was done. RN.~ Lu were obtained at rest, and 20 min~s d~r ] rag/k9 i.v. at/~mrhahn. Ih furiously6e~nibed~,mrresl~r~ was tonsider~ positive when LVEF increased at least 30 % above the re~'t value. Six segments (sg) (Septel, Apical, Inferior, Posterior, Lateral, and Anterior) were consideredin wall motion (WM) analysis using LAG and anterior views. WM was classified~.~ normal (NI) or abnormal (AbN)~ S_T/sg as Hi or hbN, whereas 9 images us improved (I) or having no changes (Hth). ~ were dividedin two groups: GroupA (6,4): Positiveresponseto Amr 7 pts (42 seg), and GroupB (GB): Negate response13 pts (78 seg). "Segmentary pattern' was classifiedas 'Normal' (Nl restWM I HI s TI / Nchn Ri), 'lschemk' (NI restWM/AbN S TII I Ri), 'Stunned" (AhN rest WM / NI S_TI / Nth Ri), "Hibernated' (AbN restWM / Abt,I S Ii/ I Ri) or 'Necrotic' (AbN restWM / AbN 511 / NL'hRi). Irem~ts: GA (n=42 ~Q) GB (n~78 ~) Chi Square Normal 19 % (8/421 8 % (6/'/8) pns 2 % (2/78) pns Isthemic O% Stunned 26 %'(i'i142) 15 % (12/78) pns p = .06 Hibernated 50 % (21/42) 31% (24/78) IpnS Netrofit i 'S % (2/42) 44 % (34/78) p < .001
We have used stress dobutamine to compare echocardiography (Echo) with 99mTc-Sestamibi (MIBI). 87 patients (pts) were studied, 74 males and 13 females, -57.4++10 years, 56 pts with previous myocardial infarction and 31 with angor; 36 pts had coronariography. Pts were infused with dobutamine until maximal dose of 40mg/kg/min or a new regional wall motion abnormality (RWMA) was detected by Echo or if standard clinical criteria appeared. No major side effects were referred. During the infusion Echo study was performed and 15 mCi of MIBI was administered at test end. Rest SPECT was performed at 48 hours. MIBI and Echo were analyzed qualitatively, considering 12 segments of left ventricle. We considered two lesions types: necrosis= irreversible M1BI lesions=stress and rest Echo RWMA and isehaemi~reversibleMIBI lesions=stress Echo RWMA. Of 1044 segments analyzed, 78% had the same classification. The anterior wall was the most discordant (73%).The most concordant studies were in the patients without previous infarction (86%). For myocardial isehaemia, we found only 24% concordance. Coronariography results: 36 pts with significants lesions in 49 vessels (lesion >- 70%) The global coronariography/MIBI concordance was 82% and 62%for Echo. Our results show a poor match in the detection of ischaemie myocurdiam, the main purpose of the method. No statistical differences related with the infarction localization were found. In pts without previous myocardial infarction we have obtained better results, perhaps because the valorization of RWMA is easier, which may account for the principal indication for s~ess Echo.
CONCLUSIONS: Analysis of regional wall motion at rest, and slress - reiniscfion TI 201 porfusionimages, could be usefulto identify segmentswith different fundional status. Necrotic myocardial segmentarypattern was predominantly associatedwith negative responseto amrinane.
P07-158
P07-160
DIRECT COMPARISON OF LOW-DOSE DOBUTAMINE E C H O C A R D I O G R A P H Y AND T H A L L I U M SPECT FOR DELINEATION OF M Y O C A R D I A L VIABILITY
DETECTION OF VIABLE MYOCARDIUM BY CONTRAST ECHOCARDIOGRAPHY AND REST 99mTc-MIBI SPET. A PRELIMINARY STUDY
J-L. Vanoverschelde, B.L. Gerber, T. Marwick, A-M. D'Hondt, W. Wijns, J.A. Melin, University of Louvain, Brussels, Belgium
G . R u b i n i , S . l l i c e t o , F . L a u r i e r o , D . R u b i n i , L. G a l i u t o , L. Sorgente, M. L e p e r a P . R i z z o n , A. D ' A d d a b b o . Depts. of Nuclear Medicine, University o f Bari- Italy
The accuracy of low-dose dobutamine echocardiography (DbE) and exercise- redistribution- reinjection thallium (TI) SPECT for prediction of myocardial viability was studied in 52 patients (pts) with coronary disease and regional LV dysfunction undergoing revascularization (RVS). Recovery of function was evaluated by echo 5 + 3 months after RVS. Wall motion was graded in 16 segments from normal (1) to akinetic (3). At tbllow-up, 32/52 pts were considered to have viable myocardium based on improved wall motion in -> 2 adjacent akinetie segments and no deterioration of global LV function, while 20/52 pts had no viable tissue and further increased LV volumes. An improved wall motion in ~ 2 adjacent akinetic segments during DbE (10 /~g/kg/min) correctly identified 88% of the pts with and 75% of those without viable myocardium. Overall accuracy was 83%. With TI, visual redistribution had a sensitivity of 78 %, a specificity of 35 % and an accuracy of 62 %; quantitative redistribution (increase in TI uptake >10% from exercise to redistribution or reinjection) had a sensitivity of 50%, a specificity of 45% and an accuracy of 48%; and a > 5 0 % TI uptake at reinjection on adjacent short-axis crosssections had a sensitivity of 75%, a specificity of 70% and an overall accuracy of 73% (NS vs DbE). Thus, both DbE and quantitative TI SPECT have comparable accuracy for identification of reversible dysfunction in patients with chronic LV dysfunction due to coronary artery disease.
Two dimensional echocardiography (2DE) evaluates myocardial d y s f u n c t i o n s and, d u r i n g i n f u s i o n o f L o w D o s e D o b u t a m i n e (LDD) r e c o g n i s e s h y p o - a k i n e t i c M y o c a r d i a l S e g m e n t s (MS) with contractile reserve. Myocardial Contrast Eechocardiography ( M C E ) w i t h intracoronary i n j e c t i o n of a s o n i c a t e d contrast medium gives information about myocardial microvascular integrity. From intraceUular uptake of 99mTc-MIBI it is possible to obtain the regional perfusion pattems. To evaluate i f there is a 99mTc M I B I uptake in post-infarction dysfunctioning M S with contractile reserve and m i c r o v a s c u l a r integrity, we studied 6 pts w i t h A M I (4 anterior, 1 l a t e r a l and 1 posterior). All pts underwent 2 D E monitoring, L D D (up to 10 m c g / k g / m i n ) at day 5, M C E at the time of coronary angiography, and rest 99mTcM I B I S P E T w a s performed w i t h i n 2 days. A 16 s e g m e n t model was used to analyse the data. 34 o f 96 M S w e r e h y p o or akinetics at first 2DE. 19 MS s h o w e d L D D improved kinetic (+), M C E microvascular integrity (+) and 99mTc-MIBI uptake (+); 8 MS L D D no i m p r o v e d k i n e t i c (-), M C E no m i c r o v a s c u l a r integrity (-) and no 9 9 m T c - M I B I (-); 4 M S were L D D -, but M C E + and 9 9 m T c - M I B I +. 2 M S L D D +, M C E + and 99mTcM I B I -; 1 MS L D D -, M C E - and 9 9 m T c - M I B I +. There is good agreement (91,2%) between M C E and rest 9 9 m T c - M I B I uptake, and a m o n g the three techineques (79,4%). 9 9 m T c - M I B I uptake in h y p o - a k i n e t i c M S is a m a r k e r of postinfarction m y o c a r d i a l viability.
JOURNAL OF NUCLEAR CARDIOLOGY Volume 2, N u m b e r 2, Part 2
Abstracts Monday afternoon, April 24, 1995
P07-161
P07-163
THE COMPARISONOF THE DOBUTAM1NEECHOCARDIOGRAPHY AND DOBUTAM1NE RADIONUCLIDE VENTR1CULOGRAPHY FOR THE DIAGNOSISOF CORONARYHEART DISEASE E.Altmyay, AOguzhan, KMK~r, TKurak EOzalp, HKtsac~k O.Ara~ K.Ozdemir, AAkin Ankara UnivelsityFa,mlty of Medicine IXp~maent of NuclearMedione06t00 Ankara-TURKIYE The aim of the studyis to compareto diagnaostlcpotentialof dubu,~nine(IX)B) smmswith echocardiography(ECHO) and radionudidew.nmcul%~'aphy(RV). We have I~fo~med ECHO and RV during DOB inlhsionin 63 panents(pls) who underwent corunaIy angm'o'aphy(CAG) tbr the diagnosmof" coruna~r art~y disease(CAD). DOB was adminislrated~4B1an ingxsionpump at each dose from 5 lag/kg/minto a ro~,c~num40 ~t~k.smm the dose increasewas terminated when pts reached 85% of age p~echctedm~ximumheart rate or ischeammfindingsobserved. If at~ u r r , dose, adequate heart rate was not reached and no myocardi~d~ w~s induced,alropi~ was injected0.25 mg up to lmg ix
OPTIMAL USE OF 99mTc-MIBI SPECT AND DIGITAL MULTIPLANE TRANSESOPHAGEAL 2D-ECHO PERFORMED DURING HIGH DOSE DOBUTAMINE AFTER ACUTE MYOCARDIAL INFARCTION.
P07-162 Tc99m=MIBI-SPET CORONARY A R T E R Y
G. Rubini, C. Memmola, S. Iliceto, F. Laurfiero, D. L. Sorgente, D. Rubini, M. Lepera P. Rizzon, A. D'Addabbo. Nuclear Medicine Dept.Bary University, Italy. High dose dobutamine ~ during echocardiography or perfusion imaging has recently been used in post-MI pts stratification. We tested the accuracy of multiplane transesophageal echocardiography (MIE) performed simultaneously to 99m-Tc NIBISPI32T during HDDfor the evaluation of ischemic risk in 12 pts with previous MI undergone thrombolysis and coronarography. D was intravenously administred at increasing doses, up to 40 g/kg.min. The Stress-Rest MIE images of LV wall motion were digitally stored. At peak D-infusion 740 M B q of 99mTc1VIBIwere injected and SPET performed after 2h. Day after rest N:F_L-Twas performed. LV was divided into 14 correspondig segments and the 168 segments available for comparative analysis were defined at ~,132T and MIErespectively: a) normal (N), in the absence of p e r f u s i o n defects (PD) or WM abnormalities (A); b) infarcted (IN) in the presence of fixed PD or akinesia; c) ischemic (IS) when reversible PD or new W M A developed during HI]] The examined segments were classified with HDI)SPEF analysis in 1(/5 N, 33 IN, 30 IS; of these HEDMIE correctly identified 101N, 32g,1, 25 IS, thus showing to be accurate (sensitivity=83%, specificity=96%) in detecting the SFETidentified myocardial ischemia. Simultaneous D test evavualtion of LVcontraction and perfusion is feasible. The S/R test showed equivalent diagnostic potential if associated to digital MIE or SPETin post Ivllevaluation of residual myocardial ischemia.
P07-164 AND MRI DISEASE.
IN
CHRONIC
M . L . D e R i m i n i , S . C a p p a b i a n c a , L.Mansi,*P. Spadaro, F.Di Gregorio,T. Cinque. Inst.of R a d i o l . S c i e n c e - N u c l . M e d . a n d * C a r diology-Med. School II U n i v e r s i t y - N a p l e s . Kinetic function in coronary artery disease is s t r i c t l y r e l a t e d to p e r f u s i o n defects. We studied i0 p a t i e n t s (pts), affected with d i l a t a t i v e ( D C ) and left ventricular ( L V ) aneurysm, with Tc99mMIBI-SPET (MIBI) and MRI. LV was divided into 6 segments(S) and e v a l ~ a t e d with a 4 steps score (from 0 as normal to 3 as fibrosis) r e l a t e d to MIBI uptake and MRI LV kinetic. SCORE n (% ) 0 1 2 3 MIBIstressS:15(25) ; 6(10) ; 18 (30) ;21 (35) MIBIrest S:22 (36.) ;12 (20) ;8 (13.) ;18 (30) NRI S:23(38.) ;9(15) ;12(20) ;16(26.) MRI tissutal c h a r a c t e r i z a t i o n revealed normal tissue in 22 S (36%), fibrosis in 19 S (27%) and no clear evidence about ischemia. NRI showed a g r e e m e n t only with MIBI rest. Residual ischemla is revealed by MIBI stress.
SIMULTANEOUS EVALUATION OF ADENOSINE Tc-99m MIBI TOMOGRAPHY AND ECHOCARDIOGRAPHY IN PATIENTS WITH CORONARY ARTERY DISEASE. Alberto Cuocolo, Emanuele Nicolai, Leonardo Pace, Bruno Ricciardelli, Antonio Nappi, Pasquale Sullo, Fiorenzo Squame, Stefania Cardei, Luigi Argenziano, Marco Salvatore. Universit& "Federico I1" and Istituto Nazionate dei Tumori, Napoli, Italy. Recent studies suggest that adenosine test associated with Tc99m MIBI imaging or echocardiography (Echo) has good diagnostic accuracy for detecting coronary artery disease (CAD). We performed simultaneous adenosine Tc-99m MIBI SPET and Echo in 22 patients (21 men, mean age 52_+6 yrs) undergoing coronary arteriography for diagnosis and evaluation of CAD. Adenosine (140 gg/Kg/min) was infused iv for 6 min. Tc-99m MIBI (740 MBq) was injected at 4 min and a rest study was performed on a separate day. Echo was performed in control conditions and during adenosine infusion. Adenosine induced a significant (p<0.01) increase of heart rate. Blood pressure was not different after adenosine compared to rest. Interpretation of all imaging results was performed by independent blinded observers. One patient had normal coronary vessels, 12 patients one-vessel, 4 two-vessel and 5 three-vessel disease (>50% coronary stenosis) on coronary angiography. The sensitivity, specificity and predictive accuracy for detection of stenosed vessels were 83%, 74% and 79% for Tc-99m MIBI and 77%, 61% and 70% for Echo. Thus, these preliminary results suggest that adenosine Tc-g9m MIBI SPET is more accurate than adenosine Echo in the diagnosis and localization of CAD.
S4I
$42
Abstracts Monday afternoon, April 24, 1995
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
P07-165
P07-167
O
COMPARISON OF FIRST-PASS MRI AND 2~ SPECT IN MYOCARDIAL INFARCTION.
N D A
Jan T. Keijer, Albert C. van Rossum, Machiel J. van Eenige, Jeroen J. Bax, Frans C. Visser, Cees A. Visser. Free University Hospital Amsterdam,ICARVU and ICIN,Netherlands.
ASSESSMENT OF RIGHT VENTRICULAR MOTION WITH MAGNETIC RESONANCETISSUE TAGGING AND SLICE FOLLOWING
Y
With subsecond magnetic resonance imaging (MRI) techniques it is possible to image the first pass of the contrast agent Gd-DTPA through the heart, after a rapid central bolus injection. Flow parameters like mean transit time (MTT) can be derived from myocardial signal intensity-time curves, according to indicator dilution theory. Methods: Seven pts with a recent (1 to 9 months old) ~ l infarction underwent first-pass MRI, resting 2~ (T1-201) SPECT and coronary angiography. 1 pt had l-vessel disease (l-v), 5 2-v, 1 3-v. Short-axis images were obtained at the basal (5 pts), midventricular (7 pts) and apical (4 pts) level. MTr values were obtained from 8 circumferential myocardial regions of interest. Circumferential profiles were constructed and quantitatively compared with resting TI-201 SPECT, Results: In all pts, maximum MTT of midventricular regions associated with the ECG infarct location was prolonged (>20 %) compared to control regions. Maximum MTT of regions with angiographic amnesia was also prolonged in allpts. Sensitivity of MRI with TI-201-SPECT as the gold standard was 71% and specificity 59% (n=56 regions, midventricular level). Circumferential and longitudinal extension of MTI" obtained from different levels showed logical continuity as easily visualized in a bull's eye plot. Conclusions: First-pass MRI can identify regions of myocardial infarction corresponding with defects on resting TI-201 SPECT. Multislice MR imaging provides insight in the spatial extension of infarcts.
M
P M A P R I L
2 4
E Nagel, M Stuber, SE Fischer, P Boesiger, R Simon, OM Hess, Department of Cardiology, University Hospital Kiel, Germany With MR tagging the complex motion pattern of the right ventricle (RV) can be exactly followed. Slice following methods allow to measure exactly the same myocardial region throughout the cardiac cycle. To evaluate RV motion we examined 5 volunteers. A 2-dimensional cartesian tagging grid was placed on 3 short axis slices of the heart using MR tagging. Movement of any points within the myocardium could be evaluated with a semiautomatic computer system. In contrast to the left ventricle (LV), the RV did not contract towards ist center of gravity but towards the LV with the lateral segment contributing significantly more to contraction than any other segment. In RV short axis views chamber area decreased 32+10% at the heart base, 44+8% at the equator and 35+9% at the apex. Short axis contraction in the RV was significantly lower than in the LV but is made up for by higher long axis contraction. Conclusion: The cardiac motion of the RV is characterized by a systolic movement towards the LV with maximal motion of the lateral wall and a larger effect of long axis contraction as compared to the LV. Slice following allows accurate assessment of the same myocardial tissue during the cardiac cycle in spite of this large long axis component.
P07-166
P07-168
Assessment of Myocardial Viability by Low-Dose Dobutamina-MRh Comparison to FDG-PET.
SEGMENTAL VIABILITY AFTER MYOCARDIAL INFARCTION EVALUATED BY THALLIU VI-201 REINJECTION WITH PATENCY VESSEL ANGLOGRAPHY AND ECHO-DOBUTAMINE CORRELATION
Frank M. Baer, Eberhard Voth*, Peter Theissen*, Christian A. Schneider, Edand Erdmann, Harald Schicha*, Udo Sechtem. Klinik Ill for Innere Medizin and Klinik for Nuklearmedizin*, University of Cologne, Germany. Dobutamine induced systolic wall thickening (D-SWT) and preserved end-diastolic wall thickness (DWT) measured by magnetic resonance imaging (MRI) may be used as evidence for viable myocardium as assessed by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). Thirtyfive patients with myocardial infarcts (infarct age _>4 months) underwent restand dobutamine-MRI (10 gg dobutamine/min/kg) and FDG-PET studies. Segmental analysis was performed in corresponding MRI and PET short axis tomograms. MRI was defined viable if a basally akinetie segment had D-SWT ->1 mm or DWT was _> 5.Smm. Segments were graded viable by PET if FDG-uptake was >_50% of the maximum FDG-uptake. D-SWT and DWT yielded good sensitivities (81%/72%) and specificities (95%/89%) in predicting residual glycolytic activity. Grading a segment viable based on both, D-SWT or DWT yielded a sensitivity of 88% and a specificity of 87% for FDG-PET defined metabolic activity. Thus, viable myocardium is characterized by preserved DWT and D-SWT. Both parameters should be evaluated to maximize the sensitivity of MRI in the detection myocardialviability.
H.Morais, C.Fonseca, G.Cantinho, J.S.Nogueira, A.Aleixo, A.Sales Lufs. Medicine Deparlment, S.Francisco Xavier Hospital, Lisbon, Portugal In order to evaluate the viability segment diagnostic value of Thallium-201 reinjection (TLR), we stu~ed 17 pts., 14 males and 3 females, mean age 55.4 year.,, with previous myocardial infarction (MI) (anterior-2; se,,tal-4; inferior-10; posterior-l). Nine patients were submitted to thrombolytic therapy. Reperfusion criteria (RC) were also analyzed. All pts underwent coronary angiog~ aphy. MI segmental perfusion TLR was divided in fix,.:'.d (F) and reversible (R), being correlated to the MI ~elated vessel (V). The MI related vessels were divided in 3 groups: occluded (O), patent (P), retrograde filling (RF). Echo-low-dose-dobutamine .(ED) in MI segmem was evaluated as segmental motion m~provement (I) oi nonimprovement (N-I). Results: Of the 17 pts, 12 pts (70%) TLR-F detects matched O-V. R defects with P and RF V and all were matched with ED results. Of the remiining 5 pts, 3 ED were concordant with TLR, both were discordant with vesselpatency. Of the last 2 pts. with discordant TLR and ED, 1 pt RC favored viability and ED result. In the last one, depressed ventricular ft,action favored F-TLR result. Conclusions: 1- TLR is a reliable method to evaluate viability comparing MI vessel angiography. 2 - The use of both methods -TLR a~:d ED - may improved diagnostic reliability of viability ()5/17, 88%).
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday morning, April 25, 1995
P07-169
P07-171
NON-IMAGING ANGIOCARDIOGRAPHIC MONITORING (CARDIOSCINTTM) AND ECOCARDIOGRAPHYFOR EVALUATING LEFT VENTRICULAR FUNCTIONIN PATIENTSWITH CORONARY ARTERY DISEASE. PRELIMINARYDATA.
Tc-99m SPET TETROFOSMIN VS TI-201 SPET REST/ REDISTRIBUTION AND DOBUTAMINE ECHO IN VIABILITY ASSESSMENT AFTER AMI IN SINGLE VESSEL CAD
Carla Silenzi,Nino Ciampani, Marco Mazzanti, Carlo Costantini, Giovann: Cianci, AugustoPurcaro. Lancisi Heart Hospital, Italy.
R.Benti, U.La Marchesina, A.Finzi, G.Marotta, A.Bnmo, C.Canzi, M.Caslellani, E.Reschini, S.Perlini, C.Sdraiati, P.Gemndini. Nuclear Medicine Dept.- Ospedale Maggiore, Milan, Italy
CardioacintTM (Oakefield, U.K.) is a previously described non-imagin~ nuclear techniquethat continouslymonitorizeleft ventricularsysto-diastolic function using a miniaturizedgamma-cameraover left ventricleregion, Aim of the study was to assess the usefulnessof Cardioscint to seriatelymeasure left ventricular function in patients (pts) with acute coronary sindrome (ACS). To this end we comparedCardioacint with ecocardiographyin term~ of analyzing systolic and diastolic functionparameters.We evaluated 12 pts (8 males and 4 females, mean age 58.7• years) with ACS in absence el valvular or congenital disease in normal sin us rythm and withou t arrbythmias Each patient was undertaken to angiocardiographic monitoring followec
within 1hourby twodimensionalandDopplerechocardiographicexamination Cardioacint was performed previous injection of stannose pyrophosphate and 20 mCi of 99m-Tc. End-diastolic volume (EDVc), end-systolicvolume (ESVc), ejection fraction (EPc), peak filling rate (PFRc) and one-thir~ diastolic filling(F3c)werestudied.Tothe two dimensionalechocardiograpb) we examined the left ventricular systolic function with ejection fractior (EFe) determining ventricular volumes from apical four chamber with the single plane area lenght method. From inflow pattern recorded in the apica~ for chamber view (with sample volume positioned within the left ventricle near the free edges of the mitral leaflets) we evaluated by pulsed Dopplel echocardiography, diastolic filling using early flow peak velocity (E), late peak velocity (A), E/A ratio, acceleration time (AT) deceleration time (DT) total flowvelocityintegral (FVI)and at one-thirdof diastole(E3e) and E/FV] ratio (PFRe).RESULTS: the EFc was 0.47i'O.12 and the EFe was 0.48i'0.~ (r=0.96). By diastolic filling study we observed F3c of 30.1+13.4% and F3r 41:t:9.5% (r=O.93).PFRc was 4.53i-0.78 stroke vol/sec and PFRe 4.87+1.4~ strokevol/sec(r=O.72).CONCLUSIONS: weobtained a verygoodcorrelatiot between Cardioacint and two-dimensionalechocardiographic data in tl~ study of left van~cular systolic function; good correlation was found it diastolic fillingmeasurementsamong two methods.
Fourteen patients with stenosed (>70%) LAD or RC artery (normal Cx) and previous infarction (1-6 months) in vessel related myocardium were studied by TI-201 at rest (TI-RS) and redistribution (T1-RD), Tc-99m Tetrofosmin at rest (TF-RS), baseline echo (E-BA) and low dose (5-10 pg/Kg/min) Dobuta'mine echo (E-DO). SPET assessment of perfusion was obtained both quantitatively and qualitatively and waU motion before and during E-DO was evaluated in 16 segments for each patient. Abnormalcy rate of perfusion was 30, 25 and 25% of 224 segments for TI-RS, TI-RD and TF-RS respectively. Perfusion score improved between TI-RS and TI-RD in 23/69 abnormal segments (33%), as expected, and in 24/69 segments (35%) between TI-RS and TF-RS. TF uptake in segments with Thallium redistribution (RED) ranged from 100 to 36% (mean 59%); in segments without RED 80 to 19% (mean 46%). Wall motion improved during E-DO in 10% of the h.vpocontractile segments. TF uptake in these segments was 87f17~ in segments with no E-DO response TF uptake was 74*21%. Our data support the aptitude of TF-rest SPET imaging in the evaluation of residual viability in infarcted patients with LAD or RC single vessel disease. Best agreement between TI-201 redistribution and wall motion improvement after low dose E-DO was obtained in hypoperfused segments with 54 to 62% of normal Tetrofosmin uptake in Cx artery supply territory.
$43
T U E S D A u P M
P07-170
Tuesday AM, April 25
INCREMENTAL DIAGNOSTIC VALUE OF DOBUTAMINE STRESS ECHOCARDIOGRAPHY (DSE)AND Tc-99m MIBI-SPECT FOR DETECTION OF CORONARY ARTERY DISEASE (CAD).
$25-172 to $32-204 and P08-205 to P13-263
V.Di Bello, CR.Bellina, E.Gori*, L.Talarico, G. Boni, N.Molea, C.Di Muro, E.Magagnini, F. Matteuoci, M.T. Caputo, E.Lazzeri, D. Giorgi, G. Santoro, R. Bianchi, C.Giusti. II Clinical Medical Institute, Nuclear Medicine, University of Pisa; * Statistic Department, University of Florence, ITALY. The incremental diagnostic value of DSE and MIBI-SPECT, for the evaluation of presence and extent of CAD, was assessed with ordered logistic regression and receiver-operating characteristic curves in forty five consecutive patients (33 males and 12 females: 53 • 6.8 y.), referred for a moderate level of pre-test probability for CAD; none of patients bad prior myocardial infarction. DSE was performed following standard protocol; one minute before the stop of test, an injection of 740 MBq of MIBI was i.v. infused. The stress MIBI SPECT imaging were acquired one hour after stress. For resting study patients were injected of 740 MBq of MIBI between 24-36 b after stress. Coronary angiography was performed in all patients (significant coronary stenosis >50%). Clinical data (sex, age, presence of chest pain, positivity of ECG during tes0 were 64.3%• 10.7 accurate in prediction of CAD. The addition to clinical model of DSE data (wall motion stress and rest score index and relative difference) yielded a diagnostic accuracy of 81.4%+4.3 (p<0.159); whereas the addition to clinical model of SPET parameters (perfusional stress and rest score index and relative difference) improved diagnostic accuracy to 92.3% -+ 5.5 (p<0.003). Both nonmvasive methods for detection of CAD (DSE and SPECT) showed a good diagnostic accuracy especially when tests-derived parameters were combined with clinical dam. SPECT model showed an higher sensitivity essentially in presence of a lower exent of CAD.
$25-172 SAFETY O F 1SOPROTERENOL STRESS TEST ASSOCIATED WITH NUCLEAR TECHNIQUES, Ph. P6zard, Ph. Bienvenu, A. Furber, Ph.Geslin. J. J Lejeune, A. Tadei, P. Jaltet, C H U Angers, France. Isoproterenol (IPNA) stress test may be an useful alternative to Dobutamine test but its safety' remains controversial. We report the side-effects observed on 800 consecutive patients (pts) undergoing IPNA stress myocardial scintigraphy (n = 449) or radionuclide angiography (n = 351). 344 pts had a proven CAD, 68 pts had three-vessel disease or left main artery stenosis. Ejection fraction (EF) was < 0.30 in 54 pts. - Methods : After Atropin IV 1 rag, IPNA was infused in incremental doses since heart rate was _>130 bpm. - Results : Death, acute cardiac failure, life-threatening arrhytmias did not occur. There is no relationship between arrhytmia and C A D or low EF presence. side-effects N % ST-segment depression _> 1,5 m m 150 19 non-Q-wave in farction 1 0.1 paradoxal bradycardia 17 2 nonsustained VT 5 0.6 PVCs (> 5 mn) 124 15 Supraventricular arrhytmias 27 3.4 Thus, IPNA stress after atropin is safe. It is performed faster than currently described Dobutamine stress test.
A P R I L
$44
JOURNAL OF NUCLEAR CARDIOLOGY March/April 1995, Part 2
Abstracts Tuesday morning, April 25, t995
$25-173
$25-175
COMPARISON BETWEEN Tc99mTETROFOSMIN AND
Tc99mTetrofosmin is a new technetium labelled lipophilic cation evaluated for use as a myocardial perfusion tracer. Biodistribution studies indicate better heart-to-adjacent organ biokinetics than for Tc99mMIBI. To compare the uptake relation between this 2 tracers 16 to 21 mCi of Tc99mTetrofosmin and Tc99mMIBI were injected at rest 72 hours apart in 10 volunteers (mean age 58+_12 years) with no history of cardiac diseases (left ventricular ejection fraction 59_+5%) who were starting a programme of radioimmunotherapy for tumors. Myocardial SPECT images were obtained 60 minutes after the rest Tc99mTetrofosmin injection and 90 minutes after the rest Tc99mMIBI injection. Regional uptake assessed quantitatively using a 16 segment model. High quality SPECT images with good myocardial delineation and adequate contrast between the heart and background were obtained with both tracers. Myocardial count rate were 5.4_+1.4 vs 5.2_+1.9 counts/pixel/rnCi for Tc99mTetrofosmin and Tc99mMIBI respectively, (p=NS). Tc99mTetrofosmin and Tc99mMIBI heart/lung ratios averaged 2.4_+0,5.and 2.6_+0.4, (p=NS) while heart/liver ratios were 1.2_+0.3 and 1.2_+0.4, (p=NS). Regression analysis between all 160 myocardial regions was r=0.83, p<0.001. Coefficient of variation uptake among all myocardial regions was similar with both Tc99mTetrofosmin and Tc99mMIBI (9.6_+2.2 vs 9.9_+2.7, p=NS). Thus, using an early imaging protocol resting quantitative Tc99mTetrofosmin uptake distribution showed to be similar to that of Tc99mMIBI.
BIODISTRIBUTION AND PRELIMINARY CLINICAL EVALUATION OF 99mTc-NOET AS MYOCARDIAL PERFUSION TRACER. M. Git, anti, A. Duatti, L. Uccelli, C. Cittanti, P. Colamussi, R. Pasqualini, D. Fagret, F. Chossat, D. Bekhechi, P.Y. Marie, F. Brunotte, D. Le Guludec, A. Bertrand, J.E. Wolf, J. Machecourt, M. Comet, A. PiffaaeUi. Preliminary biodistribution data in man of Bis[(N-ethyl, N-Ethoxy) dithiocarbamate] nitrido technetium (V), were obtained, and the possible clinical role of this tracer in diagnosis of CAD was investigated. The tracer was extracted rapidly from blood (skeletal muscles (36%), lungs(24%), heart (5.2%), liver (21%) and spleen (9%). The heart uptake varied from 5.2% at 30' to 4.8% of the injected dose at 4 hrs. There was an initial lung uptake (24% at 30') that showed a T 1/2 of 11'. The liver uptake (at 30', 2 and 4 hrs) was respectively: 21%, 27% and 20% of the injected dose. To assess its possible role in CAD diagnosis, 15 mCi of TcN-NOET were injected to 25 patients after exercise and two SPECT imaging sets were obtained. Images, acquired at 0,5 and 4 In-s,were compared with stressredistribution 201-Thallium (TI) SPECT imaging (2.5 mCi) and with coronary angiography. TcN-NOET vs TI concordance was 92%; the overall sensitivity and specificity vs coronary angiography were respectively 79% vs 68%, and 83% vs 83%. The overall agreement for the presence of disease in individual coronary arteries was 96%. The comparison of delayed images showed in 11 patients an initial defect with normalization 4 hrs post injection with TI and Tc-N-NOET and in 4 patients a persistent defect. In 8 other patients images were normal. In the 225 segments (9 segments for each patient), there was a good agreement for normal versus abnormal perfusion with concordance in 211/225 segments (94%).The tracer showed: 1) rapid, high and stable heart uptake, 2) biodistribution features suitable for imaging, 3) good diagnostic accuracy, in comparison with TI and coronarography, 4 ) presence of redistribution.
S25-174
S25-176
TWO-STEPTARGETINGOF EXPERIMENTALINFARCTIONWITH
INTERACTION OF 99mTcN-NOET WITH BLOOD COMPONENTS IN ISOLATED, PERFUSED RAT MYOCARDIUM: A POTENTIAL MECHANISM OF RADIOTRACER REDISTRIBUTION.
Tc99mMIBI UPTAKE MEASURED QUANTITATIVE SPECT SCINTIGRAPHY.
BY
A.R. Galassi, A. Di Primo, G. Privitera, A. Milazzotto, I. Bcllanuova, A. Galassi, S. Musumcci. Chair of Nuclear Medicine, University of Catania, Italy.
T U E S D A Y P M A P R I L 2 5
STREPTAVIDINE-ANTIBODYAND RADIOLABELEDBIOTIN. D. Ls Guludsc, M.C. Peker, M. Faraggi, A. Meulemans. Laboratoire de Biophysique,Fac. Xavier-Bichat, Paris, Francs. Two-step targeting of infarction using the streptavidine (Sav)-Biotine (B) system and In1tl antimyosin-antibody (AM) was evaluated. The myocardial uptake (autoradiography), biodisbibution, and image quality of two different AM were evaluated: In-111-DTPA-Fab (Myoscint, Centocor), and two-step Fab'2-Sav followed by In-111DTPA-B. A MI was induced in 28 rats by left coronary artery tying. 24 h after surgery, 16 rats were injected with Myescint (G1, 10 + 1 pg), and 12 rats with the conjugated Fab'2 (G2, 11 + 2 pg), followed by In111-B injection 24 h later. Anterior 5 minutes-images were acquired at 6, 12, 24, 48 h on a gamma camera (pin-hole collimator). Biodistribution and autoradiography were performed at the same times. Results: A better delineation of the infarcted area was obtained on images of G2 since the liver was never visualize& The specificity of myocardial uptake in the infarcted area was confirmed by quantitative autoradiography. The best blood to myocardial ratio was obtained at 48 h of the tracer injection for G1 and at 12 h for G2. Although absolute myocardial uptake was 8.2 times lower in G2 vs G1, the signal to noise (heart / liver) ratio was 6.9 times higher for the conjugated AM (0.19 + 0.02 in G1 vs 1.31 + 0.2 in G2, p<0.0001}. Conclusion: two-step targeting of infarction with AM and Sav-B system allows delayed injection of the tracer and imaging, which is crucial in this clinical situation, and improves image quality.
Gerald Johnson III, Kiem N. Nguyen, Adriano Duatti, Roberto Pasqualini and Robert D. Okada. W. K. Warren Medical Research Institute of Univ. of Oklahoma, Tulsa, Oklahoma, USA. The purpose of this study was to examine clearance kinetics of 99mTcN-NOET in normal rat hearts perfused with Krebs-Henseleit buffer (KHB), KHB with red blood cells (RBO and albumin (ALB) and KHB with RBC alone. Following a 1.0 mCi (37.0 MBq) bolus, myocardial clearance of 99mTcN-NOET was monitored for 1 hour using a NaI detector in 3 groups of isolated, perfused rat hearts. Group 1 served as KHB controls. Group 2 was perfused with KHB+ALB+RBC. Group 3 was perfused with KHB+RBC without ALB. Results: (mean• *=p 0.0001 from KHB) Group Myocardial Clearance Significance Group i (n=7) 0.005 • 0.004% Group 2 (n=6) 70.6 • 5.1% * Group 3 (n=3) 34.9 • 3.0% * These results indicate that 99mTcN-NOET has an affinity for binding to ALB and RBC. Thus, efflux of 99mTcN-NOET from the myoeardium to blood components represents a potential mechanism of redistribution which may explain discordant data reported in animal and human literature.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday morning, April 25, 1995
$25-177
$25-179
BIODISTRIBUTION AND AUTORADIOGRAPHIC LOCALIZATION OF I- 125-LABELED SYNTHETIC PEPTIDE FRAGMENTS IN EXPERIMENTAL ATHEROSCLEROSIS
SIMULTANEOUS ASSESSMENT OF REGIONAL FUNCTION AND PERFUSION BY TETROFOSMIN: EFFICACIES AND LIMITATIONS OF A SINGLECRYSTAL 7-CAMERA
Lu P, Zanzonico P, Lister-James J, Goldfine SM, Herrold EM, Lees RS, Lees AM, Dean RT and Borer JS The New York Hospital-Cornell Medical Center, New York, USA
Hiroshi Kobayashi, Tomoaki Nakata,, Kenjiro Miyamoto, Akiyoshi Hashimoto, Shigemichi Tanaka, Osamu Iimura. Sapporo Medical University, Sapporo, Japan.
SP4, a 2kD synthetic oligopeptide derived from apolipoprotein B, localizes in atherosclerotic plaques in experimental animals. To further elucidate its biodistribution and binding site, 24 cholesterol-fed (CF) and 20 normal (NL) New Zealand White rabbits were injected with 1-125-SP-4 and sacrificed 15-30 rain (6 NL;6 CF) or 2 hr (14 NL;18 CF) later. Autoradiograms and activity concentrations (% injected dose [ID]/gm) were obtained, Aortic uptake of 1-125-SP4 was uniformly higher in CF than in NL rabbits (p<0.05). No significant differences in %lD/gm were observed between NL and CF rabbits in other tissues. In all cases, 1-125-SP4 blood clearance was rapid (60-70% ID/lhr). Microautoradiographic analysis of CF and NL rabbits (n=2) shows SP4 accumulation in foam cells (23,517• grains/mm~ in fatty plaques vs 14,669=11,035 grains/mm2 in medial muscle [P<0.0001]). Thus, 1-125-SP4 specifically localizes in the foam cells of atherosclerotic plaques.
The clinical efficacy of combined assessment of regional wall motion (RWM) and perfusion by Tc-99m labeled tetrofosmin and a routinely used single-crystal 7 -camera was evaluated in 40 patients with coronary artery disease and 8 control subjects. Following the assessment of left ventricular RWM by first-pass angiography (FPA) and computer-assisted analysis, myocardial SPECT was performed. RWM was compared among FPA, 2-dimensional echocardiography (2DE) and contrast left ventriculography (LVG) and with myocardial perfusion. Although, compared to LVG, FPA and 2DE had similar sensitivities to detect asynergic RWM, the specificity of FAP was lower than that of 2DE (73% vs 91%, p<0.05). The agreement of perfusion and RWM scores was equivalent among the 3 methods. However, the sensitivity of FPA for detecting perfusion/contraction mismatch was lower, compared to 2DE and I.NG (4% vs 9 % vs 18%). These findings suggest that the simultaneous assessment of regional wall motion and perfusion by tetrofosmin and a singlecrystal 7 -camera has a limitation to precisely detect perfusion/contraction mismatch in coronary artery disease.
$45
T U E S D A u P M
$25-178
S26-180
USE O F T c - 9 9 m S E S T A M I B I I N F U S I O N FOR D E T E C T I O N OF H I B E R N A T I N G M Y O C A R D I U M .
COMPARISON OF INCREMENTAL PROGNOSTIC VALUE OF NUCLEAR TESTING IN MEN AND WOMEN. Rory Hachamovitch, George A. Diamond, Hosen Kiat, Ishac Cohen, J
SD Miron, R Finkelhor, R Bahler, DB Sodee, E M Bellon, Case Western Reserve University, M e t r o H e a l t h M e d i c a l Center, Cleveland, U S A To e v a l u a t e w h e t h e r a p r o l o n g e d i n f u s i o n of Tc99m sestamibi allows for v i s u a l i z a t i o n of v i a b l e m y o c a r d i u m in areas of h y p o p e r f u s e d myocardium, 25 p a t i e n t s were prospectively studied. Each p a t i e n t was i m a g e d four times in two c o n s e c u t i v e days as follows: day one: a) i m m e d i a t e l y after i n j e c t i o n of T I - 2 0 1 at rest, b) one hour after a bolus i n j e c t i o n of T c - 9 9 m s e s t a m i b i at rest; day two: a) i m a g i n g in the TI-201 w i n d o w for 24 hour r e d i s t r i b u t i o n , b) imaging after a o n e - h o u r i n f u s i o n of T c - 9 9 m sestamibi. The two s e s t a m i b i and the two t h a l l i u m studies w e r e e v a l u a t e d for p r e s e n c e of redistribution. This was p r e s e n t b o t h on the t h a l l i u m and the s e s t a m i b i s t u d i e s (concordant) in 13 cases, and a b s e n t on b o t h the t h a l l i u m and the s e s t a m i b i s t u d i e s (concordant) in 9 cases. In two cases r e d i s t r i b u t i o n was seen on the t h a l l i u m images only and in one case it was seen on the s e s t a m i b i images o n l y (discordant). Tc-99m sestamibi infusion may give i n f o r m a t i o n about p r e s e n c e of v i a b l e m y o c a r d i u m w h i c h is s i m i l a r to that g i v e n by TI-201 24h o u r imaging.
Arthur Cabico, J Gonzalez, JD Friedman, Daniel S. Berman. Cedars-Sinai Medical Center, LA, USA. To compare the prognostic accuracy, incremental prognostic value and cost of dual isotope myocardial peffusion SPECT (DIMPS) in men (M) and women (W), we identified 2592 consecutive patients (1696 M and 896 W) who underwent DIMPS and were followed for 20~ 5 months for events [cardiac death (CD), non-fatal myocardial infarction(MI)]. During this time 32 MI and 18 CD occurred in the M and 25 MI and 8 CD occurred in the W. Clinical, exercise and nuclear variables were assessed using a stepwise Cox proportional hazards model and receiver operator characteristic (ROC) cu~e analysis. This revealed that nuclear testing added incremental prognostic value in beth M and W after inclusion of the most predictive clinical and exercise variables (overall g 2 =109 in M vs. 156 in W; p<0.005; ROC area increase: 0.78 + 0.04 to 0.89 + 0.03 in W, 0.75 + 0.04 to 0.78 + 0.03 in M; both p <0.05). ROC curve analysis was also used to compare the relative discrimination of the final scan results in M and W; this revealed that nuclear testing was better able to identify high risk W than M (ROC area - 0.72 + 0.03 in M versus 0.83 + 0.04 in W; p<0.01). As a result, a testing strategy including the combined use of exercise ECG, nuclear scan and cardiac catheterization had the greatest cost saving while identifying the same number of high risk patients as other strategies examined. Also, this strategy was superior in W compa.~l to M costing 24% less per patient and stratifying high risk patients three to four times more effectively.
A P R I L
$46
T U E S D A u
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
Abstracts Tuesday morning, April 25, 1995
$26-181
S26-183
IMPROVEMENT IN HEART FAILURE SYMPTOMS AFTER REVASCULARIZATION tN PATIENTS WITH I SCHEMIC CARDIOMYOPATHYPREDICTED BY PET
SEQUENTIAL USE OF 2~ VIABLE MYOCARDIUM
Marcelo Di Carli, Farbod Asgarzadie, Heinrich R. Schelbert, Richard C. Brunken, Michael E. Phelps, Jamshid MaddahL UCLA School of Medicine, Los Angeles, CA, USA.
B.L. Gerber, J-L. Vanoverschelde, A. Bol, C. Michel, A. Robert, W. Wijns, J.A. Melin, University of Louvain, Brussels, Belgium
We assessed the relation between the magnitude of improvement in heart failure symptoms after coronary artery bypass surgery (CABG) and the anatomic extent of myocardial viability assessed by quantitative analysis of preoperative Positron Emission Tomography (PET) images. We studied 36 patients with ischemic cardiomyopathy (LVEF: 28+6%) undergoing CABG. Preoperative extent and severity of perfusion abnormalities and myocardial viability (flow-metabolism mismatch) were assessed by quantitative analysis of PET images with N-13 ammonia and F-18 deoxyglucose. The patients' functional status was determined before and after CABG using a Specific Activity Scale. The total extent of a PET mismatch correlated linearly and significantly with the percent improvement in functional state after CABG (r=0.87, p<0.0001). A PET mismatch ">18% was associated with a sensitivity of 76% and a specificity of 78% for predicting a change in functional state after CABG. Patients with large mismatches (->18%) achieved a significantly higher functional state compared to those without significant mismatches (<5%) (5.75:0.8 vs 4.95:0.7 METS, p=0.009). This resulted in a improvement of 107% "in patients with large mismatches compared to only 34% in patients without significant mismatches. In patients with ischemic cardiomyopathy, the magnitude of improvement in heart failure symptoms after revascularization is related to the preoperative extent and anatomic location of a flow-metabolism mismatch on PET imaging. Patients with large perfusion-metabolism mismatches exhibit the greatest clinical benefit after CABG.
Patients (pts) with left ventricular dysfunction, who have signs of myocardial viability have better clinical outcome if they receive surgical rather than medical treatment. Therefore, tests for identification of potentially reversible myocardial dysfunction should be highly sensitive. To assess the usefulness of sequential use of 201TI-SPECT stress-redistribution-reinjection imaging and 13NH3FDG PET for correct identification of viable myocardium, we studied 31 pts with low ejection fraction (33_.+11%) and severe anterior wall dysfunction with both tests before revascularization. Pts were considered to have viable myocardium at baseline if endsystolic volume decreased and regional anterior wall motion score improved by at least one full grade at 2-D echo after revascularization. Eighteen pts had viable myocardium, while the remaining 13 pts were considered to have non-viable myocardium. The presence or absence of PET mismatch had higher sensitivity (89%) and specificity (62%) than visual redistribution or >50% quantitative 2~ uptake at reinjection (both 67% sensitivity and 46% specificity). A sequential strategy was analyzed : quantitative (>50%) 201T1 uptake was used as a first test and PET with mismatch as a second test only when 2~ was negative. This strategy had a similar sensitivity (16/18 or 89%) as compared to the use of PET alone. However, the advantage of this strategy would be to avoid PET in 19/31 (61%) of all patients.
$26-182
$26-184
L O N G - T E R M P R O G N O S I S IN P A T I E N T S U N D E R G O I N G N U C L E A R I M A G I N G F O R E V A L U A T I O N OF VIABILITY BY M I B I - S P E C T A N D F D G - P E T
U L T R A S T R U C T U R A L A N A L Y S I S R E V E A L S DIFFERENT D E G R E E S O F M O R P H O L O G I C A L DEGENERATION IN H I B E R N A T I N G M Y O C A R D I U M
J.vom Dahl, C.Altehoefer, G . S c h u l z , P . B u e c h i n , I.Beilin, U.Buell, P.Hanrath. Univ. o f A a c h e n , G e r m a n y
E.R.Schwarz, J.vom Dahl, J.Schaper, C.Altehoefer, W. Schaper, U.Buell, P.Hanrath. Univ. of Aachen, Germany
PET imaging of myocardial perfusion and metabolism has proven to identify patients (pts) at high risk for future cardiac events (CE). To evaluate the clinical impact of an approach using SPECT with Tc-99m sestamibi and PET with F18 FDG, 161 pts were contacted 29+6 months after nuclear imaging. Pts were categorized as having predominantly scar (group A, n=90), viable but not compromized (B, n=26), or ischemically compromized myocardium (C, n=45). 27/90 (30%) pts in group A were revascularized (A1), and 63 were treated medically (A2). Revascularization rates in group B and C were 81% (B1) and 80% (C1) resp. CE were defined as cardiac death, MI, emergency revascularization, or resuscitation. Symptoms at follow-up were categorized according to NYHA and CCS classifications and improvement (NYHA+, CCS+) was defined as change at follow-up >1 grade. Group A1 A2 B1 132 Ct C2 Card. event (%) 18 17 9 20 0 22* NYHA+ (%) 30 2t 38 20 30 11' CCS+ (%) 63 25t 76 0 69 11" ~ p<0,05 vs At, * p<0,05 vs CI Pls revascularized due to symptoms despite classification as scar improved clinically without reduction of CE. Pts with viable or ischemically compromized tissue benefitted most. Thus, "hybrid" nuclear imaging provides clinically important informations for further treatment planning and prognosis.
To correlate angiographic results, nuclear imaging, and morphologic characteristics in patients (pts.) with suspected hibernating myocardium, 24 pts. had biopsies taken from the anterior wall during CABG. All had perfusion imaging by Tc-99m MIBI SPECT and metabolic imaging by F-18 FDG PET with evidence of preserved viability in the anterior wall. Angiography revealed a severely stenosed or occluded L A D with contractile dysfunction in the L A D distribution territory. At follow-up angiography, wall motion in the LAD territory improved from -2.1+0.7 SD to -1.3+0.6 SD ( c e n t e r l i n e a n a l y s i s ) , s u p p o r t i n g the p r e o p e r a t i v e identification of reversible dysfunction. By electron microscopy and immunhistochemistry, all biopsies contained viable myocytes without evidence for transmural scar. There was substantial interindividual variation of the degree of degeneration as demonstrated by loss of myofilaments, size and shape of nuclei, cellular debris and sequestration, accumulation of glycogen, and degree of fibrosis. Categorizing the pts retrospectively by the severity of degeneration in those with mild or modest (n=l 1) and those with severe (n=13) degeneration did not result in different preoperative imaging patterns or functional outcome. Thus, hibernating myocardium shows different degrees o f morphological degeneration caused by chronic hypoperfusion. The adaptive mechanisms proposed in hibernation are insufficient to protect the structural integrity of myocytes.
AND PET TO IDENTIFY
P M A P R I L
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday morning, April 25, 1995
S26-185
$26-187
DETECTION OF MYOCARDIAL VIABILITY IN IRREVERSIBLE DEFECTS OF EXERCISE SPECT-TI201 WITH REST-REINJECTION BY MEANS OF REST-SPECT WITH A METHYLATED LABELLED FREE FATTY ACID.
REGIONALMYOCARDIALMOTION AND THICKENINGASSESSEDBY GATED MIBI TOMOGRAPHYAND MRI Constantinos Anagnostopoulos, Mark Gunning, Dudley Pennell, Robin Laney, Richard Underwood. Royal Brompton Hospital, London, UK We have validated ECG-gated emission tomography (GT) using MIBI for the assessment of regional ventricular function by comparing it with cine magnetic resonance imaging (MRt). Gated tomography was performed at rest in 24 patients referred for perfusion imaging (17 male, mean age 58, 9 with previous myocardial infarction (MI)). Scores were assigned to each of 9 myocardial segments for wall motion (WM) and for thickening (WT). Cine MRI was analysed in an identical fashion. Four out of 216 (2%) segments were uninterpretable by GT because of inadequate tracer uptake. In 8 patients without CAD, WM and WT were normal by both GT and MRI. GT showed abnormal WM or WT in all patients with previous MI and in 5 of 7 patients with CAD but no prior MI. Association between WM and WT (r,=0.86) was good. Overall, there was good agreement between GT and MRI for both WM (178/212, x = 0 . 6 6 ) and WT (184/212, x = 0 . 6 9 ) . In segments with severely reduced perfusion however there was poorer agreement (x=0.31). Interobserver and intraobserver agreement was high (x from 0.61 to 0.78). Thus, in patients investigated for CAD, there is high overall agreement between GT and MRI but the agreement is lower in segments with severe perfusion defects.
Pierre Y. Marie, Pierre Olivier, Micka~l Angioi, Nicolas Danchin, Gilles Karcher, Yves Iuilli~re, Fran~;oisCherrier and Alain Bertrand. Departments of Nuclear Medicine and Cardiology, Nancy, FRANCE. The aim of this study was to determine wether uptake of [123-I]-16lodo-3-Methylhexadecanoic acid (MIHA) inside irreversible defects of exercise SPECT-TI201 with rest-reinjection was related to a myocardial viability, as defined by subsequent improvements in perfusion or contractility after PTCA. Sixty-two patients with MI had exercise SPECT-TI201 with rest-reinjection and rest-SPECT with MIHA prior to a successful PTCA of the Ml-related artey. In patients without restenosis (n=33), contractility (X-ray ventriculography) and exercise perfusion (TI201-SPECT) were analyzed, before and > 4 month after PTCA, on a 2-segment division of the PTCA area. Exercise defects reversibility was observed before PTCA at TI201reinjection in 39 sgts (59%), and was related to subsequent improvements in contractility (p<.01, sens.: 73 %, spec.: 62%) and in exercise perfusion (p<.001, sens.: 71%, spec.: 86%). Among sgts showing irreversible Tl201-reinjection defects, an increased uptake was evidenced with MIHA in 11 sgts (48%) and correlated with subsequent improvements in contractility (p<.01, sens.: 82%, spec.: 83%) and in exercise perfusion (p=.01, sens.: 67%, spec.: 100%). In patients with MI, uptake of MIHA inside irreversible TI201reinjection defects is related to a myocardial viability, as evidenced by subsequent improvements in myocardial function and perfusion after PTCA.
$47
T U E S D A u P M
$26-186
$27-188
EFFECTS OF L - C A R N I T I N E ON PATIENTS WITH ISCHEMIC HEART DISEASE EVALUATED BY MYOCARDIAL SPECT WITH ~"~I-B-METHYL IODOPHENYL PENTADECANOIC ACID (BMIPP)
CONCORDANCE OF SPECT MYOCARDIAL PERFUSION IMAGES TO CIRCUMFERENTIAL PROFILES, TWODIMENSIONAL POLAR PLOTS AND THREEDIMENSIONAL IMAGES.
Shigeyuki Watanabe, Ryuichi Ajisaka, Kazuhiko Eda, Noriyuki Takeyasu, Masahiro Toyama, Kazuhiko Sakamoto, Tohru Takeda, Nobuyoshi Ishikawa, Yuji Itai, Yasuro Sugishita. University of Tsukuba, Tsukuba, Japan.
Joseph K Russell, Melco T Perez, Elisa Milan, Seydi Aksut, Nasaraiah Nallamothu, Jaekyeong Heo, Anti S Iskandrian. Philadelphia Heart Institute, Presbyterian Medical Center, Philadelphia, PA.
Depressed myocardial uptake of BMIPP compared to that of flow tracers, which may reflect depressed fatty acid catabolism in viable myocardium, is frequently observed in patients with ischemic heart disease. In this study, we evaluated whether Lcarnitine, which plays an impox~nt role in fatty acid catabolism and energy production, improves the depressed BMIPP uptake and myocardial ischemia A double-blind, placebo-controlled, cross-over study was performed in 8 patients with ischemic heart disease who showed a decreased BMIPP uptake compared to that of thallium at the initial examination. Subjects underwent BMIPP-SPECT and treadmill exercise testing before and after the administration of L-carnitine(900mg/day) and placebo for 3 months. BMIPP uptake score was calculated by grading its uptake from 3(normal) to 0(absent) in 13 left ventricular segments. BMIPP score was significantly improved after L-camitine, while placebo did not affect the score(23+- 11 before study, 23• 11 alter placebo, 29+_10 after L-carnitine; p<0.05, after L-carnitine vs. others). The sum of ST segment depression(mV) during exercise at the same double product was also improved only after L-carnitine(1.43+_0.21 before study, 1.55-+0.21 after placebo, 087• after L-carnitine) In conclusion, L-carnitine increases the depressed BMIPP uptake and improves myocardial ischemia.
This study examined the concordance of visual assessment of Tc-99m sestamibi tomographic images to polar plots (PP), circumferential profiles (CP) and three-dimensional images (3D). Fifty patient studies were processed and reviewed by four observers for abnormalities in the anterior, lateral, inferior, septal and apical regions. The four methods were compared to agreement reading by at least 3 of the 4 readers. Kappa statistics of visual aualysis vs CP, PP and 3D were 0.94, 0.84 and 0.99 respectively (P <0.001). For segmental analyses, the kappa scores ranged from 0.72 to 1.0. (P < 0.001). The Kappa scores of CP vs PP and 3D were 0.89 and 0.94 (P < 0.001). The kappa value of PP vs 3D was 0.86 (P < 0.001). Thus, the 4 methods provide comparable results in the overall and segmental analyses. The choice of method depends on available resources and individual preferences.
A P R I L
$48
T U E S D A u
Abstracts Tuesday morning, April 25, 1995
JOURNAL OF NUCLEAR CARDIOLOGY March/April 1995, Part 2
$27-189
S27-191
pHANTOM EVALUATION OF NON-L~IFORMATTENUATION CORRECTION USING SIMULTANEOUS TRANS941SSION ~41SSION SPECT Paul DeMan, Ellyssa Eror, Yi-Hwa Liu, Jennifer Mattera, Frans Wackers, Albert Sinusas. Yale University, New Haven CT, USA
Patient motion artifacts recognition in SPECT myocardial perfusion imaging. A. Gagnon, R. Taillefer, G. Bavaria, C. Benjamin, S.Lacombe, R. Lambert. HttelDieu de Montrtal, Canada.
Non-uniformbody attenuation is a major factor degrading SPECT image quality. Simultaneous Transmission Eraission (STE) SPECT imaging has been proposed to correct for these non-uniformities. Using a triple head SPECT system we imaged a cardiac phantom filled with TI-201 (80 uCi), placed in a water filled cylinder with external attenuators. Conventional(CON) SPECT images were obtained using high resolution parallel hole collimation and filtered back projection, STE SPECT images were acquired using fan beam collimation, maximal likelihood reconstruction, and a Tc-99m transmission line source. We compared CON SPECT with STE SPECT with attenuation correction (STE+) and without attenuation correction (STE-}. Qualitatively, CON and STE- images were comparable. STE+ resulted in visual over correction of attenuation. Reconstructed short axis images were quantitated using circumferential count profiles (CCP). Uniformity was assessed for sunlmed apical, midventricular and basal slices as % variability of mean slice counts: APICAL MID-VENTRICULAR BASAL CON 1187 • 15% 1027 f252 25% 775 ~170 22% STE1048 • 16% 854 • 22% 606 • 17% STE+ 5621 • 11% 6435 • 10% 5146 • 9% Thus, in a phantom study, compared to CON and STEimages, STE+ SPECT improves numeric CCP uniformity in the presence of non-uniform attenuation. However,visually there appeared to be over correction of attenuation.
SPECT perfusion imaging may potentialy suffer from poor specificity related to patient motion during acquisition. Patient motion is one of the most common cause of artifacts and should be evaluated before data reconstruction. The introduction of multidetector cameras has further complicated the type of motions encounters in SPECT imaging. The purpose of this study is to compare the efficacy of two methods of motion detection; the sinogram and the cine view at detecting motion. From a normal myocardial perfusion study ( patient with <5% likelihood of disease), 32 different motions were simulated. Motions were simulated with a 1 and 2 pixels shift at mid and 3/4 of the acquisition in four directions: up, down, right and left. Motions were also simulated with a 1 and 2 pixels shift in two directions at mid and 3/4 of the acquisition: left/up, right/up, down/left and down/right. The two methods of detection were used to evaluate motion on the acquisitions. Result: Taken alone, no method was able to detect all motions. Taken together the two method~ were able to identify every motions simulated.
S27-190
$27-192
Quantitative Analysis of Lung/Heart Ratio on Tc-99m Furifosmin Myocardial Perfusion Images: Comparison to Thallium-201. Donna Natale, Frans L Th. Wackers, and the Furifosmin Study Group. Yale University, New Haven, CT, USA.
IS THERE A G E N D E R D I F F E R E N C E IN THE TOMOGRAPHIC MYOCARDIAL D I S T R I B U T I O N OF T c - 9 9 m sesta-MIBI?
P M A P R I L 2 5
Furifosmin (Furi) is a new Tc-99m labeled myocardial perfusion agent that has been recently evaluated for detection of coronary artery disease (CAD) in a multicenter trial. Preliminary results showed favorable correlation with TI-201(TI). Lung uptake with T1 has been shown to be of prognostic value. It is unknown whether similar prognostic information can be derived from Furl imaging. We compared lung/heart ratio (LFIR) with TI and Furl in 29 pts with low likelihood of CAD and 25 patients with suspected CAD. Of 29 pts with low likelihood 15 had stress Furl and 14 had a stress 171 Study. Pts with CAD had both Furl and Tl studies. All pts underwent physical stress test. Pts injected with Furi had serial planar images taken in the anterior projection at 5, 10, I5, 45 and 60 mins. TI imaging was started 5-10 rain of injection. LHR was determined by an automated quantitative method: a 5x5 pixel box over the hottest area in the lung and hottest area in the heart. In pts with low likelihood mean LHR at 5 min was 0.53+_0.05 for Furi and 0.37+0.05 for T1 (p<0.0001). Furi LHR remained relatively unchanged over time (0.55+at 60 rain; p=NS), In the 25 pts with CAD LHR was 0.59_+0.06 with Furl and 0.40-2_0.08 with TI (9<0.001). Four of 25 pts with CAD had TI LHR >0.50 (mean 0,54_+0.05), whereas in the remaining 21 pts T1 LHR was 0,37_+0.06 (p<0.0001), In contrast, Furi LHR in same pts groups was 0.63_+0.07 vs 0.58_+0.06 (p=ns). Thus, LHR with Furi is significantly higher than with TI in low likelihood subjects and pts with CAD. Pts with increased TI LHR do not have significantly higher Furi LHR. In conclusion, Furi LHR may not have the same clinical value as this pattern has with TI.
T e r r y Hsia, Joanna Sloninko, M i c h a e l R. Freeman. St. M i c h a e l ' s Hospital, Toronto, CANADA There are c o n f i r m e d differences in m y o c a r d i a l distribution(DIS) of t ~ l l i u m ( T L ) between men and women. Since Tc - ~ sesta-MIBI has less scatter and a t t e n u a t i o n than TL, we studied normal(NL) subjects(S) w i t h a p r o b a b i l i t y of CAD of <5% w i t h e x e r c i s e MIBI studies. We compared 17 NL m a l e S w i t h 26 NL female S of similar age (51• vs 53• yrs, respectively) w i t h supine tomographic imaging p e r f o r m e d 30 minutes after exercise. Short axis (SA) and vertical long axis(VLA) slice r e c o n s t r u c t i o n was p e r f o r m e d and bullseye plots created by i n t e r p o l a t i n g the SA slices to 11 and a n a l y z i n g the apex from the V L A slices. A f t e r n o r m a l i z a t i o n to 100% the m e a n • activity of the septal(SEP), inferior(INF), lateral(LAT), anterior(ANT), and apical(AP) regions were c a l c u l a t e d and are compared in the table: SEP LAT ANT AP INF MEN 85• 92• 85• 84• 74• WOMEN 85• 92• 85• 87• 81• Therefore, in w o m e n T c - 9 9 m sesta-MIBI uptake is not reduced in the anterior wall as is o b s e r v e d w i t h t h a l l i u m but there is greater uptake in the inferior wall as compared to men.
Abstracts
JOURNALOF NUCLEARCARDIOLOGY
Volume 2, Number 2, Part 2
Tuesday morning, April 25, 1995
S31-193
$31-195
99mTc Sestamibi (MIBI) SPECT (S) after dipyridamole (DIP) infusion in hypertensive patients (HP).
QUANTITATION OF MYOCARDIAL 1231-METAIODOBENZYLGUANIDINE (MIBG) UPTAKE USING THE LEFT VENTRICULAR CAVITY AS ABSOLUTE REFERENCE.
O. SCHILLACI, C. MORONI, R. TAVOLARO, R. DANIELI, A. BOSSINI, R. CASSONE, A. CENTI COLELLA, F. SCOPINARO. UNIVERSITY "LA SAPIENZA", ROME, ITALY. The noninvasive diagnosis of coronary artery disease (CAD) in hypertensive subjects (SU) is particularly difficult, because of the frequent occurrence of false-positive responses in exercise-dependent tests (electrocardiography, radionuclide ventriculography and thallium-201 scintigraphy). To verify the diagnostic capability of DIP infusion (an exercise-indipendent testing) in combination with MIBI imaging in HP, we studied 32 SU (20 M and 12 F, mean age 56 + 8 years) with mild to moderate hypertension and effort chest pain. According to coronary angiography 20 of them had significative CAD (stenosis > 70%). All the SU were submitted, within 5 days, to MIBI S (at rest and after high-dose DIP echocardiographic test) and to exemise electrocardiography (EE). Sensitivity was 95% for DiP MIBI S, 65% for EE and 80% for DIP echocardiography; specificity was 88% for DIP MIBI S, 62% for EE and 88% for DIP echocardiography. Reversible perfusion defects were detected in 4 SU with normal main coronary arteries, but a significantly reduced flow velocity of the angiographic contrast medium. In conclusion,our results suggest that DIP MIBI S represents an useful diagnostic tool for noninvasive detection of CAD in HP. The positive DIP scans in SU without epicardial CAD, but slow run-off during angiography, could probably be due to a small-vessel disease condition.
G. Aernout Somsen, Judocus J.J. Borm, Eric A. Dubois, B o b van Vlias, Paul A.R. de Milliano, Eric A. van Royen. Academic Medical Center, Amsterdam, The Netherlands. To assess prognosis and the effect of therapeutical intervention in Congestive Heart Failure (CHF) patients, absolute myocardial MIBG quantitation can be valuable. The aim of this study was to validate and implement a new myocardial SPECT quantitation method. The left ventricular cavity (C) was used as an absolute reference as all systematic SPECT-reconstruction errors are similar to those of the myocardium (MYO). Activity in a venous blood sample was used to calibrate C. Volumes of MYO and C were obtained from interpolated short axis slices. Quantitation errors due to partial volumeeffects were avoided. SPECT-data from 16 CHF patients were obtained 4 hours after injection of 185 MBq MIBG (Siemens Multispect-3, 60 angles, 64*64 matrix, 60"/frame). The mean MYO/C count density ratio was 5.44(_+2.42), The intra- and interobserver coefficient of variation were both 5%. A heart phantom study showed an accuracy of 8 !%. Conclusion: The absolute myocardial MIBG SPECTquantitation method is reproducible and accurate Which makes this a promising noninvasive tool to assess cardiac sympathetic activity in vivo.
$31-194
$31-196
PROGNOSTIC VALUE OF MIBG IMAGING, RADIONUCLIDE LVEF, AND PEAK VO2 IN CHF.
ROLE OF 1231-MIBG CARDIAC TOMOGRAPHIC SCAN IN THE DIAGNOSTIC APPROACH OF THE SILENT ARRHYTHMOGENIC CARDIOMYOPATHY (SAC).
Pascal Merlet, Jean-Luc Dubois-Randr, Frrdrdc Pouillart, Daniel Loisance, Andr6 Syrota. Cardiology, Crrteil and SHFJ, CEA, Orsay, France.
M. Camerani*, R. Bettini, S. Severi*, L. Visona', E. Lorenzi*, L. Gramegna, F. Furtanello. Nuclear Medicine*- Cardiology - S.Chiara H. - Trento-haly.
In patients with congestive heart failure (CHF), a decreased cardiac I-123 Metaiodobenzylguanidine (MIBG) uptake has been shown to be a potent prognostic index in comparison with either invasive and noninvasive indices, but it has never been compared with VO2 measurement although this latter parameter is considered to be the main tool for heart transplantation decision making.To compare the prognostic value of MIBG imaging with"that of radionuclide left ventricular ejection fraction (LVEF) and peak VO2, we studied 68 CHF patients (age 52+11) due to dilated cardiomyopathy either ischemic or idiopathic, in NYHA class II to IV and with a LVEF<40%. Only ischemic patients unsuitable for revascularization entered the study. For each patients, we measured initially cardiac MIBG uptake, LVEF and peak VO2. MIBG uptake was assessed as the heart to mediastinum activity ratio (H/M) measured on the chest anterior view image obtained 4 h after tracer injection. During a 1- to 62 month-follow-up period: 7 patients were transplanted, 6 died and 55 remained alive. The multivariate stepwise regression discriminant analysis showed that the only predictor for survival was H/M (p=0.0002), Thus, cardiac MIBG imaging can be hepful in CtJF for an accurate prognostic evaluation.
SAC includes a inhomogeneous spectrum of cardiac diseases with high risk of Hypercinetic Ventricular Arrhythmias (HVA) in "clinically normal" heart. To evaluate the presence of myocardial sympathetic dysinnervation and his relation with HVA we performed the 123I-MIBG in 5 normal subjects (4 M, 1 F, mean age 26 y.) and in 32 youngs with high performance, "clinically normal" heart and HVA (28 M, 4 F, mean age 28,2 y). The cardioarrhythmologic complete invasive and not invasive study has demonstred SAC in 17/32 subjects (10 Arrhythmogenic Right Ventricular Disease-ARVD, 7 Biventricular Cardiomyopathy -BC), no cardiomyopaty (NC) in 15/32. In all the patients was also performed 99mTc-MIBI rest scan to test the integrity of the left ventricular wall. The 123I-MIBG has demonstred : a normal pattern in the 5 controls; captation defects in 10/10 ARVD, 6/7 BC and 4/15 NC; a prevalence of defects in the apex and in the inferior wall; a larger involvement of the left ventricular wall in subjects with SAC and previous history of major arrhythmic events (Aborted Sudden Death, Sustained Ventricular Tachicardia). We conclude that 123I-MIBG scan is a very sensitive tool to diagnose the left ventricular dysinnervation in SAC and there is a good correlation between the extension of the defects and the presence of major arrhythmogenic events. In particular we remark the possible high prognostic value of our results in relation with the young age and the high performance of the tested subjects.
S49
$50
Abstracts Tuesday morning, April 25, 1995
$31-197
$32-199
DIFFERENTIATION B E T W E E N I S C H E M I C AND IDIOPATHIC DILATED CARDIOMYO P A T H Y BY MYOCARDIAL IMAGING WITH 1-123 LABELED METHYL-BRANCHED FATTY A C I D
EFFECT OF REPERFUSION THERAPY ON MISMTCH OF PERFUSION AND FATTY ACID METABOLISM IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION
Yoshio Ishida, Yosiaki Hirose, Nobukazu Takahashi, Kunio Miyatake. National Cardiovascular Center, Osaka, Japan
T
U E S D A Y
JOURNALOF NUCLEARCARD]OLO~Y March/April 1995, Part 2
To eiucidate whether iodine-123-15-(p-iodophenyl)-3-(R, S)methylpentadecanoic acid (BMIPP) imaging is useful to differentiate ischemic cardiomyopathy (ICM) from idiopathic dilated cardiomyopathy (DCM), 21 patients showing LV dilatation and generalized hypokinesis (LVEF < 40%) in echocardiogram underwent T1-201 and BMIPP dual myocardial SPECT at rest. Regional tracer uptake was estimated in 20 myocardial segments by using a four-point scoring system (0=normal, l=mild, 2=moderate, 3=severe reduction). Total defect score (TDS) and the difference of TDS (dTDS) between T1-201 and BMIPP were estimated. The patients were divided into two groups based on findings of CAG and myocardial biopsy, 9 with ICM and 12 with DCM. The results : (mean+SD, p<0.001 vs Gp DCM) TDS inT1-201 TDS in BMIPP dTDS Gp ICM 4.4+3.1 13.1 +_3.5* 8.7 +_ 2.9* GpDCM 3.6+1.2 4.1+1.5 0.5+0.5 Myocardial segments with BMIPP defects but without TI-201 defects were frequently detected in all patients of Gp ICM, while the mismatched BMIPP defects were few in Gp DCM. These results suggest that the combined use of TI-201 and BMIPP imaging is useful to differentiate ICM from DCM.
Akiyoshi Hashimoto, Tomoaki Nakata, Hiroshi Kobayashi, Kenjiro Miyamoto, Shigemichi Tanaka, Osamu Iimura. Sapporo Medical University, Sapporo, Japan. The correlation of myocardial perfusion and fatty acid metabolism was assessed by dual SPECT with thallium and iodinated fi-methyl-p-iodophenyl pentadecanoic acid (BMIPP) in 29 patients with acute myocardial infarction, including 20 patients received successful primary coronary angioplasty (PTCA group), during acute and recovery phases of infarction. Thallium and BMIPP uptakes were scored visually by a 4-point system amt left ventricular ejection fraction (LVEF) was calculated. A significant correlation between thallium and BMIPP uptakes was observed. However, BMIPP scores were significantly lower than thallium ones, particularly in PTCA group and at an acute stage of infarction. Significant positive correlations of LVEF with thallium and BMIPP scores were observed during an acute stage. The grade of discordant uptakes of thallium and BMIPP significantly correlated with the improvement of LVEF during the follow-up period in PTCA group (r=0.56, p<0.05). These findings suggest that perfusion/metabolism mismatch is augmented by reperfusion therapy and closely related with functional recovery after r~perfusion therapy following acute myocardial infarction.
P M A P R I L
$31-198
S32-200
Right Ventricular Ejection Fraction Correlates With Functional Capacity in Cardiopulmonary Exercise Testing in Patients With Ischemic Left Ventricular Dysfunction.
EFFECT OF REPERFUSION ON THE DISTRIBUTION OF TC-99M-SESTAMIBI IN A CLOSED CHEST MODEL OF CORONARY OCCLUSION.
J Ferreira, V Gil, M Mendes, R Seabra-Gomes. Hospital de Santa Cruz. Carnaxide. Portugal. In patients (pt) with ischemic left ventricular (LV) dysfunction indexes of left heart performance correlate poorly with functional capacity. The purpose of this study was to evaluate the relationship between functional capacity and Right Ventricular (RV) Ejection Fraction (EF). We studied 21 pt with previous myocardial infarction and LVEF<40%. Cardiopulmonary exercise testing (CPET) was performed in treadmill with Naughton protocol and breath-by-breath gas analysis. Ejection fraction was assessed by gated radionuclide ventriculography. Pt were divided in 2 groups according to RVEF. The results of CPET were:
n LVEF Duration % RVEF<30% 7 25+8 RVEF>_30% 14 26+8 p NS
VO2max
sec L/min mllKglmin 399+143 0,92_+0.33 12.3+3.2 665+_210 1.43_+0.50 19.3+5.4 0.007 0.025 0.005
The present study suggests a clear association between functional capacity in cardiopulmonary exercise testing and right ventricular ejection fraction assessed by radionuclide angiography in patients with ischemic left ventricular dysfunction.
TF Christian, MK O'Connor, RJ Gibbons, ER Ritman. Mayo Clinic, Rochester, Minnesota, USA The purpose of this study was to examine whether prolonged reperfusion Can alter the myocardial distribution of Tc-99m-sestamibi. Seven anesthetized dogs underwent 40 rain of coronary occlusion by balloon catheter inflation. Tc-99m-sestarnibi and radiolabelled microspheres were injected during coronary occlusion. Animals were sacrificed after after 2.5-3.0 hours of reperfusion and the heart was removed and stained with triphenyltetrazolium chloride (TTC) then sectioned into 2 gm segments and counted in a gamma well counter for sestamibi and microsphere activity. Infarction was <2% of the left ventricle for all animals. There was excellent correlation between sestamibi distribution and myocardial blood flow during occlusion: r=0.89-0.98, median r=0.95. The correlation remained strong when only segments with > 50% reduction in blood flow were analyzed r=0.810.96., median r=0.88. Conclusion: Despite restoration of prolonged antegrade flow, sestamibi injected during coronary occlusion closely parallels occlusion blood flow, particularly in ischemic territories. These findings have implications regarding the measurement of collateral flow within ischemic zones and characteristics of sestamibi redistribution.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday morning, April 25, 1995
$32-201
$32-203
SERIAL EVALUATION OF RESIDUAL ISCHEMIA A F T E R A N T E R I O R I N F A R C T I O N BY S E S T A M I B I Michele Galli, Claudio Marcassa, PierLuigi Temporelli, Riccardo Campini, Orazio Zoccarato, Pantaleo Giannuzzi. Clinica del Lavoro Foundation IRCCS, Veruno (NO), Italy We recently documented that perfusion and contraction recovery in the infarcted area may continue well after the sub acute phase. To investigate the value of Sestamibi imaging in the assessment of residual ischemia, we studied 78 stable pts 5 weeks and 7 months after anterior Q-wave AMI. In polar maps, areas with Sestamibi uptake >2.5 SD below normal values were computed at rest and after exercise. At 2D-Echo, resting wall motion abnormalities (WMA) extent and ejection fraction (EF) were assessed by a computerized system. All pts had W M A and Sestamibi uptake defects at rest at 5 weeks. At 7 months, the resting Sestamibi defect extent was reduced in 48 pts (62%, Group 1) and unchanged in 30 (38%, Group 2); underlying CAD, infarct vessel patency, rest and stress Sestamibi defects, WMA and EF at 5 weeks were comparable between Groups. At 7 months, resting W M A and EF improved in Group 1 (p<.01) but not in Group 2; moreover, Group 1 showed an increase in the reversible (stress - rest) Sestamibi defect (p<.05) despite a smaller overall stress defect (p<.05). Stress hypoperfusion was unchanged in Group 2. In 44/48 (92%) Group 1 pts, the area showing reversible Sestamibi defects at 7 months matched the area showing fixed hypoperfusion at 5 weeks. The assessment of the ischemic burden by Sestamibi early after anterior AMI may be affected by the spontaneous delayed repeffusion in the infarcted area.
Delayed Recovery of Sympathetic denervatlon in Acutely Ischemic Myocardlum After Reperfusion Therapy
S51
Nobukazu Takahashi, Yoshio Ishida, Yoshiaki Hirose, Kohei Hayashida,Shigeo Kawano, Syuuji Fukuoka, Hirosi Nonogi, Toshiisa Uehara*, Tsunehiko Nishimura*, National Cardiovascular Center and *Osaka University Medical School, Osaka, Japan To evaluatewhether the recoveryprocess is affected by receiving reperfusion therapy (RT), 1-123 MIBG (MIBG) and TI-201 (TI) dual SPECT at rest was performed early (2 week) and late (3 mouths) after the onset in 17 patients (pts) with acute myocardial infarction (AMI): 6 pts with (Gp A) and 11 pts without (Gp B) successful RT. In the 4-hr delayed images, regional tracer uptake with correctionof cross-talk was estimated in 20 segments of the tomographie images by using a four-point scoring system (0=-normal,1--mild, 2=moderate and 3 = severe reduction) and total defect score (TDS) . And regional MI BGuptake in infarcted lesion(MI) and nomal lesion(N) was counted by using Bull's eye map file analysis system, then we compared the MI/N as an index of myocardial sympathetic innervation. In the early study, all pts showed larger defects in MIBG images than in T1 images. The number of mismatched segments with difference of segmental defect score > 1 was 7.5+ 5.0 in Gp A and 7.7+ 3.3 in Gp B: there is no d~ference of the extent of viable but denervated tissue. The results are as follows :(mear~+SD;*P<0.05 vs Gp B) nTDS(2wk) TDS(3mo) ATDS MI/N(3mo/2wk) GpA 6 31 -I-15 27 -I-18" 3 -t-7" 0.98-+0.3* GpB 11 29• 18-t- l0 10"t"7 1A~0.4 TDS in MIBG images and regional M/BG uptake improved more in Gp B than in Gp A during the follow-up period. These results suggest that reperfusionfor acutely ischemic myecardium prolongs the recovery of sympathetic dysfunction indicating the presence of modulating factors other than ischemia.
T U E S D A u P M
$32-202
S32-204
DOES MYOCARDIAL STUNNING OCCUR IN HUMANS AFTER ATTACKS OF UNSTABLE ANGINA ?
VIABILITY OF S Y M P A T H E T I C N E R V E S VERSUS M Y O C Y T E S IN I S C H E M I C AND REPERFUSED MYOCARDIUM.
W. Wijns, J-L Vanoverschelde, B.L. Gerber, J. Bartunek, B. De Bruyne, G.R. Heyndrickx, J.A. Melin, University of Louvain, Brussels, and Cardiovascular Center, Aalst, Belgium Myocardial stunning is characterized by the persistence of segmental dysfunction despite complete restoration of nutritive perfusion. Definite demonstration of stunning,in humans is lacking, owing to the difficulty of measuring myocardial blood flow (MBF) in absolute terms. Therefore, we measured anterior wall motion (by 2D echo) and absolute MBF with J3N-ammonia and PET in 12 pts with unstable angina. Despite PTCA of the culprit lesion on the left anterior descending coronary artery, all pts showed persistent anterior wall dysfunction at the time of PET (within 48 hours after PTCA). As judged from the changes in segmental wall motion (in 65:2 abnormal segments, mean + sd, out of 16 in each patient) from the time of PET study to 4-8 weeks later, regional dysfunction was entirely reversible in 9/11 pts. In these 9 pts, the segmental wall motion score improved from 2.4_+0.3 to 1.2_+0.1 at late follow-up. With PET, ~3N-ammonia MBF was similar among stunned and remote normally contracting myocardial segments (84_+28 vs 79_+25 ml/min/100g, p=ns). These data provide direct evidence that stunning can occur in humans following attacks of unstable angina.
Michael W. Dae, Shiro Iwanaga, Charles Espy, J. William O'Connell, Elias H. B o t v i n i c k , J o h n P. Huberty, University of California at San Francisco, California Regional denervation following nontransmural infarction suggests that sympathetic nerves may be more susceptible to ischemic d a m a g e than myocytes. To test this hypothesis, we performed dual isotope autoradiography in eight reperfused rabbit hearts using Tc-99m sestamibi (MIBI) to assess myocardial perfusion, and 1-125 metaiodobenzylguanidine (MIBG) to assess sympathetic innervation. Monastral blue dye was injected to determine the area at risk (AAR), and fluorescence microscopy used to assess sympathetic nerve morphology. Defects were primarily subendocardial. The MIBI defect size exceeded the MIBG defect in seven of eight hearts (MIBI/AAR = 0.48 + 0 . 1 6 vs MIBG/AAR = 0.22 + 0.16, p = .02), while one showed no defects. F l u o r e s c e n c e microscopy confirmed the presence of intact sympathetic nerves in ischemic regions showing MIBG uptake. M I B G defects corresponded to regions of h e m o r r h a g e , implying r e p e r f u s i o n injury. T h e s e data s u g g e s t that the sympathetic nerve endings are more resistant to ischemic injury than myocytes. Mechanisms leading to denervation in nontransmural infarction remain to be explained.
A P R I L
$52
Abstracts Tuesday morning, April 25, 1995
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
P08-207
P08-205 COLLATERAL
T U E S D A u
BLOOD
FLOW
MAINTAINS
C O R O N A R Y RESERVE AND TISSUE VIABILITY IN INFARCTED PATIENTS.
CLINICAL SIGNIFICANCEOF DISCORDANCEBETWEENMYOCARDIAL BLOODFLOWAND FATTYACID METABOLISMIN A CHRONICSTAGE OF MYOCARDIALINFARCTION;AMULTI-CENTERSTUDY REPORT.
Alessia Gimelli, Paolo Marzullo, Oberdan Parodi, Gianmario Sambuceti, Assuero Giorgetti, Piero Salvadori, Antonio L'Abbate. CNR Clinical Physiology, Pisa, Italy.
Takeshi Kobayashi, Tomoaki Nakata, Hirohisa Yamashita, Masay ori Furudate. Takashi Syougase, Hideyuki Takano, giroshi Kob ayashi. Kazuhiko Nagao. lwamizawa Rosai Hosp, Hokkaido, Japan
The physiologic significance of coronary collateral vessels in patients with previous myocardial infarction is still controversial. To this aim we studied by rest-dipyridamole N l 3 - a m m o n i a positron emission tomography 7 male patients (mean age 60+6yrs) with previous Q wave infarction, single vessel disease and occluded infarctrelated coronary artery. Collateral circulation was scored as efficient or not using a semiquantitative 4-point score. According to the efficiency of collateral circulation, 69 t o m o g r a p h i c s e g m e n t s were divided into 2 groups. Collateralized segments (group 1, n=15) showed the same hypoperfusion at rest when compared to the 54 segments of group 2 that did not show collaterals (55+15 vs 51_+23 ml/min/100g, p=ns). However, segments of group 1 showed a higher coronary reserve (2.3_+1.3 vs 1.6_+1, p<,05) and m e t a b o l i c activity assessed by F18deoxyglucose normalized uptake (81_+10 vs 55_+22%, p<.05). In conclusion, an efficient collateral circulation in the vascular territory of an occluded, infarct-related c o r o n a r y a r t e r y : 1) d o e s not p r e v e n t b a s e l i n e hypoperfusion, 2) ensures a higher coronary reserve and 3) is more frequently associated to preserved tissue viability.
The clinical value of combined SPELT imaging with 1-123-I 5-(p-iodophenyl)-3-methyl pentadecanoic acid(BM) and thal lium-20l(Tl) was assessed in ll0 patients with old myocar dial infarction. Discordance of the myocardial perfusion(T l)/fatty acid metabolic image(BM) was devided into 3 type s;type B(TI defect BM defect),and type E(similar defect area), l)The sequenti al changes in the types were observed in either early or late(90 days after onset)phase. 2)The late effects of prio r procedures on the imagings were investigated in group A
(treated with PTCA,PTCR,consisted of 67 pts) and group B (conservatively treated 43 pts).RESULTS;1)Relative freque ncy of B type(f3~)was similar to that of acute myocardial infarction(80 pts).T and E types were increased in the ra tio among the late phase group. 2)The group A showed a hig h appearance rate of type B(685), although the increment of T and E types was followed in the late phase. In conclu sion, the discordance of T1/BM images is changable with t i me. Myocardial metabolic image showing a discordant incre ase in BM uptake, however, suggests good clinical course in patients with old myocardial infarction.
P M A P R I L
P08-206 THE DECLINING SENSITIVITY OF DIPYRIDAMOLE 201THALLIUM SPECT FOR NONINFARCT ZONE ISCHEMIA AFTER UNCOMPLICATED MYOCARDIAL INFARCTION B.Palagi,J.Heyman,S.Boceolari,G.Rovelli,F.Locati,R.Picozzi,F.Ferrari,R.Fornerone,S.Devizzi,E. Cozzi-Serv. Medicina Nucleate Osped. Saronno,Div. Cardfologia Ospedale Rho-ITALY Our Study was aimed at evalua
P08-208 INFI.UENCE OF INFARCT TERRITORY ON THE DETECTION OF MYOCARI)IAL VIABILITY BY THALLIUM-201 SPECT. M. Scherrer-Crosbie, J. Rosso, JL. Monin, J. Garot, P. Dupouy, A. Castaigne, JL.Dubois-Randd, H. Geschwind, P. Gu~ret, M. Meignan. CHU Henri Mondor, Crdtoil, 94000, France. Myocardial viability was assessed m different myocardial territories by stress-redistribution-reinjection Thallium 201 SPECT in twenty one patients (pts), two weeks after acute myocardial infarction (MI). TI-201 activity was assessed visually (scale from 0 to 3) in 16 segments. Abnormal segments were considered viable if the defect improved (1 score) on redistribution or reinjection images or if Thallium uptake was moderately decreased on all images. Segmental contractility was assessed ech()graphicallyinitially and 3 m(mths after mvascularization, Viabilhy gold standard was the improvement in echographical segmemal myocard!al contr,'[ctility 3 months after revascuhtrization, 48 % of the anterior, 54% of tile posterior and 57% of the inferior segments were viable according to the gold standard which implied the following sensitivity and specificity of Thallium 201 SPECT in the prediction of myocardial viability : Global Anterior Posterior Inferior Sensitivity 79% 85% 61% 68% SpeCificity 68% 71% 67% 80% Thallium 201 SPECT is globally more sensitive than specific in the detection of myocardial viability post MI. Regional differences exist, with higher sensitivity values for the anterior segments and lower sensitivity values for tile posterior and inferior segments, The underestimation of viability in posterior and inl2rior segments might be due to related attenuation artefacts.
]
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday morning, April 25, 1995
P08-209
P08-211
LOW EJECTION FRACTION NEED NOT INDICATE POOR QUALITY OF LIFE IN SURVIVORSAFTER MYOCARDIALINFARCTION
Conclusion: Many long term survivors of AMI have a reasonable QOL despiteimpaired LV function on Tc MUGA. There is no correlationbetween QOL and EF.
A~CULARSTIMULATION AND 201=THALLI~.SPECT IN THE EARLY EVALUATION OF THE RESIDUAL ISCHAEMIA AFTER THROMBOP/SIS TREATMENT AFTER ACUTE MIOCARDIAL INFARCTION. R Nieto, D Becerra, F Prrez, JL Ballesteros*, L Pefias% F Barranco*, A Valverde, JJM Sampere Departments of Nuclear Medicine and *Intensive Cares Unit, University Hospital, Granada (Spain). The incidence of Residual Ischaemiaafter thrombolysis treatment ranges between 15 and 50% depending on the method used in its assessment. The auricular stimulation with a endovenose electrode is a good choice in order to an early evaluation of the residual ischaemia. Material and Methods: 35 non consecutive patients admitted in the coronary unit were diagnosed of acute Miocardial Infarction. 72 h after admission, auricular stimulation by bipolar catheter implanted in auricula, with 10 beats per minute; EKG, AT and pain control. In highest frequency, a dose of 148 MBq of 201-T1-C1 was injected and SPECT images were obtained at rest and 4 hours later. In addition, lung/heart uptake index in stress was calculated. No complications derived from technique were detected and only a case of autolimitedauricular {ibrilation of 2 minutes controlled by atropin was registered. Follow up: 12 months; reinfarction and unstable angina are considered like ischaemic events. Results: Our results suggested that there is a high incidence of ischaemic events (38%). The arisen of ache during auricular stimulation has a high discriminative value (sens-87%; spec=92%). The addiction of both variables had a predictive value of 80% for positives and 100% for negatives. The EKG changes during stimulation, isolated considered, has a low predictive value.
P08-210
P08-212
IIlIn~ANTIMYOSIN AND 99mTc-MIBI TO DETECT MYOCAR DIUM AT RISK AFTER ACUTE MYOCARDIAL INFARCTION. I. Cas~ns, J. Sanchis, J. Ciudad, L. Insa. Nuclear Medicine and Cardiology Departments. Hospital Cllnico Universitario. Valencia. SPAIN.
DETECTION OF R E S I D U A L VIABILITY WITH Tc99m-SESTAMIBI OR TI-201 IN THE LATE PHASE (> 4 WKS) OF MYOCARDIAL ~ A R C T I O N .
A Joy, G Manning, A Tukan, C Tiivas, MW Millar-Oraig Departmentof Cardiology,DerbyshireRoyal Infirmary, Derby, UK Left ventricular(LV) ejection fraction (EF) as assessedby Tc MUGA scan is well establishedin evaluating LV damage after acute myocardial infarction (AMI). Patients with low EF (<40%) are known to have a poor prognosis, but there is little data on quality of life in patients surviving AMI with impaired LV function. The aim of this study was to comparequality of life (QOL} with LV function in long term survivorsol AMI. EF '#as measuredin 54 patients within six weeks of AMI. Twelve months followingAMI, patients were sent a detailed questionnaire,based on the NottinghamHealth Profile, and their physical and psychologicalfunction was assessedby a ranked scale based on the means of the values of the answers given in the questionnaire. The scale went from 0 (highest QOL) to 4 (lowest QOL). Patients were divided into four groups: EF>54%, EF 41%-54%, EF 30%40% and EF <30%. Their responseswere then ,assessed. There were no differences between the mean values of the responses across the four groups. QOL index
EF >54% (n=15) Physical (SD) 1.8 (,77) Psychological(SD) 1.4 (.91)
EF 41'%-54% (n=13) 2.1 (.92) 2,1 (.89)
EF30%-40% (n=14) 1.8 (.74) 1.4 (,59)
EF<30% (n=12) 2.4 (.99) 1,6 (1.2)
We have studied 19 patients with a first thrombo lized AMI by lllIn-antimyosin(AM)and also 99mTcMIBI in 15 of them.The explorations were performed 8+3 days after AMI,with both planar and SPET (if p~ssible,in case of AM).We obtained a heart to lung(H/L) ratio of AM uptake'and percent of myocardium with 99mTc-MIBI uptake g50%(PM) from bull's eye.AM uptake and 99mTc-MIBI defects were localized in 15 segments/patient. All patients underwent coronary angiography(41• and stress/ rest 99mTc-MIBI(43• days)after AMl,with follow up(ll+3 months).We have found overlap of uptake of both tracers i n ~ 2 segments in 9 patients(Gl) and match (AM uptake in segments with perfusion defect) or mismatch (no uptake of either of the tracers)in 6 patients(G2).There were not signif! cative differences between GI and G2 in PM, H/L, residual stenosis in mm, neither patency(TIMI3). We detected reversible stress defect and/or cardiac events in follow-up in Y/9 patients(77%) of G1 and in if6(16%)of G2(p<0.05). These preliminary results show that by AM and 99mTc-MIBI studies soon after AMI, it seems possible to identi fy the patients with myocardium at risk.
Jean Maublant, Janusz Lipiecki, Bernard Citron, Dani~le Mestas, Jean-Michel Tarlet, Annie Veyre, Jean Ponsonnaflle. Centre Jean Perrin, Univ. o f Clermont-Ferrand, F. The possib~ty to detect residual viability with sestamibi or TI-201 was assessed in 15 patients (pts) with a >4-wk old myocardial infarct (MI), a >75% coronary artery stenosis and left ventricular dysfunction. B e y underwent a Tc9 9 m - s e s ~ b i rest-stress study and a 3-projection gated blood pool study before and after a successful r e v a s c u l a r i s a t i o n (revasc.). A TI-201 stressredistribution-reinjecfion study was also performed before revasc.. After revasc., the mean left ventricular ejection fraction increased in 12 pts from 39• % (n~sd) to 45.3• % (p<0.001). Wall motion improved in only 7 pts. A total of 18 segments were involved, in which the uptake of tracer before revasc.was normal or near-normal for 28% with sestamibi at rest, m d for 56% with T1-201 at redistribution. Reversible i s c h e ~ a was observed in 44 % of these segments with sestamibi and in 55 % with T1201. It is concluded that nearly 50% of the pts with a >4-week old MI demonstrate some degree o f residual myocardial viability in territories which are often abnormal at scintigraphy, ~ often with sestamibi than with T1-201.
$53
S54
Abstracts
JOURNAL OF NUCLEAR CARDIOLOGY
Tuesday morning, April 25, 1995
March/April 1995, Part 2
P08-213
P08-215
T H E NON Q WAVE VERSUS Q WAVE MYOCARDIAL INFARCTION
DEPRESSED REGIONAL FATTY ACIDI METABOLIC ACTIVITY DETECTED BY IODINE-123 p-METHYLIODOPHENYLEPENTADECANOIC ACID IN ACUTE CORONARY SYNDROME
THALLIUM-201 AND CORONARY ANGIOGRAPHY PATTERNS G. C.aatthha. E.M. Coelho, A.I, Santos, M.G, Aires, T. Martins, A. V.Marqaes, B. Costa, F. Godlnho. Iastltuto de Medlclna Nuclear and UCIM/Med I V . Hospital de Santa Maria Llsboa - Portugal
T U E S D A u
Takeshi Tanaka, Tadanori Aizawa, Kzuzo Kato, The Cardiovascular Institute. Tokyo, Japan
Acute myocardial infarction has been electrocardiographically classified according to the presence (QM0 or absence of Q wave (NQM0. This classification is questioned in terms of prognosis and therapeutics, We used thallium-20l SPECT (3"1)to compa~ NQMI and QMI, in order to identify a sub~et of features, regardless of the site and extension of necrosis. We have studied 52 QMI patients (pts), ---58.5+7.4 years, and 23 NQMI I~.s,=60!-_7.7y~a.."s,All pta performed 1"1and enronariography 2-3 months after MI, In 21"1,12 segmants (sg) were oonsidea~din the left ventricle. Analysis was done comparing the number of fixed defects in TI and the steaesis grade of the corresponding corona~ artery, considering:antedor/septal walls (AS) depends of left descendent (LD). lateral (L) of left circumflex (CX) end hfferior (I) of fight cotona~ (PC). In QMI pts, 58% had AS infarction with 48% sg with fixed defect, in 57% ischaemia pefi neonsis (IPN) is present and in 83% distant lesions were found (DL). The =77+28%. 12% pts had lateral QMI in 33% seg, 3 pts with IPN and all with DE. The =61_+34%. NQMI pts: 18% pts had AS TI defects in 17% sg. 2 pts had a moderated fixed hypoperfusion. 3 pta had IPN and all had DL. =88+17%. 91% had I lesions in 70% seg, but 37% had a TI moderate fixed hypoperfusion, 52% had IPN and 57% DL. =67+31%. 24% pls had L lesions in 60% sg, one with'moderate hypoperfnsion, none with IPN and 80% with DL. =75+25%. No important statistical differences were found regarding the extension of IPN or DL and the degree of sWalnsis,the two groups with a high incidence of multiple vessel disease, suggesting a similar long term pregnosis. It w~ possible to identify a pattern of NQMI at TI in 46% pts. which was seen hi only I pt in QMI. This may suggest a distinct pathoghysiologicel entity.
Iodine-123 13-methykiodophentadecanoic acid m y o c a r d i a l i m a g e s ( B M I P P i m a g e s ) was d e v e l o p e d for estimating m y o c a r d i a l fatty acid metabolism. Abnormal fatty acid metabolism in i s c h e m i c region was studied in 50 patients (pts) with acute coronary s y n d r o m e by B M I P P i m a g e s and thallium-201 myocardial i m a g e s (TI-201 i m a g e s ) . In 8(424) hospital days B M I P P and TI-201 were simultaneous infected and i m a g i n g was p e r f o r m e d . Myocardial Perfusion defects w a s not revealed by TI-201 i m a g e s in 21 o f 30 pts with n o n - Q - w a v e infarction, w h e r e a s B M I P P i m a g e s revealed defects corresponding to myocardial ischemic region predicted by coronary angiography in all 30 ptsl N o myocardial perfusion defect w a s detected b y T1-201 i m a g e s in pts with unstable a n g i n a pectoris, w h e r e a s B M I P P i m a g e s revealed defects in 14 or 20 pts. B M I P P defects were noted in the region with normal TI-201 uptake. Fatty acid metabolic activity w a d m o r e vulnerable to i s c h e m i a than m y o c a r d i u m it self. D e p r e s s e d B M I P P uptake d i d not represent i s c h e m i a , but a b n o r m a l fatty acid m e t a b o l i c a c t i v i t y induced by transient ischemia. B M I P P i m a g e s were clinically useful. B M I P P i m a g e s is a sensitive method to detect m y o c a r d i u m exposed to transient ischemia undetected b y T1-201 i m a g e s . T o detect culprit lesion B M I P P i m a g e s were useful.
P08-214
P08-216
P M A P R I L 2 5
DOBUTAMINE STRESS ECHOCARDIOGRAPHY(DSE) AND PET
ELEVATION OF ST SEGMENT IN EXERClCE TEST AFTER AN ANTERIOR INFARCT AND MYOCARDIAL VIABILITY. STUDY WITH SESTAMIBI
AFTER AMI IN THE VIABLE MYOCARDIUMEVALUATION.
J Castell, A Garc(a-Burillo, S Aguad6, P Blanch, H Valenzuela, T Canela, J
G Mobilia,P
Cortadallas, J Csndell. Hospital General Universitari Vail d'Hebron. Barcelona.
Zanco,G Masaro, F Chierichetti,L
Vet-
t o r a t o , F A l i t t o , R B u c h b e r g e r and G F e r l i n . Cardiology-~ntebelluna and N u c l e a r M e d i c i n e Castelfranco To e v a l u a t e the
Veneto, the
Italy.
usefulness
identification
of
of
stunned
low d o s e DSE in but
viable
(VIA)
myocardium after first AMI,IO pts were studied b y DSE l O ~ 2 d a y s , a n d b y DSE and g l u c o s e l o a d FDG PET 3 0 + 4 d a y s a f t e r AMI.Left ventricular w a l l was divided in 16 s e g m e n t s ( s ) . V i a b i l i t y b~' DSE was defined
as n o r m o - o r h y p o k i n e s i a
provement
in w a l l
motion
at
rest
From a k i n e s i a
or
im-
during
do
b u t a m i n e i n f u s i o n . W e c o m p a r e d DSE and PET in t h e corrisponding hypo-(HY)or akinetic s at rest. A F t e r 1 s t DSE we Found 113 n o r m o k i n e t i c , 3 4 notV I A and 13 V I A s ( 8 HY a t r e s t and 5 t h a t improved).After
2nd DSE we Found 113 n o r m o k i n e t i c , 2 9
n o t - V I A and 18 V I A s(9 HY a t r e s t and 9 t h a t improved),By PET, in c o r r i s p o n d i n 9 s , w e Found 24 n o t - V I A and 23 V I A s . ln c o n c l u s i o n , o u r experience suggests
that
the
best
timing
to look for stunned myocardium AMI.Extension of VIA is slightly
to is
perform
DSE
1 month a f t e r g r e a t e r b y PET.
It has been suggested that the elevation of ST segment in the exeroice test (ET) after an anterior infarct can be a sign of myocardial viability in this territory. The aim of this study was to evaluate the amount of viable myocardium in patients with an anterior necrosis, comparing those who elevate ST segment with those with no elevation. 54 consecutive patients who had suffered an anterior infarct as the only coronary history were selected. They underwent a subjective maximum bicycle exercise and a tomographic myocardial perfusion imaging with SESTAMIBI(exercise and resting). Group 1: Elevation of ST:20 patients (mean age: 56 y)(37-69) 4~ Group 2: No elevation of ST:34 patients (mean age:57 y)(24-75) 69 The extension of viable myocardium (uptake higher than 40 % at rest) was calculated upon the bull's eye image, in antero-ssptal, apical territories and total left ventrioular extension. Results: % AS"
% AP"
% TOT"
GROUP 1
5.6•
METS~
69•
22+36
72_+16
GROUP 2
5.7•
91•
63•
89•
%: percentage of viable myocardium (AS: antsroseptal, AP: apical, TOT: total) #: p=ns *: p
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday morning, April 25, 1995
P08-217
P08-219
MYOCARDIAL VIABILITY ASSESSED WITH REST SESTA MIBI AND THALLIUM REINJECTION AFTER RECENT MYOCARDIAL INFARCTION.
"MISERY PERFUSION" (MP) DOCUMENTED AT EARLY PHASE OF ACUTE MYOCARDIAL INFARCTION (AMI) BY 1502 AND PET Yusukr Yamamoto1, Hkosi Nonogi 1, Shunichi Miyazaki1, Akira Itoh1, Satosi Daikoku 1, Yosio Isida1, Hidehiro Iida2. National Cardiovascular Center, Osaka 1, Research Institute for Brain and Blood Vessels, Akita2, Japan.
Alain Le Helloco, Anne Devillers. Alexis Butt, Marc Bedossa. Marcel Laurent, Patrick Bourguet. Claude Almange. University. Hospital Rennes, FR In order to evaluate diagnostic value of rest sestamibi and thallium reinjection for myocardial viability. 15 patients (Dts) with mean age 61.5 years ~ 6,5 admitted for recent myocardial infarction, underwent rest sestamibi at hospital discharge, exercise thallium tomography with reinjection two weeks later. The severity of reduction in sestamibi or thallium uptake was scored using a 4 point grading system (normal uptake 1 to severe reduction = 4) : Perfusion defect size was concordant in i0 pts with sestamibi and thallium. In i0 segments with abnormal sestamibi/normal thallium reinjection, 8 hypokinetic segments improved after revascularization. Score analysis revealed that thallium reinjection demonstrated myocardial viability (17,7 : 4,6 with thallium vs 20 ~ 4,5 with sestamibi, p ~ 0 , 0 0 5 ) . Thallium reinjection may be used for identifying viable myocardium and seems to be better test than rest sestamibi.
$55
To evaluate oxidative metabolism at early phase of AMI, we have quantified myocardial blood flow (MBF; ml/min/g), oxygen consumption (MMRO2; ml/min/100g), oxygen extraction fraction (OEF) as well as water perfusable tissue index (PTI) for a parameter of viable mass in 16 AMI patients within 1 week using a previously validated method with 1502, H2150 and PET. We found 9 patients (56%) with low MBF and high OEF condition which is so-called MP in Stroke. Contrast left ventriculography after 1 month revealed contractile recovery (R; n=6) and no-recovery (MR: n=3) in MP segments. The results in R, NR and remote control (RC) segments are shown as below (mean• MBF PTI OEF MMRO2 R 0.55_-0.10" 0.73_*0.07 *# 0.91_-0.09" 8.61_-1.66" NR 0.47_*0.07* 0.48_.0.13" 0.95__.0.04* 7.63-*2.45* RC 1.07_-0.09 0.96_*0.06 0.62_*0.07 11.38_-1.90 (*<0.017 vs MR, #<0.017 vs RCby t test with correction) Thus, MP was documented in AMI for the first time and contractile recovery was observed in 66% of these segments where PTI value (suggesting viable mass) was significantly greater than no contractile recovery segments.
T
U E S D A u
P M P08-218
P08-220
DETECTION OF VIABLE MYOCARDIUM IN CORONARY ARTERY DISEASE BY RESTING Tc-99m MIBI TOMOGRAPHY: DELAYED IMAGING OR NITRATES ADMINISTRATION ?
RICHTVENTRICULARDYSFUNCTIONIN PATIEN]SWITHACUTEMYOCARDIAL INFARCTION:A FOLLOW-UPSTUDY. M.Cappagli, P.Poggi, *D.Bertoli, R.Russo, Rieoncini, A.Montepagoni, #S.Oramenzi, *C.Filorizzo, A.Coli, Nuclear Medicine, HCordiology, Lo SpeziaHospital,*Cardiology,SarzanaHospital,ITALY.
Simone Maurea, Alberto Cuocolo, Andrea Soricelli, Luisa Castelli, Antonio Nappi, Fiorenzo Squame, Massimo Imbriaco, Bruno Trimarco, Marco Salvatore. Universit& "Federico I1" and Istituto Nazionale dei Tumori, Napoli, Italy. Delayed images or nitrates administration may enhance the detection of viable myocardium in coronary artery disease (CAD) by Tc-99m MIBI SPET. We compared the results of resting MIBI SPET with initial (1 hr) and delayed f(5 hrs) im&ges)with those of MIBI SPET after oral nitroglycerine (NTG). All pts also underwent rest-redistribution TI-201 SPET. In 8 pts, echocardiography was performed before and after coronary revascularization (Rev). Of 682 myocardial segments, 197 showed a severe reduction (<50% of peak) of MIBI uptake on initial images. Increased MIBI uptake (>10%) was observed in 47 (24%) segments on delayed images (from 43+8% to 60+8%, p<0.001) and in 54 (27%) segments after NTG (from 42+8% to 60+8%, p<0.001). Concordant results between delayed and nitrate MIBI images were observed in the majority of segments (n=175, 89%). All segments with increased MIBI uptake on delayed and/or nitrate images were identified as viable on TI-201. In the 8 pts studied before and after Rev, 83% of segments with increased MIBI uptake on delayed images and 87% of those with increased tracer uptake after NTG showed functional recovery following Rev. Thus, delayed and nitrate MIBI imaging provide similar information to identify viable myocardium in chronic CAD.
In order to evaluatethe incidenceand lhe evoMionof right ventricular dysfunction (RVD), often reported in patients (pt) with acute myocardial infarction (AMI), 100 consecutive pt, without previous RVD, performed rodionuclide angiographyfor the evaluation of LV and RV ejection fraction (EF) at 10 days, 6 weeksand 6 months from hospitalization for a first AML The followingtable shows results (m-*s.d.) accordingto the AMI site: ISEE _n ~ 6w ~ I0~! 6w Ant 24 42'-12 42-.13 40"-.16 48;9 51-.7 51-'7 Int 44 53-'11 51,11 52-.12 49-'8 50-*8 50-'8 Lot 9 46-*6 46-'10 48;8 48*7 51-.8 50-*9 NonO 2,3 58-'10 58-~I0 60;10 5 3 , 7 51-.8 51-.7 LVEF(%) RVEF(%) Despite significant differences in LVEFamong groups at each control (p
A P R I L
2 5
$56
Abstracts Tuesday morning, April 25, 1995
P08-221
S~FETY AND DIAGNOSTIC VALUE OF EARLY ADENOSINE-THALLIUM-SPECT FOR PATIENTS WITH ACUTE CORONARY INSUFFICIENCY. J. H61ias, C. Cadiou, J. Trochu, R. Grosset~tc, D. Crochet, LF. Godin, CHU Nantes, FRANCE.
T U
E S D A Y
JOURNALOF NUCLEAR CARDIOLOGY March/April 1995, Part 2
P08-223
Withdrawn
In 2OO consecutive patients (pts) with unstable angina (UA) or uncomplicated myocardial infarction (UMI), Adenosine-Tl 201-SPECT (ATS) has been prospectively used to assess the extent of coronary artery disease (CAD), 2 to 10 days afteronset of symptoms. All pts were also investigated by coronary angiography (CA) and results obtained by a double-blinded comparison. CA showed 90 pts with multi vessel disease (MVD), 64 pts with one (1VD) and 46 pts without any significant coronary stenosis. Side effects were frequent (80%) but minor and short (33• see). ATS with major and/or multiple defects detected 75/92 pts with MVD leading to a 82% sensitivity and a 79% specificity to diagnose severe CAD. Reversibility and extend of defects identify 113/122 pts needing revascularization and the absence of need for this therapy in 56/78 leading to 84% and 88% positive and negative predictive value respectively for this purpose. So, in patients with UA or recent AMI, early ATS is well tolerated and allows a correct identification of patients with severe and/or MVD, and those who need revascularization. Therefore this procedure may improve clinical decision making and save time to select patients who need, or not, an invasive procedure.
P
M A
P08-222
P08-224
R I
LEFT VENTRICULAR PERFORMANCE AND NEUROENDOCRINE ACTIVATION IN AMI.
SPET-MIBI sensitivity in the detection of non-infarct
L
C.Leth Petersen, M.Munch, , J.Rokkedal, H.Dige-Petersen.
G. Candelpergher, ~
A. Desideri, ~
2 5
Departments of Nuclear MedicineGlostrup Hospital, Universityof Copenhagen, Denmark. AIM: to describe levels and temporal sequence of vasoactive hormones from onset to discharge in patients with AM! and to relate values to cardiac performance. Patients & Methods: 18 patients with AMI. Blood samples were drawn within the first 18 hours, 18 - 24 h, day 2, day 3, and at discharge. Simultaneous plasma concentrations of Endothelin (ET), ANF, Adrenaline (AD), Noradrenaline (NAD), Renin (RE}, Angiotensin II (AT}, and angiotensin converting enzyme (ACE) were measured. Radionuclide ventriculography was performed on the day of discharge with determination of left ventricular ejection fraction (LVEF), left ventricular enddiastolic volume-index (EDVI), left end-systolic-volume-index (ESVI), and left ventricular stroke-volume-index (SVI). Results:Concentrations of ET decreased from 2.15 at onset to 1.45 pmol/I at discharge (32%, p
In order to analyze the sensitivity (S) of SPET-MIBI in the detection of lesions of non-infarct related arteries (NIRA), we retrospectively studied 98 10atients (pts) (131 males and 8 females, aged 36-75), who underwent both coronary angiography (CA) and two-days stress-rest SPET-MIBI (analyzed semi-quantitatively), within 4 months. CA showed narrowings of _> 50% in 216 vessels, 118 of which were infarct-related arteries (IRA). 98 were NIRA. Overall individual vessel S was 78% (LAD 80%, LCX 6 9 % RCA 85%); specificity was respectively 76% (76%,87%.61%). If only NIRA were considered, overal! sensitivity dropped to 52% (LAD 53%, LCX 49%, RCA 60%), We also analyzed the influence of several variables on S for NIRA lesions and found the following statistically significant differences: degree of stenosis (stenosis 50-75%: 34% - >_76%: 73%), stress EKG (positive:61% negative:16%) and exercise maxima! percent heart rate (_>85%: 41% - <85%:60%), We conclude that S of SPET-MIBI in NIRA of MI pts is suboptimal and it increases with higher degree of stenosis, positive stress EKG and pts not reaching 85% maximal exercise heart rate.
P
related coronary lesions. Zanco, F. Canel, *N. Borsato,
Rubello, C. Cernetti, *G. Ferlin
Cardiology and ~
Medicine - Castelfranco, Italy.
JOURNAL OF NUCLEAR CARDIOLOGY V o l u m e 2, N u m b e r 2, P a r t 2
Abstracts T u e s d a y morning, A p r i l 25, 1995
P08-225
P08-227
BIOCHEMICAL INFARCT SIZE AS A PREDICTOR OF VENTRICULAR SIZE AND FUNCTION MEASURED WITH BLOOD-POOL SCINTIGRAPHY IN PATIENTS WITH ANTERIOR WALL INFARCTION L.H.B.Baur, E.E. van der Wall, LJ. Schipperheyn, A, van der Laarse, J.A.K. Blokland, A.V.G.Bruschke, University Hospital, Leiden, The Netherlands
THE V A L U E OF GATED T O M O G R A P H I C Tc-99m-SESTAMIBI PERFUSION IMAGING IN A C U T E ISCHEMIC SYNDROMES Christopher Nicholson, James Tatum, Robert Jesse, and Joseph Ornato. Medical college of V i r g i n i a Hospitals/YOU, Richmond. VA.
The cumulative value of ~-HBDH release assessed within 72h of the acute infarct (Q72) gives an indication of myocardial infarct size. We investigated the relation of parameters of biochemical infarct size and cardiac function measured with blood-pool scintigraphy 3 wks alter the acute event in 27 pts with an anterior wall infarct. Results: Mean Q72 was 1261 + 803 (U/l). peak CPK-MB (CPK, MB) 806:t: 575 U/I. End-diastolic and endsystolic volume (ESV) index were 9 3 + 3 2 and 54+27 ml; LVEF was 43+13 % Q72 correlated strongly with LVEF (R=-O.60;p 1150 U/I had a LVEF ,~ 40% whereas only 12 of 13 patient with Q72 < 1150 U/I had a L V E F < 40%. So positive predictive value of a Q72 < 1150 U/I is 100% and negative predictive value 92 %. Peak CPK-MB also related to cardiac function after 3 weeks but the correlation was less strong. Conclusions: The biochemical infarct size parameters Q72 and Peak CPK-MB have a clear relation with cardiac function 3 weeks after the acute event, Q72 > 1150 U/I is a strong predictor for L V E F < 40%.
E a r l y studies u t i l i z i n g t o m o g r a p h i c Tc-99m sestamibi perfusion imaging (MIBI} in the e v a l u a t i o n of acute ischemlc syndromes (AIS) d e m o n s t r a t e high s e n s i t i v i t y (SN) and increased s p e c i f i c i t y (SP) o v e r clinical and ECG evaluation. However, for cost effective utilization, SP m u s t be maximized. Inclusion of gated tomographic cinee in the e v a l u a t i o n of MIBI perfulion studies appears t o s i g n i f i c a n t l y ~mprove SP. The known a s s o c i a t i o n of wall m o t i o n abnorm a l i t i e s with s suggests g a t i n g may also improve SP in AIS by significant reduction of false positives. In this study, 102 patients with suspected AIS (patients at low risk for MI and m o d e r a t e risk of u n s t a b l e anginal u n d e r w e n t rest g a t e d MIBI studies. O n subsequent evaluation by invasive or non-invasive follow-up, 17 had nignificant c o r o n a r y artery disease. Static rent MIBI t o m o g r a p h i c images were graded by 2 readers b l i n d e d to patient outcome. Cases considered equivocal by both readers were c o n s i d e r e d abnormal. Non-gated MIBI d e m o n s t r a t e d a SN of 94%(16/17) and SP of 69%(59/851 with a p o s i t i v e p r e d i c t i v e value (PPV} of 38%. The same readers then interpreted studies w i t h gating. T h e r e was no change in SN 94% but marked improvement in SP 97%(83/85) and PPV 88%. The findings strongly support the use of rest gating w i t h PI in the assessment of AIS to increase s p e c i f i c i t y and overall PPV.
P08-226
P08-228
TREADMILL EXERCISE TEST RESULTS AFTER MYOCARDIAL INFARCTION: WHICH RELATIONSHIP WITH TEUE EXTENT OF REVERSIBILITY ON THALLIUM SCINTIG.RAPHY
Evaluation of efficacy of reperfusion therapy for myocardial infarction by myocardial tomograms using myocardial perfusion agents ~abeted with technetium-99m
Ant6nio Ventosa, Jorge Ferreira, Jo~ioCalqueiro, Vitor Git, Ricardo SeabraGomes. Instituto do Coraq~io. Camaxide, PORTUGAL
Gou Tsujimot0,Akihiko Oda,Tatsuo Maeda,Tomoyuki Yahata,Tetsuya Kawashima,Seiichirou Usuki,Teruo Takata, Masahiro Fukuhara, Kazuo Ohnish ,Kazuhiko Adachi.Kobe Rosai Hospital,Department of internal Medicine, Kobe,Japan.
There is some controversy about the significance of some pettems of treadmill exercise test (TET) result after Nil, notably the occurrence of ST segment elevation, or angina without electrocardiographic changes. To evaluate this issue, we studied 159 patients (pt) who underwent, after/vii, coronary arteriography and thallium SPECT after a conclusive, symptomlimited "lET: occurrence of angina (Ang), ST depression (STd) or elevation (STe) or, in their absence, peak heart rate >85% of predicted. Single vessel disease was present in 75 pt and multivessel disease in 84 pt. Considering 5 segments per patient, % of segments with reversible(Rev) or fixed (Fix) perfusion defects are shown in the table, n %ILev */oFrx On segment analysis, patterns of TET Ang 30 46.7 6.7 result (as considered in 2rid half of the Ang+STd 125 39.2 8.8 3.3 table) were associated with a linear Ang+STd+STe 30 46.7 An~+STe 25 40.0 32.0* decrease of the % of segments with Rev (all Ang) 210 41A 10.5 (r=0.996), STe was associated with STd 150 37.3 4.7 higher % of segments with fixed defects. STd+STe 135 32.6* 15.6" Angina, with or without ST changes, was STe 120 29.2* 27.5* associated with higher % of reversible none 180 21.i* 10.6 * significant P withinthe samecolumn defects than any other type of result. On patient analysis, occurrence of angina (all) or isolated STd was 79% specific but only 50% sensitive for reversibility. Considering STe, sensitivity would improve to 68% (with STd+STe) and 82% (also with STe), but specificity would fall to 64% and 43%, respectively. In conclusion, our data suggest that the considered patterns of TET result may express a spectrum of decreasing extent of ischemia. However, individual predictions are insensitive with angina or isolated STd, and become increasingly unspecific when considering patterns with STe, which were associated to a greater number of irreversible defects.
We evaluated the objective benefit of emergency reperfusion therapy in 10 patients with acute myocardial infarction(MI),5 with anterior and 5 with inferior MI.Seven patients received direct PTCA and 3 patients received thrombolytic agentsMyocardial SPECTwas performed before,within seven days and again one month after reperfusion therapy using as the imaging agent 99mTc-sestamibi(6cases) or 99mTc-tetrofosmin(4cases).The average time between MI onset and achievement of coronary reperfusion was 4 hours.Patency of the artery involved by infarct was evaluated by performing coronary angiography within one week of treatment.The myocardium was divided into nine segments;the perfusion deficit was assessed on a scale of 0 to &with 0 being normal and 3 a complete defect.The wall motion abnormality of the infarct-related area was assessed by echocardiography immediately after,and again, 1month after, reperfusion therapy.All 10 patients showed a decrease in the perfusion deficit score following therapy.The pretherapy score was 11.3---*4.1;within 1 week after therapy,7.3=~.2.9,and1 month after therapy,it was 6.3_+3.1.The reduction in score one week after treatment was statistically significant vs. that pretreatment.Evaluationof the wall motion abnormality by echocardiography revealed improvement in the area of infarct in 6 of the 7 cases evaluated.The exception was one patient in whom the interval between onset of MI and reperfusion therapy was 5 hours.Myocardial perfusion agents labeled with technetium m-99m were useful in the noninvasive evaluation of the effects of reperfusion therapy in patients undergoing myocardial salvage.
$57
$58
Abstracts Tuesday morning, April 25, 1995
P08-229 DOES ACUTE CHEST PAIN IMAGING PREDICT STRESS TC-99M SPECT PERFUSION RESULTS? D a v i d S. Lawrence, Victor A. Mascitelli, M i c h a e l M c M a h o n , A l a n W. Ahlberg, N a w w a r M e r c h o , R. Scott Morris, Gary V. Heller. Hartford Hospital, U n i v e r s i t y o f C o n n e c t i c u t School o f M e d i c i n e , Hartford, CT, U S A
T U E S D A Y
To determine w h e t h e r i m a g i n g o f patients (pts) with s p o n t a n e o u s c h e s t pain provides the s a m e diagnostic information as s u b s e q u e n t stress with T c - 9 9 m S P E C T myocardial p e r f u s i o n i m a g i n g , 23 pts u n d e r w e n t acute c h e s t pain imaging. 1 t pts were injected during active pain, 12 pts after a m e a n o f 85 minutes. E a c h patient u n d e r w e n t either exercise (12) or p h a r m a c o l o g i c (11) stress u s i n g T c - 9 9 m sestamibi. Interpretation w a s blinded and by c o n s e n s u s o f 3 readers. A b s o l u t e a g r e e m e n t w a s f o u n d in 20 pts, including 5 with a b n o r m a l studies in both. D i s a g r e e m e n t w a s f o u n d in 3 pts, each o f w h o m w a s injected >90 m i n u t e s after resolution o f chest pain. For each, the acute i m a g e defects were less t h a n the stress defects. Conclusion: I m a g i n g during c h e s t p a i n and stress is concordant if injection is m a d e during s y m p t o m s . Injection after resolution o f s y m p t o m s >90 m i n u t e s m a y underestimate ischemia.
JOURNAL OF NUCLEAR CARDIOLOGY March/April 1995, Part 2
P08-231 DOES MYOCARDIAL PERFUSlON IMAGING PREDICT THE SITE OF SUBSEQUENT MYOCARDIAL INFARCTION (Mt) ? Galvin J, Brown KA Cardiology Unit, University of Vermont College of Medicine, Burlington, VT. Although myocardial perfusion imaging IMP!) has been shown to predict subsequent MI, no data exists whether the location of a transient perfusion defect (TO) predicts the site of subsequent MI. We identified 69 pts with MI and a TD demonstrated on MPI performed prior to MI. All MIs were localized by ECG supported by echo or angio findings.The interval between MPI and MI was 1-94 mo [mean 26-t16(SD)]. 38 pts were excluded because of interval revascularization or inability to localize the site of M~ leaving 31 pts for analysis Pts were further divided according to time interval between MPI and MI. The relationship of MPI TD and MI coronary territory are summarized below; Infarct Zone LAD LCX RCA <2y >2y <2y >2y <2y >2y TD LAD 8 0 0 0 0 3 Coronary LCX 1 0 2 1 0 0 Territory RCA 1 2 0 2 6 5 The MI zone was predicted by the TD on prior MPI in 67% of pts with Left Anterior Descending Mts (80% if MPI <2y before MI), 60% of pts with Left Circumflex (LCX) MIs (100% if MPI < 2y before MI) and 79% of pts with Right Coronary (RCA) MIs (100% if MPt performed <2y before Mt). Thus, MPI does appear to predict the location of MI, especially when the MI occurs within 2 years of MPI.
P M A P R I L
P08-230
P08-232
Patient assessment with Tc-99m ScstaMIBI SPET after acute MI: comparison between adenosine and predischarge maximal exercise
REINJECTION OF THALLIUM-201 FOLLOWING REDISTRIBUTION IMAGING IS NOT NECESSARY AT PREDISCHARGE STRESS TESTING IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION
Roberto Casanova, Maurizio Dondi, Annalisa Patroncini, Pier Luigi Guidalotti, Elisabetta Varani, Pier Franco Capacci, Aleardo Maresta Cardiologyend Nuclear Medicine, Faenza, Italy Twenty-five clinically stable patients, submitted to thrombolytic therapy after AM] end enrolled on the basis of good radionuclide ejection fraction (>45%), no early angina and no silent ischemia at Holter monitoring, enderwent adenosine (AD) SPET, exercise (EX) SPET and coronary angiography within 5+2,10-23 and 16+5 days of AMI, respectively. Three observers evaluated sestaMIBI segmental uptake for both AD-SPET end EX-SPET on the basis of a 5-point scale (0--normal uptake, 4--no uptake). Quantitative coronary angiography (QCA) was utilized to assess stenosis severity. Mild secondary effects after AD (flushing, headache, palpitation, dizziness) were observed in 21 pts (84%). Transient AV-block end ST depression were observed in I and in 3 cases.Target heart rate was achieved from all pts during physical exercise (mean workload=8.0+l.0 METS). In only 4 cases we observed silent ST depression. AD-SPET identified 265 segmental defects, as compared to 280 detected with EXSPET (concordance 90%). Severity score was almost the same (31+16 vs 32+15, for AD-SPET and EX-SPET, respectively). Both SPET studies identified all infarct related arteries. Stenosis >70% in non-infarct related arteries was detected in 80% of the cases. Defect reversibility occurred in 50% of infarcted and in 94% of non-infarcted areas with both AD-SPET end EX-SPET. Comparison of AD-SPET end Ex-SPET in selected low-risk survivors of AM] failed to show any significant difference. Assessment of presence and extent of jeopardized myocardium can be safely performed in the early post-AMI period with predischarge symptom-limited EX-SPET. Similar results are obtained with AD-SPET which may be utilized even earlier (within 5 days) and especially when pts are unable to exercise.
Donna Marchant, Jennifer H. Mieres, Stephen J. Green, David S. Kayden. North Shore University Hospital-Cornell Medical College Manhasset, NY Reinjection of thaUium-201 IT1-201) following stress/redistribution imaging identifies myocardial ischemia in -40% of defects which initially appear fixed. However, the frequency of this finding is unknown in pts with acute myocardial infarction (MI) undergoing submaximal stress testing at hospital discharge. Therefore, we prospectively studied 60 consecutive pts following acute MI with "1"1-201 stress/redistribution and reinjeetion SPECT imaging at 7.4+_2.6 days after MI. Acute angioplasty or thrombolysis was performed in 36 pts; 24 pts had conservative management. At stress/redistribution imaging, 43/60 pts had a total of 391 segments with f'Lxeddefects. At reinjection imaging, only 13/391 segments (3%) in 3/43 pts demonstrated further thallium uptake. Reverse redistribution occurred in 77 segments (12 pts). Of these, 14/77 segments (18%) in 3 pts demonstrated no change at reinjection. Although 63/77 segments (82%) in 9 pts with reverse redistribution demonstrated improvement at reinjection imaging, none had a defect less severe at reinjection imaging than at initial stress imaging. The mean stenosis of the infarct vessel in 10/12 pts with reverse redistribution was 40~_29%. Therefore, TI-201 reinjection identifies further ischemia in only 3% of fixed defects. Most defects with reverse redistribution improve at reinjection imaging and may contain viable myocardium. These findings indicate that routine T1-201 reinjection is not cost effective and does not add significant clinical information.
JOURNAL OF NUCLEARCAr~DiOLOrY Volume 2, Number 2, Part 2
Abstracts Tuesday morning, April 25, 1995
P08-233
P09-235
E F F E C T OF A N T E R I O R ST D E P R E S S I O N ON MYOCARDIAL SALVAGE ASSESSED BY TECHNET1UM-99m SESTAMIBI IN PATIENTS WITH INFERIOR MYOCARDIAL INFARCTION
POST-ISCHEMIC "STUNNING" DOES NOT FOLLOW EFFORT ISCHEMIA IN PATIENTS WITH SINGLE AS WELL AS MULTIVESSEL CORONARY DISEASE.
Mark A. Evans, Timothy F. Christian, Ian P. Clements, and Raymond J. Gibbons. Mayo Clinic, Rochester, MN, USA.
Alessia Gimelli, Oberdan Parodi, Gianmario Sambuceti, Assuero Giorgetti, Paolo Marzullo. CNR Institute of Clinical Physiologyl Pisa, Italy.
To investigate the significance of anterior ST depression in a first inferior myocardial infarction (IMI), tomographic perfusion imaging with technetium-99m sestamibi was performed in 92 patients acutely and at discharge to determine myocardium at risk (MAR), infarct size, and myocardial salvage as a percentage of the left ventricle (SALV). ST depression, defined as > l m m in >--2 precordial leads V1 to V4 was present in 51 patients (55%) and absent in 41 (45%). All patients received thrombolysis and/or primary coronary angioplasty. MAR was greater in patients with anterior ST depression than those without (23 + 12% vs. 15 + 8%, p=.0004), as was SALV (11 + 9% vs. 6 + 7%, p=.006). Infarct size tended to be larger in the anterior ST depression group (12 + 10% vs. 9 + 9%, p=.10). Salvage index, defined as SALV/MAR, was similar in the two groups (.52 + .3 vs. .48 + .4, p>.4). Conclusion: Anterior ST depression is a simple indicator of larger M A R in IMI and identifies a subset of patients who have the potential for greater myocardial salvage with repeffusion therapy.
To assess whether myocardial "stunning" occurs following effort ischemia, ventricular function was assessed by equilibrium radionuclide angiography in 29 ischemic patients (26 male, mean age 56 yrs) with no evidence of previous myocardial infarction. Patients were divided into 2 groups according to single (14 patients, group 1) or multivessel (group 2) coronary artery disease. Ejection fraction (EF), peak filling rate (PFR) and regional wall motion index (WMI) were measured in pharmacological wash-out at rest, at peak exercise and at 1' and 5' of the recovery phase. EF at peak exercise felt similarly in the 2 groups (from .58+.09 at baseline to .54+.10 in group 1 vs .58+.09 to .53+.11 in group 2, p = n s ) w h i l e W M I during ischemia was higher in patients of group 2 (2.3+1.1 ~r 1.4+.0 segment per patient, p<.01). Baseline and stress measurements of PFR were similar in the 2 groups. EF, PFR, W M I did not show significant abnormalities at 1' and 5' of the recovery phase. In conclusion, despite the occun'ence of similar systolic and diastolic dysfunction in the 2 groups, transient ischemia did not reproduce the experimental p h e n o m e n o n of myocardial stunning in patients.
P08-234
P09-236
MYOCARDIAL SALVAGE EFFECT BY IV BOLUS [NJEC'IION OF A NOVEL MODIFIED t PA E6010 IN PATIENTS WITH ACUTE ANTEROSEPTAL MYOCARDIAL fNFARCT[ON. A COMPARISON WITH PRIMARY PTCA
Long-term prognostic value of normal Thalllum-2Ol sclntlgraphy In patients with coronary disease. Dominique Pavin, Michelle Siegenthaler, Alberto Righetti Cardiology Center University Hospital, Geneva,Switzerland
Sachiro Watanabe,Hitoshi Matsuo,Tetsuo Matsubara,Motoo Kano. Shintaro Tanihata,Yoshia Nishida,Yhkihiko MatsunoJliroshi Oda. and Hiroshige Oohashi. Gifu Prefecturat Hospital.GifuJapan.
In order to assess the prognostic value of a normal thallium exercise scintigraphy(TI-202) in patients(pts) with coronary artery disease(CAD), we studied the incidence of cardiac death(CD) and non fatal myocardial infarction (MI) in 69 symptomatic pts without Q-wawe MI or revascularisation, and who evidenced significant stenosis(_>70%) on a coronarography done within 3 months (mo) (Group 1). They were compared to 136 pts ( Group 2) with an abnormal TI-201 and angiographically significant CAD and to 102 pts (Group 3) with normal TI-201 and normal or mild (<30%) coronary lesions. When comparing angiographic data between pts with significant CAD, according to TI-201 results, pts with normal T1201 (G1) had more frequently single-vessel and distal lesions than pts with abnormal TI-201 (G2): respectively 83% vs 35% and 55% vs 23% (p<0,001). After a mean follow-up of 113+43 mo in G1,90+32 mo in G2 and 105+25mo inG3, there were 1 CD and 8 MI in G1,21CD and 17 MI in G 2 , 2 CD and 4 MI in G3. Cardiac events (CD+MI) comparison between the 3 groups was determined by Kaplan-Meier on 10 years follow-up: there was no significant difference in the incidence of combined mayors cardiac events in pts with normal TI-201 with or without CAD (Gt,G2) , while the incidence was higher in G3 (p<0,05). However, if the mortality remained very low in G1, the incidence of MI was not different from G2. In conclusion, pts with CAD and normal TI-201 frequently have single-vessel and distal stenosis and a good long term prognosis, with a low incidence of cardiac death.
E6010 is a novel modified tPA in which eysteine 84 in the epidermal growth factor domain has been replaced by serine. A direct comparison of the salvage effect between iv thrombolysis using this second generation tPA and primary PTCA was performed. Thirteen patients with anteroseptal acute myocardial infarction were ramdomly assigned to the iv TL group(n=6) and primary PTCA group(n=7). For the assessment of myocardial salvage?9=Tc MIB[ perfusion studies were performed in the acute phase(for risk area image) and 4weeks after intervention(for infarct image).The defect extent and severity were quantitatively assessed and expressed as the extent score and severity score. No differences in elapsed time from reperfusion,or the size of area at risk were observed between these groups,and the patency of the infarct-related arteries was obtained in 5 of 6 pa Thecomparisonoftheamountofmyocardium tients in the iv TL group,and all 7 patients salvagedby intravenous tPA and primaryPTCA group. The salvage elfect was nearly identical between these 2 groups. These data suggest that
Es
ss =
"
iv 'nie :t'on of Er0 0 2: t;
resulted not only in high potency rate but also in a potential salvage el- ~ fect in comparison with primary PTCA.
,o 9
Ero,0 ,o•
l
r
I ~rcA ao_+~
.2o Ego,0
PrcA
$59
$60
Abstracts Tuesday morning, April 25, 1995
J O U R N A L OF N U C L E A R C A R D I O L O G Y
March/April 1995, Part 2
P09-237
P09-239
Prognostic significance of septal defect on TI-201 sclntlgraphy In pts with left bundle branch block.
PREVALENCE AND CLINICAL IMPLICATION OF REVERSE REDISTRIBUTION OF THALLIUM-201 WITH STRESS/4-HOUR REINJECTION PROTOCOL.
Dominique Pavin, Danila Persico, Alberto Righetti Cardiology Center, University Hospital, Geneva, Switzerland Left bundle branch block (LBB8) is sometimes associated with septal defect on thallium-201 scintigraphy (TI-201) in the absence of coronary disease (CAD) but its prognostic significance is unknown. 146 pts with permanent (n=132) or transient complete LBBB were separated according to the presence (G1, n=87) or absence (G2, n=59) of septal defect on planar TI-201. Pts with left anterior descending stenosis (LAD), previous anterior infarction or revascularisation of LAD were excluded. LBBB was associated with cardiac disease in 46 pts (53%) in G1 (systemic hypertension (SH),n=26 ; CAD,n=9; dilated cardiomyopathy (DM),n=9; 1 aortic regurgitatiom, 1 patent ductus arteriosus) and in 38 pts (64%) in G2 (SH,n=19; CAD,n=16, DC,n=3). After a mean follow-up of 87-+38mo in G1 and 81+41mo in G2, we observed the following cardiac events: G1 (n=87) G2 (n=59) Septal defect No septal defect
T U E S D A
Y
Cardiac death (CD) Sudden death (SD) (%CD) High degre AV block Severe congestive failure AV block + SD Cardiac events
6 (7%) 4 (67%) 7 (8%) 8 (9%) 10 (11%) 15 (17%)
ns ns
4 (7%) 1 (25%) 3 (3%) 4/7%) 4 (7%) 9 (15%)
These data suggest, that in patients with LBBB, the presence of septal defect on exercise TI-201 scintigraphy, unrelated to LAD disease, does not adversely affect the long term outcome in coml~adson to pts with LBBB but without septal defect.
Janusz Lipiecki, Jean Maublant, Jean-Michel Tarlet, Francois Cellier, Fr6d6ric Jousse, Danir Mestas, Bernard Citron, Annie Veyre, Jean Ponsonnaille. University Hospital, Clerrnont-Ferrand, F, Although the oceurence of reverse redistribution (RR) is well documented at 4 hrs after a stress injection, its frequency and clinical implication are not clear when reinjection (reinj.) is performed. The SPECT images of a series of 577 consecutive patients (pts) who underwent a T1-201 stress/4-hr reinj, protocol were read twice. The incidence of RR was 9,7% (56 pts). A stress abnormality was observed in 91% of all pts and evidence for reversible ischemia in another territory than RR occured in 29%. RR appeared either at the periphery or at the same location than the stress abnormality in 78%. A remote myocardial infarction was present in 46% (26 pts) and RR was noticed in 65% of these territories. A follow-up of 135:6 months demonstrated a rate of cardiac events of 50% (28/56 pts), regardless of the presence or absence of reversible defects. It is concluded that (1) the frequency of RR with stressJ4-hr reinj, seems to be similar to that described at redistribution, (2) cardiac events are frequently present at follow-up in pts with RR.
P M A P R I
L
P09-238
P09-240
PROGNOSTIC UTILITY OF INCREASED PULMONARY THALLIUM UPTAKE IN PATIENTS WITHOUT ISCHEMIA N. Zafrir, S. T. Dahlberg, B.J. Villegas, J. A. Leppo, UMass, Worcester, USA; Beilinson Medical Center, Israel
EXERCISE RADIONUCLIDE CINEANGIOGRAPHY IN CORONARY ARTERY DISEASE: GENDER SPECIFIC PROGNOSTIC IMPLICATIONS P Supino, JS Borer, Comell Medical Center, New York, NY, USA
Although the combination of increased pulmonary thallium uptake (IPTU) and ischemia has demonstrated prognostic utility, the value of IPTU independent of ischemia has not been critically evaluated. Accordingly, we studied two groups of patients (pts) with IPTU and either normal (NL, n = 48) or fixed defect (FD, n=44) scans and compared them to control (CON, n=92) pts without scan defects or IPTU. During a mean follow up of 23 • 13 months, there were 15 cardiac events (death or MI) and the incidence per year was 0.6%, 2% and 12% in the CON, NL and FD groups, respectively (p < 0.00001). Life table analysis demonstrated better event-free survival in the CON and NL groups compared to FD. When compared to the CON pts, those with IPTU and NL scans had a higher incidence of congestive failure and bypass surgery while those with IPTU and FD scans had increased LV cavity size and a higher proportion of male pts (p<0.002). A Cox regression analysis showed that the number of scar CON 10 regions was the most important independent prog0.~ nostic factor (p
To determine whether exercise(ex) radionuclide cineangiography(RNCA) predicts nonsurgieal(non-S) cardiac events (myocardial infarction or death) and total non-S or surgical events(TE) differently according to gender, we evaluated clinical course of 33 clinically stable women and 251 stable men with catheterization-proven 3-vessel CAD or prior CABG who were studied by exRNCA. During avg 8 yr followup, 4 women had MI, 2 had cardiac deaths, and 6 had CABG. Both non-S and TE events were more frequent in women whose EF fell severely with ex (AEF<-8%) than in those with z~F 0 to -7% or AF.F> 0% (p<.0005 [nonS], p<.0001 [TE]). While end-point rates were similar by gender, women with AEF_<<-8%were more likely to have non-S events (9<.02) and higher TE rates(p<.001) than comparably ischemic men. Thus prognostic implications of ischemia severity, though statistically valid for both groups alone, may differ according to gender. This fact may be important in interpreting the results of RNCA for management decision making.
JOURNAL OF NUCLEAR CARDIOLOGY Volume 2, N u m b e r 2, Part 2
Abstracts Tuesday morning, April 25, 1995
P09-241
P09-243
EXCELLENT RISK STILa,TIFICATION USING AN ABBREVIATED "EXERCISE-ONLY" TC-99M SPECT PERFUSION IMAGING PROTOCOL CD Santos-Ocampo, AD Camara, FT Mendoza, EV Villacorta. Makati Medical Center, Philippines
THREE YEAR PROGNOSIS OF PATIENTS WITH SUSPECTED CORONARY ARTERY DISEASE AFTER A NORMAL DIPYRIDAMOL THALLIUM SPECT SCINTIGP,A M
Myocardial perfusion scintigraphy is usually performed using separate stress (STR) and rest (RST) images. This study theorizes that if the STR is normal, then the RST is most likely normal. Hence, the latter phase can be omitted. The clinical outcome of 135 consecutive patients who underwent STR SPECT imaging without RST was followed. There were 109 males. The mean age was 48 (range 30-71) years. Sestamibi was used in 59.4%; tetrofosmin in 40.6%. Scintigraphic interpretation yielded 118 normal, 12 abnormal and 5 equivocal findings. Clinical data (average follow-up=97 days) are shown below: Perfusion Image Result: Asymptomatic Chest pain Cor angio (normal) (abnormal) PTCAJCABG
Normal 116 (98.3%) 2 (1.7%) 0 0 0
Abnormal 4 (33.3%) 2 (16.7%) 3 (25%) 5 (41.7%) 2 (16.7%)
Conclusions: (1)Patients who have normal "exercise-only" Tc-99m SPECT studies yield excellent short-term prognosis (2)Clinical decisions without the rest images may be made in low risk patients minimizing cost and patient/laboratory time.
M Trabulo, V Gil, L Sousa, R Cunha, J Ferreira, J Calqueiro , A Ventosa , R Seabra-Gomes. Hospital de Santa Cruz, Carnaxide, Portugal. The long term prognostic significance of a normal exercise thallium is well established although it is less clear for dipyridamol. We selected 43 patients (pt) referred to a tertiary center,16 male, age 55.8_+9.2 years, with a normal dipyridamol thallium SPECT (D) and a minimum follow-up of 36 months. Pt with previous revascularization or non-coronary heart disease were excluded. Angina was present in 42 pt and 14 in 28 pt had a positive stress test. Coronary angiography was done in 10 pt: 8 were normal, 1 had minor CAD and 1 a congenital coronary anomaly. During a follow-up period of 37.8+5.5 months, one pt suffered an inferior myocardial infarction 28 months after D. No pt had unstable angina, CABG, PTCA 0r death. Twenty-eight pt still complain of chest pain. The event rate was 0.78% per pt per year. Conclusion-Long-term prognosis after a normal dipyridamol thallium SPECT is excelent, even for patients with persistent anginal pain and for those with a previous positive exercise test.
P09-242
P09-244
ISCHEMIA BY MYOCARDIAL PERFUSION IMAGING PREDICTS FUTURE CLINICAL EVENTS IN PATIENTS WITH NORMAL RESTING ELECTROCARDIOGRAMS
PROGNOSTIC VALUE OF THALLIUM REDISTRIBUTION IN PATIENTS WITH ISOLATED STENOSIS ON LEFT ANTERIOR DESCENDING CORONARY ARTERY
Robert J. Leon, Ronald G. Schwartz, JM. Eckdahl. Univ. of Rochester Medical Center, Rochester, NY, USA.
Maurice Levy, Thierry Perez, Michel Hiltgen, Michel Bellorini, Serge Godard, Bruno Gallet, Raymond Grymann, Yves Chestier, Gilbert Pochmalicki, Richard Benaim, Hopital europ6en de Paris France.
Clinical and cost efficacy of the role of radionuclide myocardial perfusion imaging (MPI) in patients (pts) with normal resting ECGs has been questioned. To evaluate this, we reviewed our laboratory database of 3,072 pts and found 754 pts who had normal resting ECG's. 55 of these (7.2%) had moderate to severe ischemia in >__2 segments. 47 pts had ETT and were not lost to followup. Of these, positive predictiv6 accuracy (PPA) for clinical events within 6 (range 0-28) months was 75% (N=35) including cardiac death (n=l), nonfatal MI (n=l), CABG (n=24), PTCA (n=8), and progression of symptoms requiring change of therapy (n=l). Lower PPA was observed for angina during ETT (70%), low exercise duration (28%), inadequate HR (45%) and BP (36%) responses to exercise, and stress ST changes (53%). Conclusion: Multisegment ischemia by MPI occurs infrequently with a normal resting ECG, but is associated with the highest PPA for identifying costly clinical events compared to standard treadmill testing variables.
To assess the pronostic value of thallium redistribution in patients (pts) with isolated left anterior descending coronary artery (LAD) we analyzed 80 pts who underwent thallium tomoscintigraphy (SPECT) between January 91 and February 94. SPECT followed exercise stress in 64/80 pts and dipyridamole injection in 16/80 pts. Stress images are followed by redistribution images with thallium reinjection. Cardiac events (CE) are defined as : cardiac death (CD), revascularization (RV), myocardial infarction (MI), unstable angina (UA). In the group of pts (21/80) with no redistribution : 1 lost for follow up, 1 non cardiac death, 4 CE (21%) (RV). Mean follow up for the 15 pts without CE is 19.39 months. In the group of pts (59/80) with partial or complete redistribution or normal SPECT : 26 pts (44%) have CE : 23 RV, 1 CD, 1 UA, 1 MI. Mean follow up for the 33 pts without CE is 18.85 months. In conclusion no redistribution in pts with isolated LAD stenosis identify a group with a significant (p<0,05) lower risk of CE when compared to the group with redistribution.
$61
$62
Abstracts Tuesday morning, April 25, 1995
J O U R N A L OF N U C L E A R C A R D I O L O G Y
March/April 1995, Part 2
P09-245
P 10-247
T H E VALUE OF MYOCARDIAL PERFUSION SUIN'rlGRAPBY (MPS) IN ANGIOGRAPHICALLY PROVEN CORONARY ARTERY DISEASE (CAD) G. Walsh, G.C. Viv~e~, C.J. Burrell, A.J. Marshall Derriford HospRal~ PI)mouth, United Kingdom
Rodionnr
The ~hoice between i n t e r v e n t i o n and medical management in pati~mts w i t h C,~D depends on the signiiieanee of the stenoses. We have investigated the influence of MPS on managemea~t of patienls with multiple legions demoogc.~ted on coronary angiography (CAG). From November 1992 to Novea~_b~ I993, 38 pati~alts '~ere referred for M r s following CAG These patients bad multiple m~o~aN~ie stenoses of severity 40-70% and the influence of these lesions on myocardial peffusion was not eer~ain. 400 ml3q T o 9 9 m MIBI were injected at rest stud s~'ess (2-day proloeol) 180" SPECT acquisitions were made using an IGE 400 ACT Gamma camera and processed on Nuclear Dia~aostic~ Garm~a I! computer. Studies were analysed visually and with a bull's eye projection. UAG lesions were assessed visually.
A~tthors:
ImagingScorein Post M1 Patients S. ||tw~ien Omar; M.S. M~khtar, M.D.; W. Radwsm, M.D.; G. Ziada, M,D.
To asse.s~the value of radinnuolide lmagin8 in stratifying patientsalter ~cute Myocardial Infarction (MI), we studied 3h paliea~ (33 male, 3 female, mean age 46) at an average of 26 week~ Oange 24 to 50 weeks) post MI which was tnterlot in 24 and inferior in 12 p~. Infarct size was asseseed by I~KG(QRS Selve~r looting system) sad Echo scoring system, patients were subjected to myoeantial perf~inn stre~s and r~t hnaging ~in~ Thidlinm-201, Image~ wer~ ~ly~ed vmually after dMding ~h~ |oR ventt/cle into 20 eegmen~ end with the degree of perfu~ion exprea~ed on a scale of 0-4 with a figure given to e~ch ~egment~o~ding te its degree of perfl~ion and final scc~r~ wan calculatedfor both rest mid stxe~. An arbltr~ score of 6 could identifyt~o group~ of patients regardh~g cardiac events (angina, MI eaadheart fai|ufe) which could not be di~imgui~hed onEKG emd Echo sco~g. Number of segmentwlthpermeneaRdefect 6and reven~ib!esegmemts -< 3 wasslgnificlmtlyprediefiveofprognosls. Survlveleurve4 showed the difference. &
'~'~ I t~'l,
.... I .... I"~ 3 I"~ I . ~ "
An61na
I
1[
io
2
2
18
5
Ile~rt Failure
8
2
2
6
8
2
l0
I" "1
R~u~ 2 11 7 8 7
T U E S D
CAG Normal l/2 Vessel 1/2 Vessel 2/3 Vessel Post CABO/PTCA
l~.q Normal Normal 1 Vessel 2/3 Vessel 3 Normal 3 '1 Vessel' 1 '3 Vessel'
TREATMENT None Medical PTCA CABG Medical PTCA Repeat CABG
2 patienk~ were inadequately stressed and MPS tmdetestimated disease extent in I case. Conciuskm MrS is a useful adjunct to CAG with si~ifieant m3plieations for patient management.
A Y
MI Total Patl~tt
I
9
16
I
24
12
1
22
14
I
1
16
20
Patien~ were also subjected to multigated ro.Aionucllde stodle~ both at r~ and after Dobutsmiae (gradual incremeut in dose from 5 to max. of 40 uc/kghnin, we~ used). Ejection Fraction (EF) at rest end with etre~s, maxlmmn fitti~ end emptyln8 r~t~, ptuteeangle for r ~ oaul styea~~md ejec~tionfraction difference between stress erel ~ t ( ~ EF) ,~ere caicul~e:d. An ~rbitr~' flg~e of 8 for ( ~ EF) coukl identify 3 groups of pts accotxlingto the occurte.nce of c~rdiac events (Angina, MI) ~ well ~.l~e~gl failorr ( H ~ . In conclusion, spear scoringprovides u ~ef~l uon-inve~ive tool in stratlfyiai post M1 gatient&Radinnuelldr ventrlcu|og~phy using muRigated cardiac blood pool imaging could clearly dletinguish pm with unfavoorable outcome after MI with signific~a~tlyhigher incidence of cardlac events for those having ~ EF difference ~ g % compared to those obove 8%.
P M A P R I L
P09-246
P10-248
Tc-99m MIBI MYOCARDIAL PERFUSION SCINTIGRAPNY IN LEFT BUNDLE BRANCH BLOCK (LBBB) A EIImann, BB van Heerden, PDR van Heerden, Tygerberg Hospital and University of Stellenbosch, Cape Town, South Africa In patients with LBBB TI-201 stress perfusion scintigraphy often detects a false positive ischaemic pattern in the interventricular septum. The aim of this retrospective study was to determine the scintigraphic appearance in LBBB with SPECT using Tc-99m MIBI. We studied 51 patients with LBBB, referred for routine MIBI stress-rest SPECT. Studies were evaluated b)/ visual analysis and the Cedars Sinai grading protocok Ischaemic heart disease was confirmed or excluded by angiography or clinically. Normal studies were obtained in 28 of the 51 patients (55%). Thirteen patients had abnormalities only in areas other than the septum, while 10 patients had septal defects. Of these, 36 of the 80 septal segments were involved - 15 irreversible. In the remaining 21 segments (7151 patients) the stress and rest studies differedby 2 or more grades indicating reversible ischaemia. This represents only 5% of the total number of septa segments. With the exception of 1 patient, ischaemic heart disease was proven. Our results show that with MIBI, in contrast to TI-201, reversible perfusion defects in the septum a r e seen only in a minority of patients with LBBB on myocardial perfusion scintigraphy . Alt these patients had proven ischaemic heart disease. Therefore the septal changes indicate true positive results, Tc-99m MIBI is a better nBYBocardialperfusion agent than TI-201 in patients with B
PROGNOSTIC EVALUATION AFTER MYOCARDIAL INFARCT (MI):INCREMENTAL VALUE OF MIBI-SPECT AND ECHO, P Zanco, A Zampiero,A Favero,N Borsato, PG Piovesana,D Rubello and G F e r l i n , Nuclear MedicineCastelfranco V and Cardiology-Camposampiero,ITA To compare the r o l e of d i f f e r e n t c l i n i c a l f i n d ings and instrumental techniques in r i s k s t r a t i f i c a t i o n o f MI pts,86 pts affected by a MI occur Pin 9 at l e a s t 3 mo b e f o r e ( 8 2 m , 4 f , aged 2 7 - 6 8 y r s ) were submitted to stress-rest MIBI SPECT and to echo,calculating wall motion index(WMi)and the ejection fraction(EF).Age, gender,risk factors for CAD,angina,stress double product and heart rate,ST depression during stress were also included in the analysis.The ensuing cardiac events(CE)were recomded;the minimum f o l l o w up was 4yrs(range 48-72mo,mean 55).At the m u l t i v a r i a t e analysis a r e v e r s i b l e defect on MIBI SPECT (p= 0,014),a low EF(p=0.015),a NMI superior to 1.4 (p=0.024)and angina(p=0.034)were s i g n i f i c a n t and independent prognostic factors of ensuing CE. Thus, in our experience,both NIBI SPECTand echo proved to be fundamental p r o g n o s t i c t o o l s in risk stratification o f p a t i e n t s with myocardial infarction.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday morning, April 25, 1995
P 10-249
P10-251
Quantitation of Acute Experimental Adriamycln Cardiotoxicity by Indium-Ill-labeled Antimyosin Fab.
ASSESSMENT OF MYOCARDIAL VIABILITY BY N - 1 3 - N H 3 AND F - 1 8 - F D G IN PATIENTS WITH RECENT MYOCARDIAL INFARCTION
Jayesh Vora,, Mehdi Boroujerdi, Jagat Narula, and Ban-An Khaw. Northea~ern University, Boston, MA. Although adriamycin (ADR) has a wide spectrum of antitomor activity, its use is limited by severe cardiotoxicity. The extent of acute myocyte damage following ADR sdminis'tration was assessed with i.v. ln-lll-antimyosin Fab (AM) to relate ADR dose to the degree of AM uptake in 2 strains of tats (Sprague-Dawley, CD; and Fischer 344, F344). ADR and AM were m'lministered by three regimens: (a) 24-24: ADR i.v. at time 0, AM at time 241-1 and sacrificed at 48H; Co) 48-48: ADR i.v. at time 0, AM at 48H and sacrificed at 96I-/; (e) 6d-24: ADR i.v. at time 0, AM at 6 days, sacrificed 24H later. Mean AM uptake in the myocardium was as follows: bXetu % I~lected Dese/g + SD ADR CD 24-24 ~ 6d-24 CD 48-48 F344 48-48 0 0.11_+0.0l(n=6) 0.1l_+0.01(n=4) 0.15+0.01(n=4) 4 0.15_+0.01(n-'-4) 0.14_+0.01(n=4) 0.10L-0.01(n=5) 10 0.21_+0.01(nffi4) 0.19~.07(n=5) 0.17+.0.02(n=4)0.t7+0.01(n-=4) 20 0.18+0.02(n=3) 0.15+0.02(n=4) 0.20+0.04(n=5) . Our study demonstrates that acute AM uptake increases linearly with ADR dose and reaches a maximum at a dose of ~10mg/kg in the CD rat& lVtaxirrmlmyocardial damage is seen at 20 mg/kg dose in F344 rats suggesting strain variability. AM uptake reflecting myocardial necrosis is similar after acute or subacute assessment of ADR cardiotoxicity denoting early occurrence of myocyte danmge.
Toshiisa Uehara, Tsunehiko Nishimura, Yoshio Ishida*, Hiroshi Nonogi*, Kunio Miyatake* Osaka University Medical School, National Cardiovascular Center*
Osaka, Japan F - 1 8 - F D G PET study is suggested to be the most reliable method for estimating myocardial viability. We compared the F - 1 8 - F D G (after oral75g-glucose intake) and N - 1 3 - N H a PET in 9 patients with recent myocardial infarction (MI) successfully reperfused in acute period. These 9 patients were divided into 2 groups, 3 of large amd 6 of small MI, by laboratory data and left ventriculography performed I - m o n t h after MI onset. Quantitative analysis using ROI method was performed on F - 1 8 - F D G and N - 1 3 - N H 3 Bull's Eye Map. The myocardial accumulation of N - 1 3 - N H 3 correlated well with the myocardial viability, and separated well the two groups (large and small MI). In contrast, F - 1 8 - F D G myocardial accumulation in the glucose-loading state did not correlate well with the myocardial viability as N - 1 3 - N H z , and did not separate the large from small MI. Thus, F - 1 8 - F D G in the glucose loading state by oral intake did not correlate to the myocardial viability quantitatively.
P 10-250
P 11-252
IS RADIONUCLIDE RIGHT VENTR1CULAR EJECTION FRACTION AN INDEPENDENT PREDICTOR OF OUTCOME AFTER MYOCARDIAL INFARCTION? L Parreira, M Ahneida, J Ferreira, V Gil, J Calqueiro, A Ventosa, R Seabra-Gonles. Hospital de Santa Cruz. Camaxide. Portugal.
PERIOPERATIVE C O N T I N U O U S M O N I T O R I N G OF LEFT V E N T R I C U L A R FUNCTION (LVF) IN P A T I E N T S (PTS) U N D E R G O I N G NONCARDIAC SURGERY M. I m b r i a c o , J. T i a n , SDJ. Yeh, A. F r i e m a n , E. Macalintal, S. Larson, S. G o l d s m i t h . M e m o r i a l Sloan Kettering Cancer Center, NY NY, U.S.A.
The pro~aostic value of left ventricular ejection fraction after myocardial infarctton is already well established. The aim of this study was to assess the value of right ventricular dysfunction (RVD) as a predictoz of outcome after myocardial infarction(MI ) We studied 37 patients (34 men, mean age 56+10 years), with nmltigated Q9mTc angmgraphy, within 1 year after myocardial infarction tanterior m 25 pts and inferior in 12 pts) Right and left ventriculaf ejection fraction (RVEF and LVEF) were measured by gated radionuclide ventriculography. No cardiac events ocurred between the study and the MI. Results: LVEF was 47_+12 and RVEF was 44+10 RVD was defined as RVEF~35% (7pts), and left ventricular dysfunction (LVD) as LVEF: 35% (6pts)During the follow-up time (mean 77-+20 months) 2 pts were droped out. 5 pts developed heart failure, 16 pts experienced coronary events (post infarction an~na, remfarction, unstable angina, CABG or PTCA). Four pts out of 5 with NYHA_>2 had RVD. but 3 pts also had LVD Coronary events were more frequentin pts wath LVD (83%) than m pts without it (38%).The presence of RVD did not correlate with coronm7 events in follow-up Conclusions: In this group of patients, right ventrictdar dysfunction did not seem to act as an independent predictor of prognosis, neverthless, it was associated with a hi~ler rate of patients with heart failure.
Postoperative myoCardial ischemia is a common finding in pts with coronary artery disease (CAD) undergoing major surgical procedures. Previous studies demonstrated low specificity of ECG ST segment changes for the detection of ischemia in these pts. Our aim was to evaluate the usefulness of an ambulatory radionuclide detector (Vest) for monitoring LVF & ECG in pts undergoing noncardiac surgery. 18 pts (14M, 4W, mean age=69:l:7) were studied by Vest (mean 195min, range 100-480 min.) within 16 hrs after noncardiac surgery. Vest study was normal in 8 pts with no history of CAD. A transient spontaneous decrease of LV ejection fraction (6-12%) lasting 1 min. was observed 34 times in 10 pts with CAD. 14 of these episodes were accompanied by chest pain & 20 were asymptomatic. In 6 of the 14 symptomatic & 5 of the 20 asymptomatic episodes, EGG ST segment depression suggestive of ischemia was recorded. This study shows that simultaneous monitoring of LVF & EGG may enhance the detection of ischemia in pts with CAD undergoing surgical procedure. Vest may also provide a better u n d e r s t a n d i n g of ischemic mptomatic & asymptomatic episodes in the early hrs of postoperative period.
$63
$64
T U
E S D A Y
Abstracts Tuesday morning, April 25, 1995
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
Pll-253
P12-255
EVALUATIONOF B-BLOKER THgRAPYIN PATIENTSWITR ~ILATg~ C~IOk~OPA~C~ --STUIIY BY 1331-MIBGMYOCARDIALSPECT--
LEFT VENTRICULAR ISCHAEMIA DETECTED BY PERFUSION STUDIES IN PATIENTS WITH SEVERE AORTIC STENOSIS AND NORMAL CORONARY ARTERIES.
Junichi Yamazaki, Mihoko lida, Masaki Igarashi, Hiromitsu Hosoi, Satoshi [shiguro, Hiroshi Muto, Toshio Kabano, Takeshi Morishita. Ist,Dep. of Int. Med.,Ohmori Hospital, TOHO Univ. School of Mad., Tokyo, JAPAN
Dennis G. Caralis, Amjad All, Eugene F. Uretz. Rush University, Rush Medical College, Rush-Presbyterian St. Luke's Medical Center, Chicago, USA.
NlBG-myocardial SPECT were performed on 16 patients with DCM before and after or during /3-blocker therapy, and severity of DCM and therapeutic effect due to /3blocker were evaluated. The washout rate(WR) of the LV, extent score(ES) and severity score (SS) were calculated from short axial images using the Bull's eye method, The correlation between LVEF and WR which was obtained after /3-blocker therapy was significant(r=-0. TS1), In the early image after/3-blocker thrapy, correlation between LVEF and SS was significantly demonstrated (r= -0.635),Similarly correlation between WR and SS in the delayed image w~s significantly de~onstruted {r=-0.573}. The normalization of the LV function and remarkable improvement of the WR were found in 3 of 4 cases where NIBO-myocardial SPECT imaging was performed before and after /3-blocker therapy. It was suggested that MIBG is useful for evaluation of the severity of DCM, indication of /3-blocker therapy, decision of the maintenance dose and evaluation of the prognosis.
We tested the hypothesis that severe Aortic Stenosis (AS) can be a cause of myocardial Ischaemia (Is) in patients (pts) with angiographically normal coronary arteries. (Is) was determined by myocardial perfusion Scintigraphic and Tomographic images with Thallium-201 IV injection following low level exercise, at rest and after reinjection 24 hours later, Entry criteria into this study: pts with severe AS, no other structural cardiac abnomalities by echocardiography and normal coronary arteries. Study population: ten consecutive male patients, age range 47-66 years, Range of Aortic Valve area: 0.4-0.8 cm=/m =. Range of Mean Valve Gradient: 60-105 mmHg. Eight pts had significant (ls~: primarily Reversible Defects and Persistent Defects as w e l l with viable myocardial segments. Following valve replacement, the ischaemic changes normalized. Two of the eight pts with severe AS had no myocardial perfusion abnormalities.
Severe AS can be a cause of LV (Is) in pts with normal coronary arteries.
P
M A P
R I L 2 5
Pll-254
P12-256
DECREASED CARDIAC SYMPATHETIC ACTIVITY AFTER 6 WEEKS TREATMENT WITH ENALAPRtL IN PATIENTS WITH CONGESTIVE HEART FAILURE; A QUANTATIVE MIBGSPECT ANALYSIS.
COMPARISON OF MITRAL REGLrRGITATION USING COLOR DOPPLER ECHOCARDIOGRAPHIC TECHNIQUES A.WD RADIONUCLIDE VENTRICULOGRAPHY.
G. Aernout Somsen, Bob van Vlies, dudocus J.J. Borm, Paul A.R. de Milliano, Eric A. van Royen, Kong I. Lie. Academic Medical Center, Amsterdam, The Netherlands. In patients with congestive heart failure (CHF) cardiac noradrenaline (NA) content is decreased 'as can be visualised by MIBG-SPECT. ACE-inhibitors improve prognosis and functional capacity and reduce plasma noradrenaline (NA). Whether ACE-inhibitors increase cardiac NA content reflecting reduced cardiac sympathetic actMty (CSA) is not known. To assess the effect of ACE-inhibition on CSA quantitative MIBG-SPECT data before and after 6 weeks enalapril treatment were compared in 23 stable, NYHA class 2-3, CHF patients. SPECT images were obtained 4 hours after injection of 185 MBq MIBG. A dedicated program (CASPAN) was used to quantitate myocardial MIBG uptake. Absolute myocardial MIBG activity was calculated using the 1231 activity in a venous blood sample. The average dose of enalapril was 13.5(_+6.11) mg/bid. Myocardial MIBG activity increased from 16.5(+_8.4) to 20.0(+-9.5) Bq/ml/MBq-iniected dose (p=0,013). Conclusion: enalapril lowers cardiac sympathetic activity in CHF patients. This might be one of the explanations for the favourable effects of enalapril.
SPavlovic, B.~ujisic, KKovacic, D.Sobic, ,.Mari~kovic, N.Kozarevic, VBosnjakovic, Nuclear Medicine Institute and Institute for Cardiovascular Diseases, Clinical Center of Serbia. Belgrade Values of re~urgitant indices estimated by radiqnuclide. ventriculograpfiy were correlated with seventy of mitral regurgitatmn determined using different transthoracic and transesophageal color Doppler (CD) techniques. There were 51 patients with different stages of mitral regyf~itation diagnosed by cardiac cathe'fe.risation.. The following parameters were determined . using transthoracic echocardiography: regurgitant iet lentil (JL), ratio of regurgitant jet length and leIt atriaI length (RJLAL), re~i-.~itant jet area (ILIA), ratio ot regurgitant jet area and left atrial area (RJAAz~),. regu~.gitant 3at wiatli (RJWT) and regurgitant jet width derived f r o m tra'nsesophageal ectiod~diography (RJWE).The results were as follows: " CD ]L - I~)LAL /RJA RJAAA RIVT /pav~
I N CORRELATION i SIGNIFICANCE , COEFFICIENT i 39 0.63 p<0.001 [ 39 0.40 p<0.05 '51i 0,50 ' P<0.001 i 51 0.30 i p<0.05 31 0.66 I p<:O.O01 s4 l 0.7s t, p
The best agreement in mitral regur~tation assessment y,~.as found between regurgitant index and regur~tant jet width obtained using transesophageal echocardiograp-hy
JOURNAL OF NUCLEAR CARDIOLOGY
Abstracts
Volume 2, Number 2, Part 2
Tuesday morning, April 25, 1995
P 12-257
P13-259
CHRONIC AORTIC REGURGITATION. PREOPERATIVE VALUE OF THE MYOCARDIALPERFUSIONIMAGESIN 30 CASES. Bialostozky D, Q~iroz At. Ramirez JC, Malo R. AlexaodersonE,Victoria D: InstittrtoNational de Cardiologia,IgnacioChavez. MEXICO.
EFFECT OF BETA BLOCKERS ON BIVENTRICULAR FUNCTION IN CONGESTIVE HEART FAILURE.
Patients (pts) with chronic aortic regurgitation(AoR) remain asym~om~ic for many years despite severe left ventricular volume overload. By the time angina or dyspnea occur, many have irreversible left ventricular dysfunctiol, (LVD) and their postoperative course will be at high risk, despite a tecinlic~lly succesfidl valve replacement. Timing for valve replacement remains ~ ehaUenge. Important informationhas been obtainedthrough systolicand diastolic indexes, e.g. preoperative ejection fraction is valuable in dafming low and high risk pls. Clinical outcome is excellent with low preoperative risk and has a long-term survival. LV systolic dysl~nction is not always an irreversibleprocess. The LV dysfunctinnmeasurements retied the consequences OFthe myocardial derageu!ent. Chronic AoR develops focal areas of neerosis, interstitialfibrosis and isehemia that plays a important role in the developmentof myocardial dysfxmctiott. Preoperativeassessment of myocardial injury has been determinedby catheterization with evaluation of anaerobic threshold and coronary reserve. Myocardialscintigraphyott~.-rsan obiectivenon invasivemethod for evaluatingmyocardial peri~sionderagements. RESULTS: 30 pts, 42 + 17 years, 23 males, 7 females. All had clinicalwork.up with ECG, Chest X ray, Echo; 19 were catheterized. PLANAR- TI-201 was performed in 22 pts and SPECT-SESTAM[BLm8. Clinical data, ECG, Xray, EC[{O and mainly hemodynamics determined the de.',jee OFAoR: severe in 13 pts., moderate in 13 and mild in 4. Myocardial p~afusinn was found abnormal (important hypoperfusion without reversibility,with re'~ersibilityand/or necrosis) in 14 pts: was associated with severe AoR in 10 pts and in 4 with a moderate degree OFAoR. Normal perfusionwas found in 16 cases: 3 with severe AoR and 13 with a motk~ate degree. In the cases with mild AoR perfi,sion was always normal.. Severe degree of AoR. is not necessarily accompanied with ilnportant myocardial deragement. Moderate AoR degree could show important myocardial nijury.Fisher'sexact test: p= 0.0046; overall sensitivity: 70%; positive predictive value: S7%. CONCLUSIONS: Myocardial perfusion images should always be included in the fraraework for a preoperative rational lreatme~t strategy since it adds to the severity of the AoR the important data of the ab~'nce or presence, the de~'ee and extension of the myocardial damage. Also postol~:rative perthsion images offers objective data of the surgical results. The abnormal perfusion findingsare involvedin the genesisof the myocardialdysfimction.
M. Henzlova,M. Kukin,J.Machac, MountSinai Medical Center, New York, New York, USA Beneficialeffect of beta blockers(BB) on leftventricularfunction in pts with CHF is known. Their effect on the right ventricular function is less well understood, tn 41 pts with symptomatic CHF, BB were added to standard therapy. Gated blood pool imagingwith LVEF and RVEF determinationand rightheart cath were done at baseline (BASE) and at 3 months (BB): LVEF(%)
RVEF(%)
lachemic
BASE BB 16_-+6 23+13
BASE 18+8
BB 22+-8
Idiopathic
16_+6 25!-_13 17+10
22-&-9
All EF changes (BASE-BB) were significant (p<0.01), both in pts
with isshemic and idiopathiccardiomyopathy. RVEF increase was alwaysaccompaniedby LVEF increase. LVEF increasedby > 5% in 20, RVEF in 21 pts (Gr.1) and by <5% in 21 and 20 pts, resp. (Gr,2). BASE hemodynamics(BP, SVR, HR, pulmonary pressures,CI, SWl, PVR) were similarin Gr.1 and 2 (all p>0.05). The magnitudeof hemodynamicchanges (BASE-BB)was similar in Gr. 1 and 2 (all p> 0.05). Thus: LVEF increase after BB is accompaniedby similar RVEF increase. It is unrelatedto CHF etiology and can not be predictedfrom baseline hemodynamics or fromthe magnitudeof hemodynamicchangeafter BB.
P13-258
P 13-260
THE USEOF 123I-MIBG TO ASSESSMYOCARDIALSYMPATHETICNEURONAL INTEGRITYIN PATIENTSWFFHCONGESTIVEHEARTFAILUREBEFOREAND AFrER ACE INHmrrloN
NON INVASlVE LV FUNCTION ASSESSMENT BY SIMULTANEOUS RADIONUCLIDE ANGIOGRAPHY AND OXYGEN CONSUMPTION AT REST AND DURING EXERCISE. M. Faraggi, A. Cohen-Solal, D. Czitrom, Y. Petegnief, R. Gourgon, D. Le Guludec, Bichat and Beaujon Hosp., Paris, France.
H K H a m d a n 1, RM Poyner 2, C M Boivin2 , PJ Mountford 2 , W A Littler I , MK Davies 1 Departments of Cardiovascular Medicine 1 and Nuclear Medicine 2 , Queen Elizabeth Hospital, Birmingham, UK M e t a i o d o b e n z y l g u a n i d i n e (MIBG) is a n o r a d r e n a l i n e a n a l o g u e which reflects sympathetic neuronal uptake and function. Previous studies have demonstrated reduced cardiac 123I-MIBG uptake in patients with congestive heart failure (CHF). OBJECTIVE: To s t u d y myocardial MIBG u p t a k e in patients with CHF undergoing therapy with Quinapril, an angiotensin converting enzyme inhibitor (ACEI).
METHOD: We have studied 7 patients so far w i t h moderate heart failure (NYHA l l / I I I ) , m e a n age 54 + 7 years. A l l patients u n d e r w e n t cardiac 123I-MIBG t o m o g r a p h y before and after 4 m o n t h s treatment w i t h Quinapril. Cardiac MIBG quantification was performed u s i n g regional analysis of the s h o r t axis views to calculate the total uptake w i t h i n the left ventricle. In addition, a heart : l u n g ratio was determined from a planar anterior view. RESULTS: After Quina~ril therapy, the m e a n increase in heart : l u n g ratio was 10.4 + 9.4Yo (one sample t-test p=0.03) and the mean increase in left ventricular uptake was 16.0 + 22.6% (p=0.1, NS).
CONCLUSION: Cardiac MIBG i m a g i n g m a y be helpful to assess non-invasively the i m p r o v e m e n t in sympathetic neuronal integrity in p a t i e n t s w i t h C H F f o l l o w i n g ACEI. The l o w statistical significance is at least partly due to the small n u m b e r of patients studied so far.
Rest and exercise (Ex) left ventricular ejection fraction (LVEF) are frequently used to assess LV function in patients with congestive heart failure (CHF). However LVEF is strongly afterload dependant and poorly correlated with symptoms and exercise capacity. The ratio between LV end-systolic blood pressure (ESBP) and LV end-systolic volume (ESV) was proposed as an invasive index of inotropism. Non invasive methods usually estimated ESBP with peak systolic brachioarterial cuff pressure, but absolute ESV determination remains critical. The simultaneous measurement of peak oxygen consumption at exercise (VO2) and LVEFEx allows to non invasively calculate ESBPEdESVEx without estimating ESVEx: Rest ESV and ESBP tESV are secondly derivated. 20 patients with proven idiopathic CHF (rest LVEF<45%) and 8 normal subjects were investigated. At peak of a maximal Ex, both LVEF and ESBP/ESV increase in normal subjects (71• to 79• and 4.2• to 9.4• mm Hg/ml both p<10-2) while LVEF decreases (28+12 to 25+15%, NS) and ESBP/ESV slightly increase in patients (0.8+0.4 to 1.1• ESBP/ESV values were 5 to 8 times higher in the control group. Discrepancies between both parameters occured for medium values of rest LVEF (25 to 45%). We conclude that ESBP/ESV can be non invasively obtained and provides additional information upon the contractile reserve.
$65
$66
Abstracts Tuesday afternoon, April 25, 1995
March/April 1995, Part 2
P13-261
P13-263
Pericardial constraint in chronic heart failure
SIGNIFICANCE OF R E G I O N A L D I F F E R E N C E OF MYOCARDIAL 1-123 MIBG W A S H O U T IN PATIENTS WITH HEART FAILURE
J J Atherton, S S Lele, H L Thomson,K N Wright,G W Muehle, T Moore, l Belenkie,A J Galbraith,JV Tyberg,M P Frenneanx.UniversityDepartmentsof Medicine,Queensland,Australiaand Calgary,Canada. Pericardial constraintmay be an important feature in chronic heart failure (CHF). We hypothesizedthat baselinepericardialconstraintcouldbe inferredif left ventricularend-diastolicvolume(LVEDV)paradoxicallyincreasedduring lower body negative pressure (LBNP), as a consequence of abolition of constraint. Methods: 11 patientswith CHF and left ventricularejection fraction<35%were compared with 6 healthy age matched controls. Radionuclide ventriculographywas performed before and during applicationof 30 mmHg LBNP. Left ventrieularend-diastoliccountswere correctedfor time decay and tissue attenuation.LVEDVwas then calculatedwith referenceto an externally ountedblood sampletakendurin~each, ~theacquisitions. Results Comparingbaselinewith 30mmHgLBNP, LVEDVchanged 20 " w by -4.5 to -26.3 ml (mean 16 -14.2-+8.6ml) in controlsvs. -24.4 12 to +62J ml (mean +8.2+-23.5ml) in CHF patients (p=0.04). The % change in LVEDV with LBNP 4 (mea~+SD) is shown in the figure. o ; There was a linear correlation between change in LVEDV and -$ baseline pulmonary capillary wedge pressure (b-PCWP)in CHF -12 ,, patients(r=0.68;p=0.03). -14 p=0.001 Conclusions: Baseline pericardial -20 ** constraintis demonstratedin the 4 C0ntr01l Patientl patients with CHF in whom LVEDV increasedduringLBNP, a
Shuji F u k u o k a , Y o s h i o Ishida, Y o s h i a k i Hirose, Nobukazu Takahashi, Tsunehiko Nlshimura*. National Cardiovasc. Center and *Osaka Univ., Osaka, Japan
response associated with higher b-PCWP, In patients with attenuated reductions in LVEDV, abolition of baseline constraint and impaired myocardial compliance are both possible explanations.
The regional difference of myocardial 1-123 MIBG (MIBG) washout is often observed in congestive heart failure. To assess the significance of this finding, 25 patients with idiopathic dilated c a r d i o m y o p a t h y (DCM) underwent MIBG myocardial SPECT at 15 rain and at 4 hr after tracer injection (111 MBq). We determined regional MIBG washout rate (WR) in L V septal (S) and lateral (L) segments of the Bull's -eye map excluding the anterior and inferior segments which were affected by lung and liver tracer uptake, respectively. The extension of MIBG defects to LV posterolateral wall from the early to delayed imaging (regional MIBG high-washout) was visually detected in 12 (Gp A) but not in 13 (Gp B). LVEF determined by LVG was lower in Gp A than in Gp B (29+6% vs. 43+8 %, p<0.01). L V E F correlated with W R in L A T (r=-0.66, p<0.01) more than that in SEP (ns). The difference of WR between S and L, as estimated S/L W R ratio, showed a close correlation with cardiac index (r=0.74, p<0.01). These results suggest that the regional difference of myocardial M I B G washout is a better indicator than globally estimated W R to assess the severity of heart failure in patients with DCM.
P13-262
Tuesday PM, April 25
ACCELERATED I- 123 MIBG MYOCARDIAL WASHOUT RELATED TO THE SEVERITY OF CONGESTIVE HEART FAILURE Yoshihiro Imamura, Hiroshi Ando, Shougo Egashira, Hiroyuki Masaki, Toshiaki Ashihara, Takaya FuEuyama, Matsuyama Red Cross Hospital, Matsuyama city, Japan
$38-264 to $43-283 and P14-284 to P16-343
"1
T U E S D A Y
JOURNAL OF NUCLEAR CARDIOLOGY
P M A P R I L 2 5
In patients with heart failure (HF) due to cardiomyopathy (CM), the abnormality of myocardial MIBG imaging has been demonstrated. However, HF also develops in cases of mechanical abnormality such as valvular heart disease (VHD). Under the h y p o t h e s i s that abnormal MIBG imaging reflects the severity of HF regardless of the cause, we investigated MIBG imagings in 75 patients. Group I consisted of 32 VHD pts (GI:NYHA classification l-9, II15, III&IV-8 pts) and Group 2 consisted of 43 CM pts (G2:NYHA 1-10, [I-17, III&IV-16 pts). MIBG imaging was obtained 15 minutes and 4 hours 'after isotope injection and the MIBG washout rates of the heart (HWO) were calculated. The HWO was significantly related to the severity of HF and correlated well with the NYHA classification in both groups (GI: 1-38• II-46+11, III&IV-63+7%; G2:1-40+8, II-48• ]]l&IV-62:6 11 %). Tbe high HWO levels decreased in HF patients whose clinical state improved, but remained high in those who were refractory to treatment. Thus, in patients with HF, HWO is proportional to the severity of HF regardless of the cause. The level of HWO is a practical diagnostic indicator of the severity of HF, and can also be used as a means for assessing the efficacy of treatment.
$38-264 GLUCOSE UPTAKE IN THE HIBERNATING MYOCARDIUM Knuuti MJ, M&ki M, Nuutila P, Luotolahti M, H&rkSnen R, Voipio-Pulkki L-M, Wegelius U. The Dept. of Nucl. Med. andCyclotron PET-Center, Turku University, Finland. The substrate metabolism in the hibernating myocardium is poorly understood. To investigate the regulation of glucose uptake (GU) in the hibernating myocardium, we studied 7 male patients twice with 18-FDG PET, once at fast and, once, during hyperinsulinemic euglycemic clamp. The patients had one occluded main coronary artery (LAD in 6 and LCX in 1) and permanent wall motion abnormality in the respective region but no previous MI; this region was suggested to represent hibernation. The GU in the hibernating and in the septal normal regions were measured at rest. The plasma glucose levels were similar during the studies. Serum insulin levels were significantly higher (84• vs. 7• mU/I, p<0.001) and FFA levels lower (70+30 vs. 670.+_170 /Jmol/I, p<0.001) during clamp than at fast. Visually, hibernating myocardium manifested as a hot spot in 6/7 patients at fast. During insulin clamp 18-FDG uptake was homogenous. The results in ,umol/min/100g: Region Fast Clamp Ratio Hibernating 15• 72• 7+3 Normal 13• 81 _+_24 11• Thus, at fast GU in the hibernating myocardium is enhanced. In addition to the known effects on normal myocardium, insulin is able to stimulate 7-fold increase in GU also in the hibernating myocardium. This suggest the preserved control of insulin and/or FFA on GU also in the hibernating tissue.
JOURNAL OF NUCLEAR CARDIOLOGY Volume 2, N u m b e r 2, Part 2
Abstracts Tuesday afternoon, April 25, 1995
$38-265
$67
$38-267
MYOCARDIAL PERFUSION IS MAINTAINED REVERSIBLY DYSFUNCTIONAL MYOCARDIUM
IN
B.L. Gerber, J-L. Vanoverschelde, A. Bol, C. Michel, D. Labar, B. Georges, M. Cogneau, W. Wijns, J.A. Melin, University of Louvain Brussels, Belgium A common hypothesis about the pathophysiology of reversible dysfunction assumes that it is the consequence of chronic hypoperfusion and thus hibernation. However, in non-infarcted dysfunctional collateral dependent myocardium, we have recently shown that resting myocardial blood flow (MBF) was normal. To verify if this would also apply to the more colmnon clinical situation of chronic reversible myocardial dysfunction in pts with a previous myocardial infarction, we measured absolute MBF with PET and 13NH3 in 39 pts with severe anterior wall dysfunction and a low ejection fraction (33 + 10 %) undergoing revascularization and in 6 normal volunteers. As judged from the changes in regional function by echo before and after revascularization, 24 pts were considered to have reversible dysfunction while the remaining 15 had persistent dysfunction. Absolute MBF in regions that improved after revascularization was higher than in those with persistent dysfunction (845:27 vs. 59+25 rnl/min/100g, p<0.007) but was not significantly different from that in remote segments (81 +23 rnl/min/100g) or in normal volunteers (88 5:22 ml/min/100g). Only 4/24 segments with improved wall motion after revascularization had baseline MBF below the lowest value of normal volunteers (60 ml/min/100g). The data thus indicate that most dysfunctional but viable segments have maintained resting myocardial perfusion.
INFLUENCEOF THE ABNORMALITYCRITERIAON VIABILITYDETECTION USINGQUANTITATIVETC-99M-SESTAMIBISPECT G. Bisi, R. Sciagr~, G.M. Santoro, P.F. Fazzini. Nuclear Medicine, University of Florence; Florence, Italy. Tc-99m-sestamibi underestimates myocardial viability, but data-based quantitative SPECT reliability is uncertain. In this study we compared the reliability of the defect extent criteria with that of new criteria which also consider the uptake defect severity. We studied 30 patients with regional asynergia, candidate to revascularization. Uptake defects were significant if their extent was > 12% (LAD or LCX) or > 8% (RCA). Their severity was analysed by multiplying the deviations below the normal limit of each pixel in the defect by the number of abnormal pixels and expressing the results as % of the maximum for the territory. A defect was found in 48/50 territories with severe dysfunction, including the 18 with post-operative functional recovery (hibernating). The mean severity in the hibernating territories was 19 -+ 17% vs. 39 -+ 24% in the fibrotic (p < 0.005). With a 30% severity cut-off, 15/18 hibernating and 7/30 fibrotie territories were found viable (p < 0.0001). After exclusion of territories with inadequate revascularization, SPECT results were (PV = predictive value): Sensitivity Specificity Pos. PV ' Neg. PV Accuracy Extent 0% 92% 0% 55% 52% Severity 83% 71% 68% 85% 76% p value < O.000Ol N.S. N.S. < 0.02 < 0.02 Thus, modified abnormality criteria which consider the uptake defect severity allow to significantly improve the value of Tc-99m-sestamibi SPECT for the evaluation of myocardial viability.
T U E S D A u P M
$38-266
$38-268
REST WALL MOTION ANALYSIS OF MYOCARDIAL REGIONS WITH STRESS ISCHEMIA DETECTED ONLY AFTER THALLIUM REINJECTION
CARDIAC METABOLISM OF 1231-~-METHYL IODOPHENYL PENTADECANOIC ACID (123I-BMIPP): COMPARISON AMONG NORMAL DOGS, THOSE PRETREATED WITH ETOMOXIR, AND THOSE WITH ISCHEMIA
M Brambilla, E Inglese, G Cannizzaro, S Carerj, G Favretto, U Ficola, D Massa, A Tisselli. M a g g i o r e , Novara, Italy.
Ospedale
T h e p u r p o s e o f t h i s s t u d y w a s to i n v e s t i g a t e the relationship b e t w e e n r e g i o n a l wall m o t i o n and residual i s c h e m i a detected only after t h a l l i u m reinjection. T w e l v e centers enrolled 402 pts (57_+9 years, 80% with previous MI) with stress p e r f u s i o n defects. P l a n a r i m a g i n g w a s performed following a stress-redistribution-reinjection protocol. T h e left ventricle w a s s u b d i v i d e d into 3 regions (anterior + septal, apex, inferior + posterolateral), that were c l a s s i f i e d as n o r m a l , s c a r r e d , i s c h e m i c , by 3 b l i n d e d observers. Rest e c h o c a r d i o g r a p h y w a s p e r f o r m e d within 15 d a y s ; a r e g i o n a l wall m o t i o n i n d e x ( R W M I ) w a s calculated (1 notTnal - 4 diskynetic). O f the 1143 evaluable regions, 503 were n o r m a l ( R W M I = 1.18+.35) and 640 h a d stress p e r f u s i o n defects. A s e x p e c t e d , w h e n thallium results after redistribution and reiniection were concordant, a s i g n i f i c a n t l y l o w e r R W M I w a s f o u n d in i s c h e m i c (1.47+.58, n = 2 1 7 ) t h a n in s c a r r e d ( 2 . 0 9 + . 8 2 , n = 1 5 8 ) regions (p<.01). A lower R W M I w a s also f o u n d in regions c l a s s i f i e d as i s c h e m i c o n l y after r e i n j e c t i o n (1.68-+,6, n=173) (p<0.01). These findings suggest a close r e l a t i o n s h i p b e t w e e n i n c r e m e n t a l u p t a k e after t h a l l i u m reinjection and ischemic but viable m y o c a r d i u m .
Ryohei Hosokawa, Ryuji Nohara, Kazumi Okuda, Yasuhisa Fujibayashi, Tatsuhiko Hata, Nagara Tamaki, Masatoshi Fujita, Shigetake Sasayama. Kyoto University Hospital, Kyoto, Japan Myocardial metabolism of free fatty acid can be evaluated by 123I-BMIPP with excellent myocardial SPECT imaging, but how BMIPP is metabolized in myocardium remains to be clarified. In this study, we investigated the metabolites of BM1PP, using open-chest dogs under anesthesia, and then compared among normal dogs (n=5), those pretreated with a carnitine shuttle inhibitor, etomoxir (n=5), and those with a coronary occlusion (10min) and reperfusion model (O&R, n=4). With etomoxir, full metabolite of ~oxidation decreased (19.3% to 4.7%:p<0.05) and BMIPP increased (25.7% to 44.8%:p<0.05) without affecting partial metabolites. The washout ratio of early phase (8min) increased (53.4% to 72.8%:p<0.05), though retention (30 min) didn't change significantly, which depended largely on early back diffusion of BMIPP with following reduction of ]3-oxidation. In the case of O&R, retention c h a n g e d ( 7 0 . 1 % ~ 9 1 . 8 % ) , andboth BMIPP and its full metabolite varied according to the severity of ischemia. These results suggest the necessity of early and delayed clinical imaging with I~31-BMIPP to assess ischemia and associated mitochondrial dysfunction.
A P R I L
$68
Abstracts Tuesday afternoon, April 25, 1995
$38-269
S39-271
1-123-1ODOPHENYLPENTADECANOIC ACID (IPPA) IS SUPERIOR TO TL-201 FOR THE ASSESSMENT OF MYOCARDIAL VIABILITY UNDER CONDITIONS OF SUSTAINEDLOW FLOW AND SYSTOLIC DYSFUNCTION.
DYNAMIC IMAGING WITH INTRACORONARY T E B O R O X I M E B E F O R E AND A F T E R PTCA. F. Tartaghi, F. Fallani, C. Corbelli, G. Piovaccari, A. Marzocchi, M. Marengo, N. Monetti, * A.S. Iskandrian. S. Orsola-Malpighi Hospital, Bologna, I. * Philadelphia Heart Institute, Presbiterian Medical Center, Philadelphia, USA.
D.K. Glover, J.Y. Yang, M. Ruiz, W.H. Smith, D.D. Watson, G.A. Belier, University of Virginia, Charlottesville, VA, USA.
T U E S D A u
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
We compared IPPA with TI-201(T1) uptake and redistribution (RD) in 9 dogs with a 59% reduction of LAD flow and thickening of-17%. TI, IPPA, and microspheres were injected after 30 min and quantitative IPPA imaging was performed at 2,20,30,60 and 120 min and defect magnitudes (DM) calculated. Microsphere flows and tracer activities were measured by gamma-well counting. LAD/LCX flow ratios were comparable for TI and IPPA injections (0.56+.05 vs 0.585:0.05). At 2 hrs, both tracers demonstrated RD with LAD/LCX activity ratios greater than injection flow ratios, but the amount of IPPA RD was greater than T1 (0.97+-0.06 vs 0.69+0.04) (p<0.01). Furthermore, IPPA DM improved from 0.64+0.04 to 0.72+-0.04 after only 20 min of RD (p<0.01) and further improved to 0.845:0.04 after 120 min indicating substantial rest RD. Thus, in this canine model of sustained low flow and systolic dysfunction, IPPA RD is superior to TI for the assessment of myocardial viability.
This study examined the kinetics o f Tc-99m teboroxime (Tebo) following intracoronary (IC) injection during papaverine-induced hyperemia before and after coronary angioplasty. There were 13 pts with 1-vessel disease (90% stenosis). I mCi of Tebo was injected IC after 10 mg of papaverine. Dynamic acquisition in a frame mode (20/frame) was performed for 5 min in the LAO projection using a multicrystal gamma camera before (N: 13) and after succesful angioplasty (N: I0). The counts were higher in the normal (NZ) than in the ischemic zones (IZ) before PTCA (11 + 8 vs 8.3 + 6.9 x 103, P < 0.02). The 5 min washout was 41 • 13% in the NZ and 40 • 12% in the IZ (P:NS). Following PTCA the counts were 9.4 + 5.3 x 103 in the NZ vs 8.2 • 5.0 x 103 in the IZ (P < 005). The ratio of IZ/NZ before PTCA was b_igher than after PTCA (1.47 • 0.38 vs 1.00 • 0.35). Thus this study shows that IC Tebo during coronary hyperemia can demonstrate perfusion defects in territories of diseased coronary arteries and can be used to document the results of PTCA.
P M A P R I L 2 5
S39-270
$39-272
DIRECT D E M O N S T R A T I O N OF THE MITOCHONDRIAL UPTAKE OF Tc-99m-SESTAMIBI.
REVERSE REDISTRIBUTION AND THALLIUM REINJECTION MYOCARDIAL SCINTIGRAPHY: PREVALENCE AND CLINICAL SIGNIFICANCE.
Jean-Arthur Songadele, Antoine Youn~s, Jean Maublant, Jean-Philippe Meunier, Annie Veyre. INSERM unit 71, Clermont-Ferrand, F. Using a model of isolated mitochondria provides a mean of measuring directly in these organelles the uptake of Tc99m-sestamibi and the effect of metabolism. Mitochondria were isolated from male rat hearts by differential centrifugation. The kinetics of uptake of sestamibi were measured sequentially for 5 min after the addition of succinate using a concentration of 0.2 and 0.4 mg of mitochondrial proteins/ml. In both conditions, sestamibi was used at activities of 37 and 370 kBq. A near-plateau of mitochondrial uptake was always attained after 30 see of incubation. With 37 kBq, its mean level ranged from 15 to 21% of total activity (n=3-6 samples) with 0.2 mg proteins, and from 23 to 27% with 0.4 mg proteins. Similar values were obtained with an activity of 370 kBq. The addition of 5 ~tM dinitrophenol, an uncoupler of the mitochondrial respiration, resulted in a rapid drop of the mitochondrial sestamibi uptake down to its background level. These experiments provide the direct proof that sestamibi concentrates in the mitochondria through an active mechanism.
S. Jones, P. Santiago, J. Vacek, T. Rosamond, University of Missouri at Kansas City School of Medicine, Mid America Heart Institute, Kansas City, Missouri, USA. Reverse redistribution (RR) is a controversial and incompletely understood phenomenon. Its prevalence and clinical import with reinjection is unknown. We reviewed 1167 consecutive reinjection stress thallium studies; 841 (72 %) were males and 327 (28%) females. RR was defined by quantitative gender matched polar map analysis. Tomograms and planar images were then reviewed to qualitatively assess RR. 6 patients (0.5%), female, met criteria for RR. Test indication was atypical chest pain. Mean peak heart rate was 90+8% of predicted maximum for age. The electrocardiograms were nonischemic. Mean weight was 86.8+12.3 kgs. Prominent brea~st and soft tissue artifacts were evident in 5/6 patients (83 %). RR was round in the right coronary artery distribution in 5/6 patients (83%). There were no cardiac events with a mean follow-up of 7.8+_4.9 months. CONCLUSION: I)RR with the reinjection technique is rare. 2)RR was found only in females. 3)RR correlates with obesity, breast attenuation and the right coronary distribution. 4)RR did not correlate with significant coronary artery disease.
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday afternoon, April 25, 1995
$39-273
$39-275
USING PET TO UNDERSTAND COUNT INHOMOGENEITIES IN SPECT MYOCARDIAL PERFUSION IMAGING: A COMPUTER SIMULATION STUDY
THE EUROPEAN NUCLEAR CARDIOLOGY DATA B A S E (ENCD): A P R O G R E S S R E P O R T
RL Eisner,EVR DiBella,RE Patterson. Emory:Crawford Long Hsp, Dpts of Meal (Cardiol)/Radiol, EUSM, Atlanta,CA,USA Using clinical PET nRb myocardial perfusion images (MPI), we developed a novel computer simulation (CS) methodology to study artifact generation in clinical SPECT 2~ MPI. The technique constructs "real" attenuated 2~ emission data from transmission and emission PET MPI patient studies. The purpose o f this study was to evaluate SPECT reconstructed images o f CSs to define the underlying cause for the "hot" lateral wall (LW) artifact found in Bull's-eye images from SPECT MPI o f normal males and females. We found: 1) The L W count increase in SPECT was due to the differential attenuation of LW vs. septal wall (SW) counts which was related to the orientation and position o f the left ventricle adjacent to the left lung (LL); 2) Images were more homogeneous when the LL was "filled" with an attenuator with an attenuation coefficient which matched that o f the heart; 3) Independent o f the size o f the patient or the position o f other attenuators, CSs predicted a "hot" LW in SPECT MPIs when the tangential projection rays defining L W pass through LL and the tangential projection rays defining SW pass through tissue. Our PET-to-SPECT CS technique can generate SPECT M P I studies from a range o f patient sizes and shapes a flexibility not present in other CS models. -
-
$69
Michel H.Bourguignon (1), Ellinor B u s e m a n n Sokole (2), Heinz Sochor (3), Roland Bidet (4). (1) Service F. Joliot, Orsay France, (2) Academic Medical Centre, Amsterdam, T h e Netherlands, (3) Cardiology, A K H Vienna, Austria, (4) M t d e c i n e Nuclr C H U Besanqon, France. The E N C D joint project o f C O S T B2, E A N M and ESC has been set up with the following goals: to establish range o f normal values and typical values corresponding to diseases, to assess variability b e t w e e n operators and centers, and to p e r f o r m software quality assurance. To participate, acquisition portfolios are available in each European country from coordinators involved in nuclear cardiology. Radionuclide data acquired in accordance with protocols (Cur J Nucl M e d 1993, 20:59-65) have been collated with c o m p l e t e d portfolios for normal subjects, and patients with typical patterns o f myocardial ischemia, r~,cent myocardial infarction and c a r d i o m y o p a t h y . The data have been c h e c k e d for c o n f o r m a n c e by a dedicated C O S T B2 working group. Progress m u s t still be made t o g e t h e r with e q u i p m e n t m a n u f a c t u r e r s .to a v o i d difficulties in e x c h a n g i n g radionuclide data in Interfile V3.3. More cases are n e e d e d before C D - R O M can be distributed for the next steps o f processing and statistical analysis. It is planned to continuously enrich E N C D with n e w data on an international b a s i s to e n c o u r a g e its application by any user for all o f the above goals.
T U E S D A
Y P M
S39-274
$42-276
EFFECTS OF ENHANCED ENERGY RESOLUTION AND SCATTER CORRECTION ON THE MEASUREMENT OF INFARCT SIZE FROM TOMOGRAPHIC STUDIES OF THE HEART
DUAL ISOTOPE TECHNIQUE VALIDATION USING A RESTTL-201 AND STRESS-TC-99M-MIBI PROTOCOL: PHANTOM AND PATIENT STUDIES
Michael K. O'Connor, Carlo Caiati, Timothy F. Christian, Raymond J. Gibbons, Mayo Clinic, Rochester, MN, and Fondazione Clinica del Lavorn, Cassano Murge, Bari, Italy. Scatter in T1-201 and Tc-99m myocardial images degrades image quality. This study evaluates the effects of enhanced energy resolution and scatter correction on the quantitation of defect size and severity from SPECT images of the heart obtained using a cardiac phantom. Gamma camera energy resolution was 8.7% at 140 key. Tomographic images containing defects of 0-70% of total myocardial mass, were acquired with and without scatter correction with TI-201 and Tc-99m. Circumferential profiles were generated from 5 representative short axis slices of the heart. Defect size was determined from the fraction of radians that fell below a fixed threshold value. The nadir value (ratio of min/max profile count) in each study was used as an index of image contrast. For both TI-201 and Tc-99m a threshold value of 60% gave the best correlation (r > 0.99) with the lowest average absolute error in estimating defect size (Tc-99m:l.4%; T1-201:2.0%). Scatter correction reduced the average absolute error to 0.8% for Tc-99m and 1.4% for TI-201. and significantly reduced the nadir values for both isotopes (P < 0.001 for both TI-201 and Tc-99m). Qualitatively, there was a marked improvement in image quality, particularly with T1-201. The combined effects of scatter correction and improved energy resolution improved image quality, amd increased the accuracy of quantitative analysis of T1-201 and Tc-99m studies.
Bernd J. Krause, C. Gtirtner, Frank D. Maul, W. Tilmann Kranert and Gustav Htr, University Hospital Frankfurt/M, Germany Rest-Tl-201 (RT) followed by stress Tc-99m-MIBI (SM) may present a protocol able to detect myocardial viability as well as ischaemia. However, dual isotope protocols are still discussed controversial due to limitations like crossover, accuracy, optimal activity ratio. The aim of this study was to validate the dual isotope RT-SM protocol performing phantom and patient studies. In phantom studies mean absolute crossover from T1-201 into the Tc99m energy window was 11.34%. Depending on attenuation in water (depth 0 to 9 cm) absolute crossover increased from 11.05 to 19.37%. 15 patients undergoing TI-201 myocardial scintigraphy served as reference group. Mean absolute crossover was found to be as high as 12.76% In order to reduce crossover, Tc-99m-MIBI activity (20mCi) was about 7 times as high as T1-201 activity (3 mCi). In phantom studies Tc-99m/T1-201 activity ratio was varied (4:1 to 13:1); mean relative crossover from T1-201 into the Tc-99m energy window ranged from 1.06% (13:1) to 3.05% (4:1). In 3 patients undergoing a modified protocol (Injection of T1-201 only (3mCi), and first dual window acquisition. Subsequent Tc-99mMIBI injection (20mCi) and second dual window acquisition) relative crossover was in the same range as found in phantom studies. The optimal Tc-99m-MIBI/TI-201 activity ratio should be about 7:1 thus allowing good TI-201 rest imaging and not causing a significant higher radiation as compared to other protocols. Relative TI-201 crossover into the Tc-99m energy window was found to be 1 to 3% which is moderate and statistically not relevant and thus does not show significant influence on the accuracy of the dual isotope RT SM protocol.
A P R I
L
$70
Abstracts Tuesday afternoon, April 25, 1995
$42-277
S42-279
Prognostic Synergy of Thallium-201 Stress/Redistribution and Reinjeetion Protocols in Revasularization Candidates
EVALUATION OF THE DIAGNOSTIC USE OF DOBUTAMINE ECHOCARDIOC~APHY AND Tc9''m SESTAMIBI MYOCARD PERFUSIONSCINTIGRAPHYFOR THE DETECTIONOF CORONARY ARTF~RYDISEASE E.Allmyay, I-[ Fasac~ KM.Kr, T.Ktaal, E.0zalp, A.O~zJmn, G.Tolmz, AAkin, K0zdemir Ankara U m v e ~ Faculty of Medi0ne Deparmaent of NutclearMedicine06 l O0 Ankam-TORK1YE In Ibis study, we aimed to comparethe use of ddxaamine tDOB) mess wi~ echoc~diography(ECHO) and Tc99m sestamibiSPBYf myocard perfmion sci~graphy for the deteOaon of ooronary artery disease (CAD). SEc~y-nLne paaents (pts) with 'chest pare' syndromeunderwent DO8 ECHO and Tc99m sestamibi myocard peffusion scintigraphy /MI 1~ underwent con:ma~ angiographyafter complem~alationof kna~ng protocol. DOB was refusedm incremental doses (5--40 pg/kg/nun) urral anginal symptoms, ST d~esmo~ h~ve responsedefectedor 85~ of age predicted~ u m heart rate achieved. If a mmemum dose adequme heartr~e wam't reached and no myocardialisdleanmwas induced,alropinewas injected0.25 nag up to 1 mg iv. DOB ECHO was pertbtrr~ at rest, at low do~ at peak dose and dunng recoveryperiod,lnmlret~on of imagingremitsOa'formedby independedt ~ blinded~ . Luminalnarrowingof 50% in a majorcoromryartewseenin two wws was consideze~ls~ffmrr In 40 of 47 pts wiflaCAD diagnosedby myocardialp~mion scinli~raphyand in 42 of 47 pts wah CAD diagnosedby DOB ECHO (~tivay 85% vs 89%). h 22 of 22 pts with normal coronary array, myocmxhallxwlhsionsonligraphyresultswere normaland in 19 of 22 pls with normalcoronaryarteryDOB ECHO remllswere aorma/(spesitifrty10t3% vs 86%) "lt~eseprdiminaryre~ts are highlyencotuagmgbut furthersaOiesare requitedto establishthe valueot'N~ m ~
D. Douglas Miller, MD, David L. Kemp, MD, Robert W. Armbmster, MD, Liwa T. Younis, MD, PhD, Jason Liu, MD, Sheila Byers, RN, Robert O. Bonow, MD. Saint Louis University Health Sciences Center, St. Louis, Missouri. Reinjection thallium-201 (T1-201) imaging protocols detect viable myocardium. The late. prognostic value o f reinjection compared to stress/redistribution imaging data has not been established. To this end, 76 consecutive pts age 57.0+ 13.7 yrs, LVEF 51.6+17.8, functional class (NYHA) 1.3i-0.6 were followed for 9.05:3.2 mos or until death (n=3) or coronary revascularization (7 bypass, 5 angioplasty). Sixteen pts undergoing early (<30 days) coronary revascularization were excluded. Clinical and scintigraphic characteristics of pts with and without cardiac events are compared below
(*p_<0.05): Age (years)
T U E S D A u
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
NYHA class # Reversible Segments # Viable Segments # Fixed Segments Increased Lung Uptake Transient LV Dilatation
B_v_e,aL(9_e~= No Event (n=38) 57.3-l"14.4 57.7:1:12.3 1.3+0.5 2.0:1:2.3 1.3+0.5 5.0+3.7" 67%* 60%*
1.3+0.5 2.05:2.0 1.3+0.5 3.1+2.5 33% 40% Stress/redistribution T1-201 imaging predicted 60% (13/22) o f cardiac events. 'I"1-201 reinjection predicted 78% (7/9) o f t h o s e c a r d i a c e v e n t s not p r e d i c t e d by stress/redistribution imaging alone. We conclude that fixed defects and associated nonmyocardial markers o f LV d y s f u n c t i o n provide late prognostic information in the non-revascularized population of pts undergoing "1"1-201 viability studies.
P M A P R I L
$42-278
S43-280
TECHNETIUM 99m TEBOROXIME RESTING WASHOUT IMAGING IN THE DETECTION OF CORONARY ARTERY DISEASE. R.F. Carretta, F.W. Weiland, P.R. Vande Streek, G. Obranovich, Roseville Hospital, Roseville, CA.
EVALUATION OF LEFT VENTRICULAR VOLUMES BY PLANAR AND SPECT RADIONUCLIDE VENTRICULOGRAPHY METHODS D. ~obi6-~aranovid,MVeljovi6,V. Bognjakovi6, S.Pavlovid N Kozarevi6. [nsitute of Nuclear Medicine,CCS, Belgrade,Yugoslavia
The abnormal washout of Tc 99m Teboroxime (TEBO) from the myocardium following a rest injection may be an alternative to stress-rest thallium studies (TI) for the detection of coronary artery disease (CAD). We studied 32 pts. with TEBO and compared their results with T1 and cardiac cath. Eight sequential three minute resting TEBO acquisitions were obtained on a triple-headed camera. A whole heart composite washout image was generated. SPECT T1 studies were performed after either treadmill or dipyridamole stress testing. Cardiac cath identified 13 normal pts., 14 with one vessel disease, 3 with 2 vessel disease, and 2 with 3 vessel disease. TEBO and T1 identified 23 and 20 of the pts. with CAD. TEBO identified 9 pts. without CAD and T1 6. Agreement between TEBO and T1 occurred in 25/32 pts. TEBO identified 47 abnormal segments while T1 identified 51. These findings suggest that resting regional washout studies with TEBO may correctly identify CAD and be an alternative to T1 treadmill or pharmacological stress testing.
In order to evaluate left ventricular end-diastolic(EDV) and end-systolic volumes by planar and gated blood pool SPECT (GASPECT) RNV methods, 38 patients with coronary disease were studied, as compared with contrast ventriculography (CV) and 2D-Echo techniques.Planar studies used our own geometric-count based(GCB) method. GASPECT studies (commercial program) were performed in 32 projections over 1800, gated for 16 frames/cycle.. Volumes measured by GASPECT and GCB methods showed mutual correlation for EDV: r=0.90, for ESV: r=0.88. Correlation between GASPECT and CV were for EDV: r=0.90, for ESV: r= 0.89, and between GASPECT and 2D-Echo were for EDV: r=0.92, for ESV: r=0.93.Correlation between GCB and CV were better for EDV: r=0.93, and for ESV: r=0.90, than between GCB and 2D-Echo ( EDV: r=0.88, ESV: r=0.89).Our results suggest that GASPECT and GCB are accurate noninvasive methods for measuring left ventricular volumes.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday afternoon, April 25, 1995
$43-281
$43-283
FIRST-PASS RADIONUCLIDE ANGIOGRAPHY WITH DUAL REGIONS OF INTEREST: COMPARISON WITH PLANAR AND SPECT GATED EQUILIBRIUM EJECTION FRACTIONS. T. A. Bryant, L. A. Taillon, J. M. Draho, and K. A. Williams. The University of Chicago, Chicago, IL, USA.
TONOGRAPHIC RADIONUCLIDE VENTRICULOGRAPHY COMPARED WITH RADIOLOGIC VENTRICULOGRAPHY IN T H E A S S E S S M E N T OF LEFT VENTRICULAR VOLUMES.
First-pass radionuclide angiography (FP), when analyzed with a single fixed (FXD) region of interest (ROI) drawn at enddiastole, often underestimates LV ejection fractious (EF) determined by other techniques. Motion of the aortic valve plane toward the apex during systole can results in improper mclusion of aortic counts within a FXD ROI; this problem could be eliminated by using dual ROrs (DROI) which account for this motion. In 70 patients who underwent FP, planar (PERNA) and 8-frame gated SPECT equilibrium studies (SERNA) on the same day, Fourier transform phase and amplitude images were used to generate functional maps of the aorta and the LV on the FP representative cycle. The low amplitude region between the aorta and LV, corresponding to the degree of aortic valve plane motion, was used to draw two ROI's: 1) over the LV at enddiastole including the aortic valve plane area; and 2) a smaller end-systolic ROI drawn over the first ROI, excluding the valve plane. Results: Both FXD and DROI FP methods had excellent correlation with SERNA (r=0.88 and 0.87, ctively), and with PERNA (both r=0.91). The mean EF of (46.7%• 14.6%). was similar to SERNA (48.3%• p=NS), but lower than PERNA (51.3%+14.8%, p<.001). The mean EF of the DROI (51.1% • 14.4%) was nearly identical to PERNA, and was significantly higher than SERNA (p<.01). Conclusions: 1) Despite excellent correlation, both 8-frame SERNA and the standard FXD ROI method of FP systematically underestimate the EF's of PERNA. 2) With FP, this problem can be eliminated by taking into account valve plane motion during the cardiac cycle, using Fourier-guided DROI analysis.
~D
Alain Le Helloco, Luc Nicol, Marc Bedossa, Patrick Bour~uet, Claude Almange. University Hospital, Rennes, FR. The aim of this study was to compare left ventricular volumes by tomographic radionuclide ventrieulograDhy (SPECT) and radiologic ventriculogranhy (V.). 20 patients (pts) with mean age 57,4 years divided in ~roup 1 (9 pts) with normal coronary an~iogram and group 2 (ii pts) with significative coronary stenosis, underwent SPECT ventriculogranhy and cardiac catheterization. SPECT volumes were calculated by 2 independant observers at end diastole (EDV) and end systole (EDS) : Radionuclide V Radiologic V. EDV ii0 ml/m 2 ~ 48 112 ml/m 2 ~ 47 ESV 61 ml/m z ~ 41 62 ml/m ~ ~ 42 EF 47,3 % ~ 17,1 47,4 % ~ 17,2 Correlations of SPECT volumes and E.F. with an~iograohy were excellent with r = O.q6 for EDV. 0,94 for ESV and 0,95 for EF. Gated blood pool tomogranhy is an accurate method for the measurement of left ventricular volumes.
S43-282
P 14-284
RADIONUCLIDE ASSESSMENT OF LEFT VENTR1CULAR ACTIVE RELAXATION AND LOAD WITH REGIONAL MYOCARDIAL ISCHEMIA
EFFECT OF GENDER ON REFERRAL FOR CORONARY ANGIOGRAPHY IN PATIENTS UNDERGOING STRESS MYOCARDIAL PERFUSION TOMOGRAPHY
M.C. Gerson, Y ShaG, B. D. Holt, M. Gabel, R. A. Walsh. University of Cincinnati, Cincinnati, Ohio USA We previously showed in dogs that the radionuclide first-half filling fraction (1/2 FF) is independent of loading conditions and sensitive to changes in active relaxation measured invasively by the time constant, Tau (J Nucl Med 1993;34:1520-8). We hypothesized that 1/2 FF is also sensitive to changes in Tau in dogs with regional left ventricular (LV) ischemic dysfunction. In 9 open chest dogs, atrially paced at 140 beats/rain, LV and left atrial (LA) micromanometers were placed and red blood cells labeled with Tc99m. The circumflex artery was ligated producing an infarct zone 38_+7% of the LV mass. LV inotropy was increased by dobutamine (DOB); LV load was increased by phenylephrine (PHENYL) infusion. BASE DOB BASE PHENYL LVSP(mmHg) 106_+19 153_+21" 103_+17 171+19' LA-LV Gradient 6.7+3.2 4.8-+3.2 6.4_+2.8 9.3_+4.5* Tau (ms) 62_+28 40+4* 55-+10 60_+10 1/2 FF(%) 34+10 46_+14' 32+17 38+13 PFR(kcts/s) 55_+28 50_+22 54_+27 68+33* *p<0.05 intervention vs respective baseline (BASE) LVSP-LV systolic pressure, PFR-absolute peak filling rate Conclusions: In dogs with acute coronary occlusion, 1) 1/2 FF detects changes in LV active relaxation independent of load, 2) PFR is related to LV load independent of LV active relaxation.
Habib Dakik, Kay Kimball, John J. Mabmarian, Mario S. Verani, Baylor College of Medicine, Houston, TX, USA Recent studies have suggested a gender bias in patients (pts) referred for coronary angiography (CA), with females less often undergoing CA. Accordingly, we analyzed the influence of gender on referral for CA after a stress (64% exercise and 36% pharmacological) myocardial perfusion SPECT scan in 3,108 pts (35% femaIes) studied in our institution during 1993. The frequency of abnormal scans was higher in males than in females (49% vs 22%, p<0.0001), as was that of ischemic defects (34% vs 15%, p<0.0001). A higher proportion of males subsequently had CA _
S71
$72
Abstracts T u e s d a y a f t e r n o o n , A p r i l 25, 1995
P14-285
P 14-287
DOBUTAMINE Tc-99m TETROFOSMIN SPECT IN THE DETECTION OF CORONARY ARTERY DISEASE (CAD) :
COMPARISON OF ARBUTAMINE STRESS AND TREADMILL EXERCISE THALLIUM-201 SPECT: HEMODYNAMICS AND DIAGNOSTIC ACCURACY
EVALUTION OF A SAME DAY REST-STRESS PROTOCOLE.
T U E S D A u
JOURNAL OF NUCLEAR CARDIOLOGY M a r c h / A p r i l 1995, P a r t 2
Mustafa Onlti, Btilent Turgut, Serdar Giinaydm. Sevil Atavcl. Levent Gtikg6z.Gazi University Medical Faculty,Departmants of Nuclear Medicine and Cardiovascular Sdrgery. Ankara / TURKEY.
Hosen Kiat and Daniel S. Berman, Cedars-Sinai Medical Center, Los Angeles for the International Arbutamine Study Group
Tc-99m Tetrofosmin, exercise-rest myocardial perfusion studies has shown encouraging results in the detection of CAD. The purpose of this study was to evaluate the efficacy of Tc-99m Tetrofosmin SPECT following dobutamine infusion in the detection of CAD. using one day rest - stress protocole. 36 patients / mean age: 58.36 + 7.2 ) with suspected CAD. who had limitations to perform treadmill exercise were included m the study. All patients had coronary angiography (CA) withine two weeks. 7-10 mCi of Tc-99m Tetrofosmine was mjected at rest conditions. Two hours after the rest - SPECT acqmsition, following dobutamine infusion (5mcg/kg / min. up to 40 mcg) 20 mCi of Tc-99m Tetrofosmin stress dose was administrated. SPECT acquisitions were done 30 rain. after rest and stress injections. A significant increase in heart rate I pre: 76.4_+12.3. post: 114.8_+11.7. p< .001 / and no serious side effects were observed after dobutamine infusion. SPECT data were evaluated in 3 planes, considering segmental uptake as hypoperfusion, ischemia and partial filling. Sress defects were identified in 52 % of the investigated segments: showing no fiiling; I4 %, partial filling; 8 % and compleate filling; 30 % in rest study. According to CA results significant stenosis ( > 50 % ) were detected in 23 LAD, 13 LCX and 11 RCA territories. The sensitivity and specificity of rest - dobutamine Tc-99m Tetrofosmin SPECT were; LAD: 87%, 80%, LCX 75%, 84%, RCA: 80%, 78%, Overall: 82%, 78% respectively. In conclusion, Dobutamine stress Tc-99m Tetrofosmin SPECT is an efficient alternative ttechnique in the detection of CAD, showing good correlation with CA, especially in patients who had disability to perform maximal exercise.
Arbutamine (ARB) was compared with treadmill exercise testing (Ex) in a multicenter study using thallium-201 (T1) SPECT. A total of 75 patients (pts) performed both forms of stress in 75 pts of whom 73 had quantitative angiography. T1 scans were scored by a central laboratory using a 20 segment (seg)/scan visual analysis (5 point system: 0=normal, 4=absent uptake. Maximum heart rate (HR) by ARB and Ex was 122 vs 141 bpm (p<0.05). Mean %HR change from baseline was similar (79% vs 82%, respectively). Maximum systolic BP for ARB and Ex was 173 vs 176mmHg, and mean %change from baseline was 31% vs 26%(p=NS for both). In the 68 pts with angiographic CAD, sensitivity for detecting CAD by ARB TI was 94% and 97% by Ex TI-SPECT (p=NS). Stress T1 SPECT segmental agreement for presence of defect between ARB and Ex in 1360 segs (68 pts) was 94% (k=0.7). Exact segmental stress T1 score (0-4) agreement was 85% (k=0.7). Of the 199 segs with discordant scores, the ARB-T1 score was higher in 98 (49%). Among 346 segs with stress defects by both ARB and Ex, defect rev agreement was 86% (k=0.7). Adverse events were mostly mild. Sustained arrhythmias were not observed; 3 pts had nonsustained ventricular tachycardia with ARB and 1 with Ex. Conclusion: In this patient population, arbutamine and treadmill exercise produced similar hemodynamic responses. The two forms of stress yielded similar sensitivity and high agreement for the presence, extent, severity and reversibility of stress myocardial perfusion.
P 14-286
P14-288
DETECTION OF RIGHT VENTRICULAR ACUTE ISCHEM/A BY MEANS OF A THREE HEADED TOMOGRAPH. F. Tartagni, A. Balletta, C. Corbelli, F. Fallani, R. Franchi, M. Marengo, N. Franco, N. Monetti. S. Orsola-Malpighi Hospital, Bologna.
THE IMPACT ON MANAGEMENT OF PHARMACOLOGIC STRESS Tc-99m SESTAMIBI SPECT AMONG PATIENTS 80 YEARS AND OLDER
P M A P R I L 2 5
In the hypothesis that multi headed gamma cameras might improve the evaluation of fight ventricular perfusion (RVP), 15 symptomatic patients (pts) with significant stenosis of right coronary artery, isolated (9) or associated with left circumflex (6), were evaluated with a single day, stress-rest Sestamibi protocol. A triple headed gamma camera (Prisma 300; Picker-Eq) was used for data acquisition and analysis in short axis slices of left ventficular (LV) and right ventricular (RV) perfusion. Long acquisition times (30') and logaritrnic analysis were used to enhance RV detection. Within 2 weeks a MUGA study was repeated for RV function evaluation. Reversible defects in LV, RV or LV+RV were detected in 9, 3 and 5 cases respectively. A decrese in RV ejection fraction > 5% during efforts was found in 5 pts: in 4 cases RV perfusion and function resulted associated. Conclusions: these preliminary results seem to demonstrate that hightly efficient multiple headed tomographs may be helpful in diagnosing RV acute ischemia.
H o s e n Kiat, Rory H a c h a m o v i t c h , G e o r g e Diamond, J A r t h u r Cabico, Ishac Cohen, John Friedman, Daniel S. Berman. Cedars-Sinai M e d i c a l Center, Los Angeles, CA. The i m p a c t of p h a r m a c o l o g i c stress testing in the elderly on subsequent patient m a n a g e m e n t has not been evaluated. Therefore, we studied 229 consecutive patients >80 yrs of age ( m e a n 84+3 yr., r a n g e 80-96) who u n d e r w e n t p h a r m a c o l o g i c T c - 9 9 m sestamibi S P E C T (PhM I B I ) and followed up for 1 yr. Visual analysis used 2 0 SPECT segments and a 5 point scoring s y s t e m ( 0 = n o r m a l , 4 = a b s e n t uptake). The scores of the 2 0 s e g m e n t s on the stress sestamibi i m a g e s were s u m m e d ( s u m m e d stress score, SSS, 0-3=nl, 4 - 8 = m o d e r a t e defect, > 8 = l a r g e defect). Referral to catheterization (cath) and revascularization (revasc) within 90 days of n u c l e a r testing, and 1 year e v e n t rate (cardiac death, MI) in relation to SSS are as follows: SSS(N) 4-8 (37) >8 (115) Cath 4% 8% 22% Revasc 1% 8% 15% Events 3 (3.9%) 2 (5.4%) 23 (20%) Cath:Event 1% 1.5 1.1 CONCLUSIO) Ph-I~[IBI appears to appropriately influence Subsequent patient m a n a g e m e n t . The similar cath:event ratios in all SSS s u b g r o u p s indicate referral to cath proportional to patient risk.
JOURNAL OF NUCLEAR CARDIOLOGY Volume 2, N u m b e r 2, Part 2
P 14-289 A Comparison Between TI2~ Scintigraphy Scalar And Ramp Uprght Bicycle ExerciseTest. R.Belardinelli, G.Cianci, A.Purcaro, Osp.Cardiologico "Lancisi" Ancona, Italy;
Abstracts Tuesday afternoon, April 25, 1995
P14-291 ETIOLOGY A N D IMPLICATIONS OF THE PARADOXICAL HYPERTENSIVE SYSTOLIC BLOOD PRESSURE RESPONSE TO DIPYRIDAMOLE Leonard Numerow, lames R. Lucas, Michael W. Dae. Elias H. Botvinick, University of Califomia. San Francisco
Exercise is the common form of stressor coupled with TI~1 myocardial scinUgraphy. Aim of the study is to compare supine bicycle exercise test with scalar work rate increment (S) with a rapid incremental protocol (ramp)(R). Ten patients aged 49+12 years were studied. Five pts had a myocardial infarction within 1 year and a angiographica!ly documented coronary artery disease (CAD)(Group A), whereas 5 pts had a suspected CAD. All pts underwent 2 randomly assigned planar TI2~ scintigraphy with S or R symptom-limited protocol on a supine electronically-braked cycloergometer. In S, work rate was increased in 2 min-stages, whereas in R work rate was increased gradually(2 watts every 6 seconds). The 2 studies were performed in a random order separated by 16-~9days between. Results : No significant differences were observed at submaximal exercise in double product (DP) between S and R at any matched work rates. However, at peak, both work rate (169~45 vs146-~38W;p<0.01)and DP(29781+3471vs 26670+3575b/min/mmHg;p<0.01 ) were greater and exercise time was shorter(8+2 vs14__4min;p<0.005) with R compared to S. A greater number of TITM imaging defects was observed after R protocol(p<0.01)which correlated with the shorter exercise time(r=-0.81). In conclusion, our results shows that the ramp protocol determines a greater cardiovascular response which is associated with a greater number of TITM imaging defects.
The paradoxical(P) rise in systolic(S) BP with IV dipyridamole(D) has been suggested to relate to induced ischemia. To evaluate the cause and implications of a PSBP response pressure(SBP) to D(0.56mg/kg), we characterized the s y m p t o m a t i c , BP. HR, E K G and related p e r f u s i o n scintigraphic(DPS) findings in 341 consecutive patients(pts) having clinical DPS. The typical blunted or mild hypotensive SBP response, average 2 2 m m H g in 292 pts. A PSBP response in 40 pts. was mild (<20mmHg) in 18, moderate(20-39mmHg) in 22 and severe(> or =40mmHg) in 9. There was no significant difference between those with and without the PSBP response in n u m b e r of coronary regions with defects(0.88 vs 0.73) or reversible defects(0.51 vs 0.46) on D P S HR increased in with SBP(p<0.05). Induced headache or chest, abdominal, neck or jaw pain were more common among those with the PSBP compared to those with the typical SBP response(20/49 vs 77/292), as was > l m m induced ST depressions(9/49 vs 19/292), both p<0.05. There were no differences in HR changes, induced pain and ST depression, between pts with a mild PSBP response and typical SBP responders. A moderate or severe PSBP response to D is suggestive of, but not specific for. ischemia, is likely unrelated to the extent of underlying coronary disease, and probably more often relates to increased catechol release from pain, anxiety or other cause.
P 14-290
P 14-292
DIAGNOSTIC ACCURACY OF EXERCISE AND DIPYRIDAMOLE MYOCARDIAL PERFUSION SCINTIGRAPHY IN W O M E N James R. Lucas, James Tom, Poonam Agarwal, Robert S. Hattner, Michael W. Dae, Elias H. Botvinick, University of California, San Francisco
"Paradoxal effect" in stress/rest 99mTc-Sestamibi (MIBI) scintigraphy: w h a t does it mean?
We compared the accuracies of exercise(E) and dipridamole (D) myocardial perfusion scintigraphy (MPS) for coronary disease diagnosis (CAD) in 185 consecutive females (F) having selective coronary angiography (SCA) within 3 months of clinical EMPS (n=30) or DMPS (155). F having EMPS were younger(50 vs 67 yrs) but those having EMPS more often had CAD(86% vs 60%), each p<0.05, and 3 vessel CAD(162/346, 47% vs 5/18, 28%), p=NS. But their incidence of prior MI, nature of induced symptoms, BP or EKG changes, C A D stenosis severity, and incidence, extent and reversibility of EMPS defects, overall sensitivity (sens) (16/18, 89% vs 371/345,92%), specificity(spec)(9/12,75% vs 27/45,60%), per vessel sens(22/33,67% vs 214/29772%) and spec(50/57,88% vs 141/168,84%) sens for 1(7/8,87% vs 25/29,86%), 2(4/5,80% vs 38/42,90%) or 3(5/5.100%) vs 59/62,95%) vesseI C A D were not different, nor were per vessel sens, 69% vs 81% and 67% vs 68%, or spec 87% vs 79% and 89% vs 79%, for L A D and R C A vessels respectively. DPS was less sens, 100% vs 6 4 % , but more spec, 64% vs 92%, p<0.05, for left circumflex CAD. There are few differences, none likely clinically significant between the accuracy of EMPS and DMPS in F and likely relate to technical factors. These values compare closely with those previously established in male or mixed populations.
o. SCHILLACI, R.DANIEL1,17,.TAVOLARO,V. PICARD1,P. CANNAS,F. SCOPINARO. UNIVERSITY"LASPIENZA",ROME,ITALY
The phenomenon of "reverse redistribution" with thallium - 201 imaging is common, but at present the underlying cause is not completely clear. Using MIBI scintigraphy, among 203 consecutive patients (pts) submitted to stress/rest images, in sixteen cases (8%) we observed worsening of perfusion defects at rest in comparison to exercise, or new defects arised in rest scans. The group consisted of 6 females (range: 48-67 years) and 10 males (range: 37-69 years). Planar (3 standard views) and SPECT scintigrams were performed within 4 days and evaluated by 3 observes independently. Four pts (2 F and 3 M), studied because of effort chest pain, were classified as normal: 3 without significative stenoses at coronary angiography and one with both negative maximal exercise test (ET) and highdose dipyridamole (D) echocardiography. Five pts (2 F and 3 M) had angiographycaUy proven coronary artery disease (CAD). Three pts (1 F and 2 M), with anginal pain, had both positive maximal ET and high-dose D echocardiography. Four pts (1 F and 3 M) had proven myocardial infarction (2 had undergone thrombolysis). Therefore, in our series "paradoxal effect" was considered a pathological result in 75% of cases (12/16 pts). These findings suggest that conclusion regarding myocardial perfusion based only on MIBI stress studies, even if normal, should be made with caution, and rest scans should always be performed.
$73
$74
Abstracts Tuesday afternoon, April 25, 1995
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
P 14-293
P14-295
ADENOSINE TECHNETIUM-99m TETROFOSMIN CARDIAC TOMOGRAPHY IN PATIENTS WITH CORONARY ARTERY DISEASE: COMPARISON WITH EXERCISE.
DIPYRIDAMOLE Tc-99m SESTAMIBI M Y O C A R D I A L PERFUSION SCINTIGRAPHY IN PATIENTS WITH LEFT ANTERIOR DESCENDING OCCLUSION WITHOUT PREVIOUS INFARCTION. PRELIMINARY DATA.
Alberto Cuocolo, Leonardo Pace, Emanuele Nicolai, Antonio Nappi, Fiorenzo Squame, Pasquale Sullo, Peter J. Ell, Marco Salvatore. Universit& "Federico I1" and Istituto Nazionale dei Tumori, Napoli, Italy and Middlesex Hospital, London, UK.
Marco Mazzanti, Giovanni Cianct, Nino Ciampani, C aria Silenzi, Carlo Costantirfl, Gabnele GabrielH, Augusto Pm'caro. Lancisi Heart Hospital, Italy. Angina or sometime dyspnea due to development of
T U E S D A Y
left
The results of adenosine and exercise Tc-99m tetrofosmin SPET were compared in 35 patients (33 men, mean age 53_+8 yrs) with coronary artery disease (CAD). All patients were submitted to 3 injections of tetrofosmin (740 MBq iv), one at rest, one after bicycle exercise and one after adenosine (140 ~tg/Kg/min for 6 min). Adenosine induced a significant (p<0.01) increase of heart rate (905:16 bpm at peak vs 79+11 bpm at rest). Blood pressure was not different after adenosine compared to rest. Double product was 22931+7039 at peak exercise and 11229+_3413 after adenosine (p50% coronary stenosis) on coronary angiography. Agreement on the presence of normal or abnormal tomograms by adenosine and exercise was 100% by quantitative analysis. Agreement on localization of the perfusion defect to a specific vascular territory was 85%. The sensitivity, specificity and predictive accuracy for detection of stenosed vessels were 83%, 83% and 83% for adenosine and 83%, 85% and 84% for exercise. Thus, despite different hemodynamic effects, adenosine and exercise tetrofosmin SPET provide similar information in the diagnosis and localization of CAD.
ventriculardysfunction (LVD) isoften the firstmanifestation of coronary arterydisease(CAD). Aim of the study was to evaluate the role of 2-day stress-restTC-99m sestamibi myocardial pcrfnsion scintigraphy (SNIPS) using dipyridamole stresstest (DST) to correctly identify the management of pts with left anteriordescending (LAD) occlusion watlaoutclinicaland ECG signs of previous MI. We evaluated 7 catheterizedpts (5 males and 2 females, mean age 69+8 years) with proximal LAD occlusion and well developed collateral flow. Valvular and primary heart disease were excluded. 3 pts (Group I) presented LVD (NYHA II) and 4 pts (Group II)presented angina without LVD asprirnarysymptom. All pts underwent DST (0.56mg/Kg i.v.in 4 rain.)25 mCi of 99rn-Tc scstamibi 4 min aftexthe end of dipyridamole infusion and the day afterwere injected, The acquisitions were performed by planar technique acquiring in
P14-294
P14-296
HEART RATE ADJUSTED ST SEGMENT DEPRESSION VERSUS MYOCARDIAL PERFUSION SCINTIGRAPHY FOR IDENTIFICATION OF SEVERECORONARYARTERYDISEASE
QUANTIFICATION OF VISUALLY NORMAL SSmTc MIBI SPECT IN WOMEN WITH A POSITIVE OR A NEGATIVE EXERCISE TEST, J.M.Schroeder-Tanka 1, P.J.Slomka 2, W,Roolkerl,M.M.C.Tiel van Buul ~, K.W.Redekop ~, K.I. Lie~, E.A. van Royen~) Academic Medical Centre, Amsterdam, Netherlands.2 Victoria Hospital, London, Ontario, Canada.
anterior, left anterior oblique 45~and lateral 70 ~ views. Ailthe studies were scored on a previously described 15 segments (S) classification o f myocardial territory using a a-points scaJe. Reversible p ~ s i o n defect (RD) was considered a difference of at least 2 pol nts score between stress and rest study. Results:Group I: all pts showed > 4 S with RD (stress score 3 or 4) in L A D territory, Group I I : < 4 S withRD (stress score 1 or 2)yore found in same territory in all pts. Conclusions: S MPS using DST has demonstrated to be clinically useful to identify pts who can benefit from a L A D revascularizatlon for resolving LVD.
P M A P R I
L
/vPJ.Forrcira, A.Ferccr-Antunes,A.Fclizardo, B,Dias, J.Morais, M.S.;P,','~,l.Lima, LA.Provid~.ncia. Departmentsof Cardiology and Nuclear Medicitl:. University Hospital.Coimbra.Portugal. In a population with high prevalence of coromry artery disease (CAD), it is of major concern the identification of higher risk patients (3 vessels; 2 vessels involving the left descending artery; lefi main disease) with a non invasive diagnostic test. The aim of this study was to determine the diagnostic accuracy, for severe CAD, of exercise test and myocardial perfusion scinngraphy, based on the following indicators: Heart rate adjustt~d ST segment depression > 3 ~tV/beats/min (ST FIR index) arid presence of reversible defects involving more than one myocardial segment. For this purpose 63 consecutive patients referred for coronary arteriography underwent treadmill testing according to Brace or Modified Bruce Protocol and Stress/Rest Sestamibi imaging. Of the 63 patients of the study sample, 54 (85,7%) were men; the mean age was 57,2 5:8,2 years; 31 patients (49,2%) had a previous myocardial infarction. Coronary artery disease was present in 54 patients (85,7%): 3 vessels-16 (29,6%); 2 vessels with left descending artery-17 (31,5%). For identification of high risk disease the sensitivity of ST HR index > 3 laV/beats/min was 63,1%, and the specificity was 53,8%; the sensitivity of myocardial scintigraphy (reversible defects involving more than one myocardial segment) was 76,9%, and the specificity was 62,2%. Diagnostic accuracy for both indicators was 58,1% and 68,0%, respectively. Concerning the question of severe CAD diagnosis, myocardial perfusion scintigraphy showed a better accuracy than ~ e ST HR index. In a population with high prevalence of disease, risk assessment and disease extent could be reasonably evaluated through myocardial pedusion scintigraphy.
Little is known why exercise ECG's are so often false-positive in women impeding the detection of CAD. We questioned if subtile differences in myocardial perfusion could be found in these women by quantitative analysis of an averaged 3D template of the 99mTc MIBI SPECT. 54 women were submitted to ~amTc MIBI scintigraphy in view of chest pain, Exercise ECG was positive in 27 (group I) and negative in 27 patients (group II). Riskfactors were equally present (88%) in both groups, cardiac history negative in all. Transversa~ s~ices of individual patients in both groups were aligned to a common 3-D orientation and sized by an automatic fitting algorithm (Slomka et al. JNM 1994, 35,127P) on a HERMES SUN workstation (NUD). This procedure resulted in 4 average perfusion templates : stress & rest group I and stress & rest group I1. No visible difference was observed between the average models of group I and II. Quantitatively, using a region growing method, the difference in local perfusion between the models proved to be less than 2%. Conclusion: abnormal exercise ECG in women is generally not associated with significant myocardial perfusion abnormalities.
JOURNAL OF NUCLEAR CARDIOLOGY V o l u m e 2, N u m b e r 2, P a r t 2
Abstracts T u e s d a y a f t e r n o o n , A p r i l 25, 1995
$75
P 14-297
P 14-299
THALLIUM-201 REST AND DIPYRIDAMOLEMYOCARDIAI SCINTIGRAPHY IN ESSENTIAl, ttYPERTENSION PATIENTS WITH :tND WITHOUT LV HYPERTROPHY;TOTALPERFUSIONRESERVEANDVIABILITY.
THE VALUE OF SEISMOCARDIOORAPHY AND THALLIUM-201-SCINTIGRAPHY IN THE DETECTION OF CORONARY ARTERY DISEASE Wolfgang Buchinger, Geor~ Binter, Bernd Schubert, Bemd EBer, Werner Klein, Uieter Brandt, Otto Eber. Barmherzige Brueder Hospital, Graz, Austria.
L.Samoilenko, A.Pshcnicyn. N.Mazur, M.Glotov, V.Sergienko. Cardiology Research Center, Moscow, Russia. The results of rest[R] and-dipyridamole [Dip] thallium-201 myocardial scintigraphy (two injections within 7 days) was evaluated in 50 untreated patients [pts] with essential hypertension (24 M and 26 F, age 44.3_+1.1 years; office diastolic blood pressure [DBPl 108,5_+1.4mm Hg). No pts had coronary stenosis and a LV ejection fraction <60% (72.0+.0.9). Pts were divided into 3 groups (Gr) according ehocardiographycal~ measured LV mass index [MMI]. G r l - no LVH (MMI<80 g/m z, n=24), Gr2- moderate LVH (MMi=80.100g/m 2, n=12), Gr3- high LVH (MMI > 100 g/m 2, n=14). T1-201 uptake ITU-R and TU-Dip,~ pc,fusion reserve (increasing of TU on 100 g LV mass ~FPR] were assessed. The following perfusion abnormalities [DP] were defined: 1) non viable (fixed, [DPFx]), 2) viable (reversible on Dip and/or R, [DPVb]). Pts in Grl vs Gr2 had similar TU-R (1,65+_0.1 vs 1,57_+ 0.1), TU-Dip (2.4• vs 2.2_+0.1), TPR (35.1+3.9 vs 27.7+_3.5), greater DPVb (9.4• vs 7.0• p<0.01) and less DPFx (2.7_+ 0.35 vs 5.2+_0.5; p<0,001). Grl vs Gr3 had greater TU-R (1.65+_0.1 vs 2.8• p<0.001). TU-Dip (2.4+0.2 vs 4.1+_0.4; p<0.001). TPR (35.1+_3.9 vs 18.2_+1.5; p<0.0l) and DPVb (9.4+_0.67 vs 7,73_+0.52; p<0.05), less DPFx (2.7+.0.35 vs 4.87+_0.6;p<0.01). Gr2 vs Gr3 had less TU-R (p<0.001), TU-Dip (p<0.00t), TPR (p<0.01), and similar DPVb (p<0.01) and DPFx (p<0.05). R and Dip imaging in asimptomalic pts with EIt showed:l) pts with high LVH had a significant reduction of total perfusion reserve compared with pts without LVH and moderate LVH; 2) pts without LVH had greater regions of viability and less fixed DP compared with moderate and high LVH pts.
In a prospective study the diagnostic value of seismocardiography (SCG) in diagnosing coronary artery, disease (CAD) was evaluated. SC.G is a noninvasive f o r m of investigation to detect CAD. Acceleration ot the chest wall caused by cardiac movement is recorded before and immediately afi.er bicycle stress testing. This way information can be obtained on altered mechanical function due to ischemia. Bicycle stress testing, SCG, and Thallium201-myocardial SPECT was performed in 335 patients with suspected CAD. In 28 patients a coronary angiograp'hy was carried put as well. In 22 of those 28 patients one or more signitlcant stenosis were detected. In 8/28 bicycle stress testing showed pathological results. SCG was abnormal in F0 patients. By means of scintigraphy all patients suffering from CAD were true positive. False positive results were obtained in 2/28 with stress testing and in 1/28 with SCG. In scintigraphy 5/28 reversible photopenic lesions indicating myocardial ischemia could not be correlated to signiticant stenosis. In stress testing 1.4/28 a n d in SCG 12/28 false negative results were obtained. Our results indicate, that SCG compared with stress testing onlyr improves the diagnosis of CAD but does not reach the sensitivity of Thallium-201-myocardial SPECT. Our conclusion therefore is, that SCG cannot replace cardiac perfusion imaging.
P 14-298
P14-300
LEFT VENTRICLE PERFUSION: EFFECT OF LONI3-TERM ISOPTIN SR [IS] TREATMENT IN PATIENTS WITH ESSEN FI::~L tIYPERll:,NSION [EH].
DIAGNOSTIC AND PROGNOSTIC SIGNIFICANCE BLUNTED P E R I P H E R A L N E M O D Y N A M I C RESPONSE INTRAVENOUS DIPYRIDAMOLE.
L,Samoilenko, A.Pshenicyn, M.Glotov, N.Mazur, S,Pasha, V.Sergienko. Cardiology Research Center. Moscow, Russia. 2~ dipyridamote [Dip] myocardial scintigraphy w a s p e r f o r m e d in 20 a s i m p t o m a t i c p t s w i t h m o d e r a t e E H t o e v a l u a t e IS e f f e c t o n t h e d i f f e r e n t t y p e s o f p e r f u s i o n d e f e c t s . 8 m a l e s a n d 1 2 f e m a l e s , a g e d 43.4_+ 1.6 y e a r s , w i t h o f f i c e d i a s t o l i c b l o o d p r e s s u r e [ D B P ] 1 0 8 . 6 + 1 . 9 m m H g a n d m a s s i n d e x L V [ M I ] =127.9_+ 8.4g/m 2 (the formula of Devereux) without CHD were examined after two week pharmacological washout period (Dip) and after six-month 240 r a g / d a y IS t r e a t m e n t ( D i p ) . T h e f o l l o w i n g d e f e c t s [ D P t w e r e d e f i n e d : I) w i t h o u t r e d i s t r i b u t i o n [ D P W R ] , 2) r e v e r s i b l e [ D P R d ] . All p t s h a d r e d u c t i o n D B P ( 9 0 . 5 + ! , 8 ; p < 0 . O 1 ) , MI (115,1+5.8; p<0.01), DP (12.8:t:0.5 vs 9.5_,*0,6; p < 0 . 0 0 t ) a n d D P R d (5.2+_0.64 vs 2.9_+0.5; p < 0 . 0 1 ) . N u m b e r o f D P W R w a s n o c h a n g e (7.6+_0.7 vs 6.6-+ 0.8). IS t r e a t m e n t in p t s w i t h E H s i g n i f i c a n t d e c r e a s e d t h e number of reversible myocardial perfusion defects.
OF TO
James Tatum, R o g e r Quint, A m a n d a Graham, Karin schmidt. M e d i c a l C o l l e g e of V i r g i n i a Hospitals, Richmond, V A E l e v a t i o n in heart rate (HR l is an expected peripheral h e m o d y n a m i c r e s p o n s e to intravenous d i p y r i d a m o l e (IV DIP). A b l u n t e d H R increase has been thought to i n d i c a t e submaximal coronary flow increase leading to d e c r e a s e d diagnostic imaging potential. Direct measurements suggest that maximal c o r o n a r y flow increase is not n e c e s s a r y for d i a g n o s t i c imaging and that peripheral r e s p o n s e does not reliably predict coronary response. F r o m 1986 to 1992, 3715 patients underwent IV DIP stress testing with thallium-201 t o m o g r a p h i c imaging in our laboratory. The m e a n increase in H R was 17.4 bpm, 23.5% above a b a s e l i n e average of 74 bpm. Patients who failed to increase HR 10% above b a s e l i n e w e r e d e s i g n a t e d as n o n - r e s p o n d e r s (NR) (n=488 [13%]). A m a t c h e d r e s p o n d e r (R) group (n=483), m a t c h e d for age, sex, and approximate (120 days) date of study, was identified. Imaging results b e t w e e n the groups were not s i g n i f i c a n t l y different: normal R=198, NR=140 (p=NS); r e v e r s i b l e d e f e c t s R=190, NR=204 (p= NS); and m u l t i - v e s s e l high risk p a t t e r n R=82, NR=95, chi square 0.979 (p=NS). There was no significant d i f f e r e n c e b e t w e e n groups for MI (R=14, N R = I O [p=NS]) or d e a t h (R=37, NR=33 [p=NS]) d u r i n g follow-up. This data strongly suggests that a b l u n t e d H R increase in conjunction w i t h IV DIP does not affect the diagnostic and p r o g n o s t i c p o w e r of associated imaging.
$76
Abstracts Tuesday afternoon, April 25, 1995
March/April 1995, Part 2
P14-301
P14-303
QUANTITATIVE ASSESSMENT OF THE SEVERITY OF PERFUSION DEFECTS IN SPECT STUDIES OF THE HEART
REVERSE REDISTRIBUTION IN RESTING THALLIUM-201 MYOCARDIAL SCINTIGRAPHY IN CHRONIC CORONARY ARTERY DISEASE: AN INDEX OF MYOCARDIAL VIABILITY.
Carlo Caiati, Michael O'Connor, Timothy Christian, Raymond Gibbons, Fondazione Clinica del Lavoro, Cassano Murge, Bari, Italy, and Mayo Clinic, Rochester, MN.
T U E S D A u
JOURNAL OF NUCLEAR CARDIOLOGY
In Tc-99m sestamibi SPECT, the nadir in short axis circumferential profiles is significantly associated with angiographic collateral grade. This study examined the effects of infarct size, scatter and radioisotope on the relationship between the nadir and actual activity in the infarct zone in a cardiac phantom. SPECT images of the phantom containing 0,20,35 and 50% defects with severity 0-90%, were acquired for T1-201 and Tc-99m with and without scatter correction. Three indices - the nadir, nadir in basal slice and profile area below a fixed threshold (defect area) showed an excellent correlation with known defect activity (r > 0.95). There was no significant difference between nadir and basal nadir indices. After scatter correction, the slope of the regression line for the nadir index with Tc-99m, increased from 0.73 to 0.81 and the average absolute error in estimating true defect activity decreased from 6.7_+4.1% to 3.2+2.8%. For TI-20I the slopes varied between 0.53-0.62 with absolute errors of 12-18%. Scatter correction did not significantly alter these results. Isotope and scatter correction had no significant effect on results for defect area. Defect activity and size, scatter correction and isotope were all significantly independent determinants of the 3 indices, and models incorporating these factors accounted for 96-99% of the variability in the 3 indices. These results provide the technical basis for the use of these indices for the noninvasive measurement of residual blood flow in the infarct zone.
Leonardo Pace, Alberto Cuocolo, Paolo Marzullo, Emanuele Nicolai, Alessia Gimelli, Nicola De Luca, Bruno Ricciardelli, Marco Salvatore. Universit& "Federico I1" and Istituto Nazionale Tumori, Napoli and Istituto di Fisiologia Clinica, CNR, Pisa, Italy. Nineteen patients (17 men and 2 women, mean age 53~8 yrs) with coronary artery disease underwent rest-redistribution thallium-201 (T~) and rest tachnetium-99m methoxy isobuty| isonitrile (MIBI) scintigraphy before coronary revascularization (CR). Regional TI and MIBI uptake were quantitatively analyzed. Echocard~ographic left ventricular wall motion (WM) was assessed before and after CR with a 3-point scale (1=normal, 2=hypokinetic, 3=akinetic/dyskinetic). Two patterns of reverse redistribution (RR): were identified: RR-A (normal TI uptake in rest and abnormal in redistribution images), and RR-B (abnormal TI uptake in rest and significant decrease in redistribution images). Of the 247 segments analyzed, 85 were normal, 37 reversible defects, 83 fixed defects, and 42 RR (19 RR-A and 23 RR-B). RR-A segments differed from RR-B in WM score (1~4_+0.7vs 2.0+1.0, p<0.05) and in MIBI uptake (75+14% vs 60_+13%, p<0.001). Electrocardiographic Q waves were present in 26% of RR-A segments and in 57% of RR-B segments (p<0.05). After CR, all dyssynergic segments with RR-A showed improved WM, while only 40% of dyssynergic segments with RR-B had such an improvement (p<0.05 vs RR-A). Our results suggest that dyssynergic segments with RR-A should be considered viable.
P M A P R I L
P 14-302
P 14-304
Tc-99m MIBI CARDIAC TOMOGRAPHY ASSOCIATED WITH ADENOSINE CONTROLLED CORONARY VASODILATION IN PATIENTS WITH CORONARY ARTERY DISEASE.
COMPARATIVE DATA ANALYSIS OF EXERCISE ECG AND MYOCARDIAL PERFUSION S C I N T I G R A P H Y IN P A T I E N T S W I T H A N G I N A A N D SILENT I S C H A E M I A O. Partos, M. Gydrgy, M. IstvAnffy Dept. o f Nuclear Cardiology, Hungarian Inst. o f Cardiology, Budapest, Hungary
Emanuele Nicolai, Alberto Cuocolo, Leonardo Pace, Andrea Soricelli, Antonio Nappi, Fiorenzo Squame, Pasquale Sullo, Stefania Cardei, Marco Salvatore. Universit& "Federico ll" and Istituto Nazionale dei Tumori, Napoli, Italy. The aim of this study was to investigate the usefulness of adenosine Tc-ggm MIBI tomography in the diagnosis and localization of coronary artery disease (CAD). We studied 57 patients (52 men, mean age 52+10 yrs) with proven CAD (.~50% coronary stenosis): 49 with previous myocardial infarction (MI) and 8 without MI. All patients underwent Tc-99m MIBI tomography after administration of adenosine (140 gg/Kg iv for 6 mini. Adenosine induced a significant (p<0.01) increase of heart rate (90_+16 bpm at peak vs 71_+12 bpm at rest). Blood pressure was not different after adenosine compared to rest. Side effects occurred in 44% of the patients. However, all symptoms were mild and resolved spontaneously within 2 rain after discontinuing adenosine infusion. A total of 171 coronary territories were quantitatively analyzed. The overall sensitivity, specificity and predictive accuracy for detection of stenosed vessels were were 88%, 80% and 85%, respectively. Sensitivity, specificity and predictive accuracy for detection of stenosed vessels were 92%, 82% and 88% in patients without MI and 87%, 80% and 76% in those with previous Ml. In conclusion, adenosine Tc-99m MIBI cardiac tomography is safe and accurate in evaluating the presence and localization of CAD.
73 patients (pts.), (45 male, 28 female, mean age 55.5 years) have been studied with anamnestic chest pain. Myocardial ischaemia has been verified by sign and symptom limited exercise test (stress E C G - Bruce protocol) and by 2 0 l - T h a l l i u m myocardial perfusion Single Photon Emission C o m p u t e r T o m o g r a p h y (SPECT). Two groups were selected. Group "A", 27 pts. with exercise induced angina and G r o u p "SI", 46 silent ischaemic pts. with significant stress E C G - S T depression and/or reversible regional myocardial perfusion defect. There were not found significant differences between Group "A" and Group "SI" in age, anamnestic events (recent myocardial infarction, anginal pain), in exercise tolerance (maximal workload, double product) and in S P E C T score o f reversibility rate and extension o f hypoperfusion as well. Conclusion: similar underlying ischaemic pattern could be supposed in stress induced myocardial ischaemia with or without chest pain based on stress E C G and S P E C T data.
JOURNAL OF NUCLEAR CARDIOLOGY V o l u m e 2, N u m b e r 2, P a r t 2
P14-305 A NEW ROLE OF 201THALLIUM REINJECTION ASSESSMENT OF DEGREE OF STENOSIS OF CORONARY ARTERIES; (PRELIMINARY RESULTS) EI-Haddad, Sh. *;Moustafa,H. *;El~Yabban~Kh.*; Gharieb,S. **; FawZy,A. *; ElTawil~A. *r and EI-Naggar, W. ** *Nuclear Medicineand.**CardiologyDepartments.CairnUniversity.Egypt
Forty-four cases with coronary artery disease had been subjected to both: (l)Coronaryangiographyto detect coronaryarterystenosis(i.e. in 132 vessels)and grouped into four groups:group I with stenosis<50*/0(30 vessels),group 1I: with >50-<90%stenosis(44vessels),group 111with >90-99%(40 vessels)&group 1V with 100% stenosis(18 vessels).(2)Two201TI injectionswith 3 sets of SPECT imaging, two after stress injection(stress[st.]&redistribution[RD). & anotherset of imaging one benr after reinjection. Then all SPECT imageshad been gradedsemiquantitatively,into:l:nnrmal uptake, 2:probably normal but with heteragenans border. 3=moderate reduction in uptakeA-severereductionin uptake,&5=absentuptake RESULTS:During St. image 16/30 (53.3%) of group I and 12/44 (27.2*/0)of group II show grade I uptake, while 20/40 (50%) of group III and 16/18 (88.8*/'0)show grade 4 or 5. On RD image, 18/30 (60%) of group I and 20/44 (45%) of group 11 show grade I uptake, mean while 16/40 (40%) of group III and 10/18 (55.5%) of group IV show grade4 or 5 uptake. On ILlimage,24/30(80%) of group I and 20/44 (45.5%) of group II show grade I uptake, while 18/40 (45%) of group IIl and 16/18(88.8'/o)of group IV show grade4 or 5. Probability system had been applied for the 3 sets of imagesand revealedthat: grade(l) uptakeon st. imagecarrieshigh probabilityof either normal or CAD with stanosis<50%, meanwhilegrade 4 or 5 carries high probabilityof either group 11I or IV. On the other hand. RI image revealed that grade I uptake,carrieshigh probabilityof normal or stenosis <50%, while grade 4 or 5 carrieshigh probabilityof 100%occlusionand may be 90-99% stanosis, Concerningstenosisof 50-<90%, image changesthat improve on either RD or RI imagescarrieshigh probabilityfor this group,whilethose st.abnormalities that either remain the same or worsen on the followingimagescarries high probabilityof 90-99% stanosis.Sensitivity of this probabilitysystemin detectionof degree of stenosishas beenfound to be 92%, specificity 89% and accuracy 88.4% CONCLUSION:Three sets of images with two 201TI injections,can provide a good probabilitysystemfor predictingdegreeof stenosisof coronaryarterydisease.
Abstracts T u e s d a y a f t e r n o o n , A p r i l 25, 1995
P15-307 DEFECT REVERSIBILITY USING THALLIUM-201 REINJECTION: COMPARISON OF STRESS-REDISTRIBUTIONREINJECTION WITH STRESS-IMMEDIATE REINJECTION B.L.F. Van Eck-Smit, E.E. Van der Wall, A.F.M. Knijper, A.H. Zwinderman, E,K.J. Pauwels, A.V.G. Brusehke, University Hospital, Leiden, The Netherlands We determined whether thallium-201 (TI-201) stress/redistribution/ reinjection scintigraphy and TI-201 stress/immediate reinjection scintigraphy provide similar information on reversibility of stress peffusion defects. In 305 patients (pts) with stress perfusion defects we!compared the scintigraphic findings of 210 consecutive pts who underwent the standard TI-201 stress/redistribution/reinjection p~'otocol (Group I), with 95 consecutive pts who subsequently Onfferwent the TI-201 stress/immediate reinjection protocol (Group ii). In al! pts three-view planar images were analyzed visually and quantitat!'vely. In Group I, defect reversibility was observed in 433 of 622 (70%) stress perfusion defects compared to 220 of 320 (69 %) segments in Group II (p=NS). With respect to Q-wave related segments, defect reversibility was seen in 102 of 172 (59%) segments in Group I compared to 34 of 63 (54%) in Group II (p=NS). Based on defect reversibility, the diagnosis of myocardial ischemia was made in 184 of 210 (88%) pts in Group I compared to 86 of 95 (91%) pts in Group II (p=NS). Conclusion: Immediate T1201 reinjection imaging provides similar data on defect reversibility as the standard TI-201 reinjection approach. In practical terms, t h e stress/immediate reinjection approach is advantageous as it reduces imaging time, enhances patient throughput and can be considered as one completed imaging procedure.
Pl 5-306
P15-308
ANTIMYOSIN ANTIBODY IMAGING IN EXPERIMENTAL AORTIC REGURGITATION
CLEARANCE OF THALLIUM-201 FROM THE PERIPHERAL BLOOD: COMPARISON OF IMMEDIATE AND STANDARD REINJECTION B.L.F. van Eck-Smit, E.E. van der Wall, P.P.A.M. Verhoeven, A.H. Zwinderman, E.K.J. Pauwels. University Hospital, Leiden, The Nethedands
Lu P, Zanzonico P, Goldfine SM, Magid N, Herrold EM, Borer JS The New York Hospital-Cornell Medical Center, New York, USA Our laboratory has shown histopathologically that fiber dropout and myo.cytolysis may precede heart failure in experimental aortic regurgitation (AR). To determine if this process can be detected by noninvasive scintigraphic imaging, in rive gamma camera imaging, tissue activity concentration (% injected dose [ID]/gm) and autoradiography were undertaken in 24 New Zealand white rabbits (4 normai[NL], 4 sham-operated, 15 with catheterinduced AR, including 6 studied acutely (at 3-5 wks postoperation) and 8 studied chronically (at 98-128 wks postoperation). %ID/gm of the heart showed uptake significantly greater (P<.05) in both chronic AR (0.34-4-0.22) and acute AR (0.32A:0.12) than in NL rabbits (0.10~0.07), and a trend higher than in shams (0.24+0.08). Autoradiography of the myocardium ex rive showed intensive subendocardial uptake in some of chronic AR animals, but not in other groups. Thus, In-lll labeled antimyosin imaging may permit detection of AR-induced myocardial damage before functional deterioration.
The aim of the study was to determine the influence of exercise (Ex) and the time interval between Ex and reinjection (RI) at rest o n thallium-201 (TI) plasma levels and clearance from the peripheral blood. A total of 53 pts were studied. In all pts TI (75 MBq) was injected at maximal Ex. In 26 p t s 37 MBq was reinjected immediately after completing the Ex-images (immediate RI) and in the remaining 27 pts TI (37 MBq) was reinjected after completing 3-h redistribution images (standard RI). Serial blood samples were taken during the first 30 rain after TI administration and residual TI activity was measured shortly before RI. From blood activity curves peak activity, residual activity and decay constants were calculated. Results Ex-injection Immediate RI Standard RI peak activity (% of initial peak) 100 84+76 56+47 ns residual activity(kBq/ml) 0.88+0.48 0.72+0.64 ns clearance rate(min"~) X (3-12 min) 0.17+0.09 0.14:1=0.5 0.13+0.003 ns 3, ( > 15 rain) 0L03+0.06 0.01+0.03 0.015:0.01 ns Conclusions: TI kinetics is uninfluenced by Ex or time interval between Ex and RI. Based on these findings there is no need to postpone RI till 3-4 hours following Ex.
$77
$78
Abstracts Tuesday afternoon, April 25, 1995
P15-309
P15-311
NONINVASIVE ASSESSMENT OF THE SYMPATHETIC NERVOUS SYSTEM IN HUMANS
A SIMPLIFIED APPROACH TO THE DEVELOPMENT AND VALIDATION OF CRITERIA FOR ABNORMALITY IN QUANTIFICATION OF MYOCARDIAL PERFUSION SPECT
SD Rosen, S Guzzetti, A Dfitsas and PG Camici. MRC Clinical Sciences Centre, RPMS, Hammersmith Hospital, London, UK.
T U E S D A u
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
With no 'gold standard' for non-invasive assessment of activation of the sympathetic nervous sytsem (SNS) in vivo, we investigated 3 different SNS indices: i) plasma catecholamines levels, measured by high performance liquid chromatography); ii) frequency domain analysis of heart rate variability and iii) g adrenoceptor density (tAR) measured non-invasively by means of positron emission tomography (PET) with IIC-CGP-12177. Pooled data was obtained from 20 controls [age 47 (14) years, mean (SD), range 21-77]. Results: No correlations were found amongst: plasma catecholamines; the frequency domain parameters [RR, RR variance, total low frequency (LF, -0.10Hz) and high frequency (HF, ,-0.25Hz) spectral power, LF/HF ratio, and day-night difference in LF (0LF day/night); or BAR. BAR [8.76(2.06) pmol/g] was correlated with systolic blood pressure [119 (13), R=0.51, p=0.05]. With increasing age, there were reductions in: total LF [54.3 (8.9) normalised units (nu), R=0.5, p<0.03]; LF/HF [2.7 (l.l), R=0.49, p<0.04] and ~LF day/night [13.5 (13.0), R=0.57, p<0.02]. The lack of any simple relationship between any of the indices measured probably reflects the multiplicity of actions of the SNS, separate components of which are being measured by the techniques employed.
Kenneth Van Train, Joseph Areeda, Michael Patterson, Hosen Kiat, Guido Germano, John Friedman, Ernest Garcia*, and Daniel Berman, Cedars-Sinai Medical Center, Los Angeles CA, *Emory University Hospital, Atlanta, GA. We have previously developed and validated procedures for quantification of myocardial perfusion SPECT imaging which involve comparison of a patient's result with a pool of reference patients (<5% likelihood of CAD) and applying criteria of abnormality to classify the study as normal (nl) or abnormal. Our standard approach for the development of each nl limit requires over 100 man-hrs employing multiple application programs. The approach uses a reference, a pilot, and a prospective population, each with a minimum of 40 patients. Consensus visual scoring by 3 observers is used as the gold standard. Patient studies are sampled using a combination spherical and cylindrical coordinate scheme resulting in between 400 and 600 samples/study. After matching visual segments with areas of quantitative values, ROC analysis is used to determine the optimal number of SDs required to separate nl from abnormal segments. To reduce development time a database application was developed with statistical procedures and graphic output in portable C which automates analysis of criteria for abnormality. The approach can be used to initially compare normal responses (mean & std) between different myocardial perfusion agents, acquisition protocols, and nl populations to determine if specific normal limits are required for the study. The new comprehensive integrated approach has reduced normal limit development time by 70% over the previous approach.
P M A P R I
L
P15-310 [N-METHYL-IIc]PROPIONYL-L-CARNITINE UPTAKE IN HUMAN MYOCARDIUM SD Rosen, V Cunningham, H Boy& VW Pike, RJ Davenport, R Gunn, S Osman, MP Law and PG Camici. MRC Clinical Sciences Centre, RPMS, Hammersmith Hospital, London, UK. L-camitine, essential for intra-cellular fatty acyl transport, might benefit ischaemic muscle. Its natural derivative propionyl-Lcarnitine additionally releases propionate which can enter directly the citric acid cycle (through its anaplerotic conversion to succinate) leading to the anaerobic production of GTP. We have used positron emission tomography (PET) with the tracer N-methyl-llcpropionyl-L-carnitine (PLC) to demonstrate myocardial uptake of PLC in I0 normal volunteers [9 male, age 38 (9) years, mean (SD)]. After a blood pool scan using C150, PLC was administered iv and its myocardial uptake followed over 90 min by dynamic PET. Left atrial regions of interest, defined on the C150 scan, were applied to the PLC images Io correct the data obtained from continuous blood sampling for delay and dispersion relative to arterial blood. Quantitative images of myocardial PLC uptake were obtained by spectral analysis of the time activity curves, allowing discrimination between radioactivity in blood and that in the myocardium. An irreversible component of PLC uptake was found [Ki = 0.00252+_0.00093 (ml plasma) / rain / (ml myocardium)]. This study demonstrated that PLC is concentrated in human myocardium and illustrates the value of applied PET in pharmacological research.
P15-312 EFFECT OF ATrENUATION CORRECTION IN MYOCARDIAL SPECT W S Richter, G Armbrecht, M Cordes, H Eichstaedt, R Felix. Strahlenklinik, Klinikum Rudolf Virchow, Freie Universit~it Berlin, Germany A i m o f this study was to assess the effect o f Chant's attenuation correction (AC) in myocardial SPECT. After definition o f a synthetic transaxial slice o f the thorax raw data were calculated using dedicated software (J Pattyn, Belgium). Variables o f simulation included a circular 180 ~ orbit and homogeneous absorption (coefficient=0.125). From the synthetic raw data transaxial S P E C T slices were reconstructed with and without A C (filtered backprojection: Metz-filter). Simulations w e r e performed for septal, apical, and lateral wall defects, contrast b e t w e e n defect and normal was set at 0.3 and 0.6. Without A C , defect depth was considerably overestimated septal and lateral and underestimated apical. After AC, defect depth was calculated more realistically (see table). lat sept api contrast: 0.3 0.6 0.3 0.6 0.3 0.6 no AC AC
0.51 0.35
0.78 0,71
0.47 0.35
0.74 0.71
0 0.34
0.56 0.68
Attenuation correction improves detectability of apical defects and reduces the overestimation of defect depth septal and lateral. Chang's correction may be of particular value in myocardial viability studies.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday afternoon, April 25, 1995
P15-313
P15-315
ANALYSIS O F T e - 9 9 m S E S T A M I B I P L A S M A CLEARANCE USING A 2-COMPARTMENT MODEL WS Richter, M Cordes, H Amthauer, H Eichstaedt, R Felix. Strahlenklinik, Klinikum Rudolf Virehow, Freie Universit~it Berlin, Germany
A COMPARISON OF MANUAL AND AUTOMATIC LEFT VENTRICLE AXIS ALIGNMENT IN SPECT
Aim of the study was the characterization of the sestamibi plasma clearance. In 16 patients (12m, 4w, age: 54.2_+8.5 years) blood samples were taken from 1 min after injection of 300-350 MBq Tc-99m sestamibi up to 150 min p.i. Sestamibi plasma clearance data were fitted using an open 2-compartment model (central compartment-plasma; disposition compartmentintracellular space). Results: Sestamibi clearance exhibited a bi-exponential behaviour. The half-lifes of the fast (FC) and slow (SC) components were 1.54 rain and 78.0 min, respectively. They accounted for 36.7% (FC) and 63% (SC) of the total sestamibi plasma clearance. The kinetic rate constants calculated from the compartment model were 0.28/min for the flux from plasma to the intracellular space and 0.022/min for the backflux from the cells to plasma. Conclusion: The data point to the existence of transmembrane shifts of sestamibi after its initial intracellular uptake up to 150 min p.i. These phenomena may be important in myocardial scintigraphy, especially when imaging is performed with substantial delay after injection.
MYOCARDIALPERFUSION IMAGING. G.W. Middleton. University Hospital of Wales, Cardiff, UK Accurate comparison of stress and rest SPECT myocardial perfusion images requires correct reorientation of both datasets orthogonal to the left ventricle (LV) axis. Manual and automatic LV axis alignment were compared in 30 patients imaged following stress and rest using 400MBq 99Tcm Tetrofosmin Reorientation angles, a horizontal angle (HA) on a transverse slice and a vertical angle (VA) on a sagittal slice, were obtained automatically using the minimum count angle on a LV angular profile (AP) and the slope of a linear regression of the minimum count positions on LV linear profiles (LP). Mean HA using manual alignment and mean VA using LP were significantly smaller (p<0.05) for both stress and rest. The variances were smallest for AP, but only significantly different (p<005) compared with LP The mean differences between stress and rest for HA and VA, were smaller (p<0.05) using AP. Automatic axis alignment, easily implemented using standard angular profile software, is more reproducible than either manual or LP alignment, particularly for the horizontal angle
P15-314
P15-316
MYOCARDIAL FLUORODEOXYGLUCOSE UPTAKE W I T H GLUCOSE-INSULIN-POTASSIUM INFUSION. M.Merhige, J.Gona, S.Husain, B.Murphy, P.Galantowitz, D.Wack, SUNYAB & VAMC PET Center, Buffalo, NY, U S A
CHOOSING THE APPROPRIATE TIME FOR TI-20I SPECT MYOCARDIAL ACQUISITION AFTER REINJECTION: 15 VS 60 MIN. D, Daou, M. Pueyo, F. Archambaud, R. Lebtahi, D. Leguillouzic, B.O. Helal. Bicetre Hospital, France.
Myocardial uptake of Fluorodeoxyglucose (FDG) is unpredictable after oral glucose loading (OGL). We measured FDG uptake during infusion of glucose (300 gm/L), insulin (60 U Reg Humulin/L) and potassium (40-60 mEq/L) (GIK) at 1.5 ml/kg/hr in 8 nondiabetic coronary patients. Plasma G and K were drawn at baseline and 15 min. intervals. FDG was given 30 min. after starting GIK and PET imaging performed. Peak myocardial and blood pool (M:B) activity was compared in i 0 0 G L patients. FDG activity was significantly more predictable after GIK than OGL: M:B for GIK= 6.8 +/- 2.0 vs OGL = 9.7 +/-7.2 (p<.01) K fell in all GIK patients; 2 required supplemental K. Conclusions: GIK is practical and results in predictably high myocardial FDG uptake. K should be monitored when insulin is used in PET myocardial viability studies.
T1-201 reinjection (R) increase the sensitivity for defect (D) reversibility as compared to redistribution. The most appropriate time for R and acquisition (A) remains unsolved. We compared in 11 pts the SPECT image quality at 15rain (A15), 60min (A60) and 24h after T1-201 R. The R was done 165min after stress. Were visually compared by two independent observers (O1, 02) the impact on D size and intensity and on the final SPECT report. The reconstructed heart image was divided into 13 segments (S), each scored as: 0:normal, l:mild, 2:moderate, 3:severe or 4:absent T1-201 uptake. There were NS difference between respectively A 15 and A60 on: 1) image quality evaluated by heart to pulmonary (2,5 +0,4 vs 2,5+0,3) and to abdominal activity ratio (1,4+0,3 vs 1,4+0,3) 2) the number of all segment defect (SD) (O1: 2,2+_2,4 vs 2,3+_1,9; 02:2,6+_2,5 vs 2,5+_2) 3) the number of SD improving their score by >1 (O1:2,2+_2 vs 2,5+_2,2; 02:2,5+_2,2 vs 2,9_+2,5) or >2 scores (O1: 1,5+1,8 vs 1,6+1,6; 02:1,3+_1,5 vs 1,4+_1,6) 4) final SPECT report did not differ whether considering A15 or A60. We conclude that A 15 as compared to A60 appears to have similar SPECT image quality and diagnostic value.
$79
$80
T U E S D A u
Abstracts Tuesday afternoon, April 25, 1995
JOURNALOFNUCLEARCARDIOLOGY March/April 1995, Part 2
P15-317
P15-319
CLINICAL ASSESSMENT OF COMBINED PRONE AND SUPINE MYOCARDIAL 99mTc-MIBI SPET
IMPROVEMENT OF AUTOMATIC QUANTIFICATION OF TI-201 AND SESTAMIB1 SPECT IMAGE~; BY FUZZY SEGMENTATION.
C Gibold, A Loboguerrero, JC Liehn, J Ouzan, T Pron, C P6rault, H Wampach, A Bouchard lnstitut Jean Godinot, BP 171, 51056 REIMS, FRANCE
Didier Scellier, Jean-Yves Boire, Fran~oise Wicczorek, B6atrice Merle, Jean-Christophe Cauvin, Jean Maublant, Annie Veyre. INSERM U71, Clermont-Ferraa~d, F.
We propose a new acquisition protocol for MIBI SPET in order to reduce the number of attenuation related false positives. Supine and prone MIBI SPETs were performed at stress and rest in 31 male patients without a history of inferior infarction and with a low counts activity in the inferior wall. All of them had a coronary angiography. Visual interpretation of images was done by 3 blinded experts. Results : For the inferior wall, the specificity was 32 % and 66 % respectively on supine and prone imaging. The inferior attenuation creates false positives for ischemia. The sensitivity was 75 % on both SPET imaging. Three out of 8 patients with normal LAD and normal aspect on supine images were misclassified as ischemic in the anterior wall on prone images. Then, with MIBI, it is possible and recommended to combine prone and supine acquisitions in patients with abnormal stress inferior wall.
Automatic quantification is not always in agreement with visual appreciation because of the poor delineation of the hypoactive regions. Fuzzy logic eliminates the dichotomic decision of segmentation by an approach which takes into account local context, and helps to classify the pixels of ambiguous areas. In a program of quantification already implemented which uses segmentation and skeleton transformation, the step of filling of the defect by a bullet model was modified with the fuzzy logic approach. The pl 3bability for each pixel to belong to the myocardium is computed with input data such as the activity, the shape function of the skeleton, the distance to the myocardium, and the localisation relatively to anatomy, i.e., cavity, apex, base. When applied to a series of 30 patients with thallium-201 and sestamibi stress test, this new approach improved the delineation of the hypoactive areas by the automatic program. Results were in better agreement with visual interpretation than without fuzzy segmentation.
P M A P R I L 2 5
P15-318
P 15-320
LOCAL UPTAKE VOLUME RENDERING TECHNIQUE : APPLICATION TO MYOCARDIAL SPECT
NO MYOCARDIAL UPTAKE OF mI-BMIPP: COMPARISON WITH PET FINDINGS. Takashi Kudoh, Nagara Tamaki, Eiji Tadamura, Naoya Hattori, Madoka Tateno, Tatsuo Torizuka, Yoshiharu Yonekura, Junji Konishi. Kyoto University, Kyoto, Japan Recent reports suggest that 0.2% of all patients who received t2q-[~-metbyl-iodophenyl-pentadecanoic acid (BMIPP) scan show n'o tracer uptake in the myocardium. PET studies on such patients were performed to evaluate free fatty acid (FFA) and oxidahve metabolism. Five patients without myocardial BMIPP uptake and 8 normal subjects received -C-palmitate a n d ' C - a c e t a t e PET. Palmitate PET was performed under fasting condition. Clearance rate constant of acetate (K mono) was used as an index of oxidative metabolism. FFA uptake and utilization was evaluated by heart/blood count ratio (H/B ratio) at lOmin. H/B ratio of palmitate K mono of acetate Patient 1,76+0.11* 0.063+0.02 Normal 4.06_+0.94* (*p<0.05) 0.072+0.02 In all patient H/B ratio of palmitate was lower than normal contrdL K mono of acetate was similar as in normal control but relatively low except one case with hypertension. Thus, in cases of no myocardial uptake of BMIPP, the FFA uptake and utilization were strikingly suppressed, while oxidative metabolism was relatively preserved. In conclusion, BMIPP scan occasionally shows no myocardial uptake. This indicates striking reduction of FFA utilization with metabolic shift from FFA to other substrates even in fasting states.
A Loboguerrero, C Perault, C Gibold, J.Ouzan, T Pron, H Wampach, A Bouchard, JC Liehn Institut Jean Godinot, BP 171, 51056 Reims, France A Local Uptake Volume Rendering (LUVR) is proposed as an aid to interpreting myocardial SPECT. A 3D double information, representative of both the tracer uptake and the shape of the myocardium, is extracted by cylindrical and spherical sampling of the short axis slices. Then, this double information is displayed through shading for shape data, and through colours for contents of the voxels. This method was assessed on one hundred twenty four MIBI 99mTc SPECT from thirty one patients with a known coronary artery disease determined by coronary angiography. The standard stress and rest slices, together with the stress and rest LURIs have led to similar interpretations concerning the presence or absence of a defect. However, the LURIs have demonstrated, over the 2D slices of the myocardium, the ability to show a global view of the vascular territories.
JOURNALOFNUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday afternoon, April 25, 1995
P15-321
P15-323
A SI'UDY OF MYOCARDIAL TL-201 REINJECTION KINETICS WITHA CLINICAL AND COMPU]'ER MODEL,
FRACTIONED DOSE T c - 9 9 m SESTAMIBI INJECTION IN RESTING UPTAKE DEFECTS. Zambia Khader, Kjell Karp, Keith Dawkins. S o u t h a m p t o n General Hospital, Southampton, UK and University Hospital of Northern Sweden, Ume&, Sweden.
J. Ivtachac~MK All, S. Lerakis, N Cho, S Vallabhaiosula, Mount Sinai Medical Center, New York, New York We wished to study the effect of low plasma TI-201 levels on myocardial TI-2Ol redistribution and reini~ction kinetics in ischemic disease. Measurements of plasma and myocardial TI-201 kinetics were obtained over 24 hours in 30 subiects after either exercise (8] or dipyridamole [22l stress. Plasma TI-201 kinetic components were correlated with myocmdial washout kinetics. A compartmental model was used to study the effects of plasma TI-20] levels and resting ieiniection on myocardial TI-201 kinetics in combinations of coronar,u stenosis and tissue iniury. C linical m easurem ants showed that a rapid fall in plasma Tb201 levels after injection and low steady-state TI-201 levels correlated with faster myocardial washout [p<0.01]. Computer simulation showed that tow plasma It-201 levels caused increased and accelerated redistribution in viable myocardium. S irn ubted reiniection at rest caused a worsening of TI-201 defects in regions with critical stenoses. Reiniection led to transient improvement in relative uptake in regions with im paired myocardial retention and non-critical stenoses. This benefit was m ore notable with low plasma ]1-201 levels. These results help in the understanding of the use of TI-201 redistribution and reiniection im aging of iniured myocardium.
Availability of 20 l-Thallium in blood exceeds that of Tc-99m sestamibi after some minutes. Even t h o u g h Tc-99m sestamibi m a y redistribute in low flow conditions this m a y explain the smaller resting defects with Thallium reported in some studies. We studied 10 patients with severe coronary artery disease. Rest SPECT imaging was done after 300MBq Tc-99m sestamibi and repeated after 4 doses of 50MBq injected with 5 m i n u t e s interval. Tomographic images were evaluated as to the size of uptake defects with < 50% of m a x i m u m in the myocardium. After fractionated dose sestamibi u p t a k e defects decreased in 6 of the patients. T h u s an increase in availability of T c - 9 9 m sestamibi in the blood pool m a y be important in evaluation of resting defects and myocardial viability with this tracer.
S81
T
U E S D A u
P M P 15-322
P 16-324
AUTOMATIC REGISTRATION OF MYOCARDIAL PERZJSION STUDIES USING A POTENTIAL BASED RIGID TRANSFORMATION.
EFFECT OF CORONARY REVASCULARIZATION ON LEFT VENTRICLE FUNCTION STUDIED BY GATED RADIOISOTOPE ANGIOCARDIOGRAPHY DURING FAST TRANSESOPHAGEAL LEFT ATRIUM PACING
Michael L. Goris, Gregoire Malandain and Isabelle Marque. Stanford U. School of Medicine, Stanford, CA. and INRIA, Nice, France 9 Myocardial intervention studies are in essence cmmparisons between two images. To simplify the comparison, image s~npling transformations (e.g., Bull's eye) have been used which minimize the effect of size and shape, but not of orientation. We did study the effect of true image registration on the quantitative comparison between stress and rest perfusion images. The comparison was both direct (pixel/pixel) or through sampling transformations. Automatic image registration, with the tested method did allow direct quantitative comparison, and decreased the apparent difference between stress and rest images in patients with normal studies and low probability of coronary artery disease, as well as in patients with large infarctions, without angina. Automatic image registration using a potential based method performed better than skilled human operators in routine analysis.
R.Roszczyk,E.Dziuk,J.Adamus,J.Wnuk Central Clinical Hospital WAM, Warsaw, POLAND The purpose of the study was a comparative analysis of changes of left ventricular function in patients with CAD after Coronary Artery Bypass Graft or Percutar.eous Transluminal Coronary Angioplasty studied by radioisotope angiocardiography prior to, during and after fast t~ft atrium pacing. The studies were carded out in 41 patients prior to, and 3 months after surgery. The mean Ejection Fraction (EF), Peak Ejection Rate (PER), Ejection Fraction of the initial 1/3 of systole (EFI/3s), Filling Fraction of ti~e initial 113 of diastole (FFI/3d) and Regional Contractility indexes (RCI) at rest in the same patients before and after revascularization were not differing significantly. However after revascularizafion EF, PER, PFR, FFI/3D rose and RCI decrease during pacing: prior to sugery after sugery LVEF % 20.6+_12.4 43.2+_6.2 p<0.001 PER ED/s 1.8%0.8 2.4+_0.9 p<0.05 PFR ED/s 2.2+-0.4 2 . 9 + - 0 . 6 p<0.001 EF 1/3s% 1&3• 17.9+-6.9 ns 6.2• 2.6 12.8• p<0.001 FF 1/3d% RCI 16.6+_ 3.6 12.5+_0.8 p<0.01 Revasculadzation has an influence on the decrease of transitional, reversible left ventricle dysfunction during workload-particulary improving left vendcular compliance.
A P R I L
$82
T U E S D A Y
JOURNAL OF NUCLEAR CARDIOLOGY M a r c h / A p r i l 1995, P a r t 2
Abstracts T u e s d a y a f t e r n o o n , A p r i l 25, 1995
P 16-325
P16-327
EFFECT OF PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOFLASTY ON LEFT VENTRICULAR SYSTOLIC AND DIASTOLIC FUNCTIONS IN PATIENTS WITH CORONARY ARTERY DISEASE: ASSESSMENT WITH DOBUTAMINE STRESS RADIONUCLIDE VENTRICULOGRAPHY. Dan-Jiang Wang, *Cheng-Yi Cheng, Shih-Ping Yang, Mason Shing Young, *Wei-Lian Chert. Division of Cardiology, *Department of Nuclear Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.
PREDICTION OF IMPROVED WALL MOTION AFTER PTCA IN STABLE ANGINA BY NTG AND THALLIUM REVERSIBILITY Michael R. Freeman, Wayne B. Batchelor. St. Michael's Hospital, Toronto, Canada
Fourteen patients (M 9, F 5; age 62+6 SD) with coronary artery disease (CAD) underwent dobutamine stress radionuclide ventriculo-graphy CRNV) before and after successful percutaneous translumina] coronary angioplasty (PTCA) to study the effect of PCTA on left ventricular systolic and diastolic functions. Dobutamine infusion was started at 5~g/kg/min with the increment of 5 /~g/kg/min every 10 minutes until angina, high blood pressure (SBP> 210 mm Hg) or maximum dose was achieved (20/~g/kg/min). Radionuclide ventriculography was performed before dobutamine infusion and at each dose level of dobutamine infusion thereafter. It revealed that before PTCA only peak ejection rate increased significantly (3.2+0.7 to 4.4+0.5 end-diastolic volume/sec, p<0.05) during dobutamine infusion, leaving the left ventricular ejection fraction (LVEF) (55+6% to 56x9%, NS) and left ventricular peak filling rate (PFR) (2.7+0.5 to 2.4+0.8 end-diastolic volume/sec, NS) unchanged. However, after successful PTCA both LVEF (54:t:10 to 65• p<0.01) and PFR (2.9+0.7 to 3.7+0.6 end-diastolic volume/sec, p < 0.05) increased significantly during dobutamine infusion. In addition, 9 of these 14 subjects who were found to have regional wall motion abnormality during dobatamine infusion before PTCA turned out to have near normal regional wall motion after successful PTCA. The preliminary results from this study indicate that 1) both systolic and diastolic functional impairment as well as regional wall motion abnormality can be restored by PTCA in patients with CAD, 2) dobutamine stress RNV is a safe, reliable and easily performed method in evaluating the functional status of left ventricle in CAD patients.
To evaluate the ability of PTCA to improve(IMP) wall motion abnormalities(WMA) in stable angina we studied 17 pts with single vessel disease and corresponding WMA. WMA IMP was predicted by NTG response and presence of reversibility (REV) of exercise(Ex) SPECT thallium defects(DEF) with 4hr redistribution (RED) or reinjection(RI) imaging. Radionuclide ventriculograms prior to PTCA and at one month were scored in 10 segments per pt (-1-dyskinesis to 3-normokinesis) with IMP defined as normalization or an increase in score >2. Visual (VIS) and quantitative(QT) REV was defined as >25% reduction in DEF size. WMA IMP in 9/17 pts st I month was not predicted by age, Q waves, Ex duration, chest pain or ST response. The # of pts with WMA IMP following NTG and TL REV at 4 hrs or with RI were: WMA after PTCA NTG VIS TL REV QT TL REV 4hRED RI 4bRED RI Improved(n=9) 8/9 8/9 8/9 6/9 7/9 Not improved(n=8) 0/8 3/8 5/8 2/B 2/8 p 0.002 0.03 0.2 0.07 0.02 Thus, PTCA improves ventricular function in stable angina and is predicted by NTG response and presence of thallium defect reversibility.
P 16-3-26
P16-328
RELATION BETWEEN CORONARY INTIMAL INJURY AND MYOCARDfAL POLYMORPNONUCLEAR LEUKOCYTE CONTENT IN THE REPERFUSED MYOCARDIUM. A Garcfa-Burillo, JA Barrab~s, M Ysamat, JM Gonz~lez, J Caste,, MA Gonz~%lez, D Garcfa-Dorado, C Hera', J Candell. H.G.U. Vail d'Hebron. Hospital CFnic'. Barcelona.
IMMEDIATE AND DELAYED ( 4 HOURS ) IMAGINGS OF THALLIUM 201 (RE-)DISTRIBUTION AFTER INJECTION AT REST: prognostic interest for Revascularisation Procedures (RP).
P M A P R I L
Accumulation of polymorphonuclear teukocytes (PMNs) in the reperfused ischemic myocardium has been reported in correlation with the extent of myocardial necrosis. The aim of this study was to test the hypothesis that the presence of PMNs in areas of myocardium at risk is related to coronary intimal injury, independently of the presence or absence of myocardial necrosis. In a porcine model, pigs were submitted to 30 rain of coronary occlusion of the LAD and later reperfusion, without histological myocardial infarction, with (n =7) and without (n =4) catheter-induced coronaryintimal injury. 12 experiments were performed and one of them was excluded due to transitory reocclusion of the LAD causing myocardial necrosis. PMNs were isolated and labelled with 99mTc-HMPAO (labelling efficiency 19 -+3 %).They were reinjected in each animal after 20 rain of reperfusidn. After five hours of reperfusion their hearts were excised and cut in slices and myocardial fragments were obtained, two from the control myocardium and two from the area at risk. The specific activity in control myocardium and in the area of risk was calculated. In each animal we evaluated regional myocardial blood flow bv means of colored microspheres and the size of the area at risk. Histological analysis of myocard}um and coronary arteries was also performed. Before coronary occlusion, regional myocardial blood flow was 1.33 _+0.17 ml/min/g. After 30 rain of reperfusion an increment was observed in the area at risk (2.23 +_0.23). After 5 hours of reperfusion it had retuTned to basal values (1.35 • without differences in animals with and without coronary intJmal injury. The ratio of specific activity in the area at risk to specific activity in control myocardium was was 1.4 -+0.2 in the group with catheter-induced intimal injury and 0.7 +_O.1 in the no intervention group (p =0.03), in the absence of myocardial infarction. CONCLUSION: Catheter-induced coronary intimal injury is associated with higher content of PMNs in the area of myocardium at risk. Accumulation of PMNs in ischemic areas doesn't depend on the presence of myocardial necrosis.
P.Bourgeois, M.Ramchurn, J.Creplet, A . D e P a e p e and B.Cham, Universit~ Libre de Bruxelles, Brussels, Belgium S P E C T investigations of the "early" (T1) and delayed (4 hours later or T2) distributions (dist.) of TI201 after inj. at rest, performed pre- and post- operatively (op), have been compared (preop T2 versus preop T1, n=80 and T1 postop versus T1 preop, n=75) in 80 patients (pts) with CAD related acute ischemic event and submitted to succesfull RP. Left ventricular ejection fractions (LVEF) have been compared in 65 pts as well. Preop., 34 pts showed improvement (impr.) of T2 when compared to T1 (T2>T1, "ischemic") w h e r e a s others exhibited no change ( T I = T 2 , n=20) or worsening (T2T1 showed impr. of T1 whereas such impr. w a s found in *only" 20 of the 41 (S< 0.001 using Fisher's test) with T2=T1 (9120) or T2T1, mean increase of LVEF (n=27) was + 1 0 . 8 % (S < 0.001 for paired stat-test comparing preand post-op LVEF, 21 pat. with > +4%) whereas these were, in pts T2 +4% ) and, in pts T2=T1 ( n = l g ) , + 1 . 8 % (NS, 6 with > +4% ). Thus, the imaging and comparison of the early and delayed dist. of TI201 after inj. at rest allow to detect "ischemic" cases very likely to benefit of RP, "RR" pts also seem to benefit from a functional point of v i e w whereas T I = T 2 pts donot but/and although perf. impr. was found in 50% of these two last groups of pts.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Tuesday afternoon, April 25, 1995
P16-329
P16-331
TL-201 SPECT FOR E V A L U A T I N G MYOCARDIAL PERFUSION IN PATIENTS RECEIVING HETEROTOPIC HEART TRANSPLANT
USE OF QUANTITATIVE SPECT MYOCARDIAL PERFUSION ASSESSMENT WITH Tc-99m-MIBI IN PREDICTION OF PERFUSION AFTER CORONARY BYPASS SURGERY
P Vaduganathan, Z X He, C Raghavan, H Dakik, JJ Mahmarian, MS Verani. Baylor College of Medicine, Houston, TX, USA
A.Teresifiska,M.Brodzld,B.Szumilak,E. Gosiewska,Z.Juraszyfiski, Z.Slipko. National Institute of Cardiology, Warsaw, Poland
$83
Heterotopic heart transplantation (HHT) is a viable option for patients (pts) with donor/recipient size mismatch or fixed pulmonary hypertension. We investigated the use of TI-201 SPECT to assess graft myocardial perfusion 12-36 months after HHT. Nine HHT recipients underwent 2 separate SPECT acquisitions over 180 ~ arcs spanning the left and right hemithoraces, respectively. Within 2 days of the SPECT study, graft heart coronary angiography was attempted in all pts, but technically feasible in only 6 SPECT images of the graft were normal in all 6 pts, none of whom had significant coronary stenoses TI-201 SPECT of the native hearts was normal in 3 pts with dilated cardiomyopathy and showed large defects in 6 pts with ischemic heart disease. Thus, SPECT is feasible for assessing myocardial perfusion of both native and donor hearts and may be useful for the surveillance of coronary arteriopathy following HHT, particularly when the graft coronary arteries cannot be cannulated
The goal of the work was to investigate the correlation between quantitative results [QUANT] of LV perfusion studies performed before and after coronary bypass surgery [CABG]. Twenty five pts were studied with Tc*99m-MIBI SPECT according to standard 2-days stress/rest protocol. These were pts with reliable QUANT: the cases of non-perfused apex, non-standard length of septum and high extracardiac scaterred radiation were excluded from the report. QUANT were derived from normative evaluation of BULL'S-EYE maps and consisted of four values: area of abnormal perfusion in s~ess (AS) and rest (AR) and mean perfusion level within AS and AR (IS and IR, resp.). Linear correlation for parameters AS, AR, (AS-AR), IS, IR, and (IS-IR) between pre- and post-CABG was investigated. The correlation was statistically significant (p<0.05) for abnormal areas as well as for mean perfusion levels within the areas: ARpre vs ARl~ost, ASnre vs ASoost, IRpr e vs IRDost, ISpre vs ISlmst (r=0.88, 0.79,0.80,0.i55,resp.). "There was no si~gniticant correlalion between (AS-AR)pre nor (IS-IR)pre and any of post-CABG parameters. It is concluded, that there does exist a significant dependence of post -CABG on pre-CABG quantitative results. The parameters which can predict the post-CABG results most precisely are: pre-CABG abnormal area size and mean perfusion level within the area. The improvement in abnormal area size or in mean perfusion level from stress to rest in pre-CABG studies seems not to correlate with post-CABG quantitative results.
P16-330
P 16-332
THE USE OF PET TO ASSESS THE EFFICACY OF GASTROEPIPLOIC ARTERY (GEA) BYPASS GRAFT
N Spyrou, F Sogliani, R Foale, R De L Stanbridge, PG Camici. MRC Clinical Sciences Centre, RPMS, Hammersmith Hospital and St Mary's Hospital, London, UK. In view of the favourable results of coronary artery bypass grafting (CABG) using the internal mammary artery other arterial conduits have been sought. The gastroepiploic artery (GEA) has often been used, but assessment of its function has proved difficult. The aim of this preliminary investigation was to ascertain whether coronary revascularisation using the GEA is effective in relieving ischaemia in patients with coronary artery disease. Regional myocardial blood flow (MBF, ml/min/g), at baseline and following dipyridamole infusion (Dip, 0.56mg/kg over 4 minutes), was measured with H2150 and dynamic PET in 5 patients with coronary artery disease before and 1 month after GEA bypass to the coronary artery supplying the inferior wall. Baseline MBF was corrected (c) for the rate pressure product (RPP). Myocardial flow reserve (CVR), was calculated as MBFdip/cMBFbas. Pre-op
Pt 1 Pt 2 Pt 3 Pt 4 Pt 5
MBFbas 1.13 0.69 1.5 1.37 1.05
MBFdip 0.89 0.95 0.74 1.35 1.79
Post-op
CVR 0.79 1.37 0.49 0.99 1.7
MBFbas 0.86 1.14 1.12 1.56 0.9
MBFdip 1.8 2.17 1.16 1.73 2.15
CVR 2.1 1.9 1.03 1.11 2.38
In eondusion: I) All five patients showed a substantial increase of MBFdip and CVR following GEA bypass; 2) PET allows the non invasive assessment of effectiveness of GEA coronary bypass.
ASSESSMENT OF LEFT VENTRICULAR FUNCTIONAL IMPROVEMENT AFTER DYNAMIC CARDIOMYOPLASTY FOR ISCHEMIC AND IDIOPATHIC DILATED CARDIOMYOPATHY WITH RADIONUCLIDE VENTRICULOGRAPHY Gialin Vural*, Tamer Atasever*, Fehmi Katlrmo~lu**, Mustafa Unlti*, Kemal Beyazlt **. Gazi University Medical Faculty,Department of Nuclear Medicine* and YIH Cardiovascular Surgery** Department ANKARA/TURKEY Dynamic Cardiomyoplasty is a surgical procedure whereby a patient's native skeletal muscle is wrapped around the failing ventricles for circulatoy support. The left ventricular ejection fraction ( LVEF % ). Regional ejection fraction ( RVEF % ), peak ejection and filling rates ( PER, PFR, s-1 ) were prospectively studied using e q u i l i b r i u m radionuclide ventriculography (RV) in 10 patients before and 6 months after performing cardiomyoplasty. All of the patients were male and mean age was 38.3 years ( range: 31-50 ). Five of the patients were free of significant coronary artery disease ( i d o p a t h i c - c a r d i o m y o p a t h y ) , other 5 were i s c h e m i c cardiomyopathy. Functional capacity of patients were class III according to New York Heart Association Classification. Preoperative mean L V E F of the study group was 25.5 + 4.2% ( min: 19 - m a x : 3 3 ) , postoperative mean LVEF was 32.6 + 9.2% ( min:20 - max:53 ). Increment in postoperative LVEF values were significant, p<0.05. However improvement of ischemic and idiopathic groups were not different. Most of the patients showed improvement in their life quality. As a conlusion, RV is useful in the assessment of dynamic cardiomyoplasty response for ischemic and idiopathic cardiomydpathies.
$84
Abstracts Tuesday afternoon, April 25, 1995
P16-333
P16-335
M Y O C A R D I A L INDIUM-111 A N T I M Y O S I N UPTAKE AFTER UNCOMPLICATED C O R O N A R Y A R T E R Y BYPASS S U R G E R Y
EVALUATION OF PATIENTS WITH END STAGE CARDIAC INSUFFICIENCY BEFORE AND AFTER CARDIOMIOPI_ASTY BY RADIONUCLIDE ANGIOCARDIOGRAPHY. G.Calsamiglia, G.Cannizzaro, M. Rinaldi, C.Aprile. - Fondazione Cliniea Lavoro - Montescano (Pavia) - Italy -
Ettore Astorri, Giovanni Andrea Contini, Paolo Fiorina, Annalisa Astorri, Gilberto Gavaruzzi*, Cattedre di Cardiologia e di Cardiochirurgia, Universil~ di Parma, *Servizio Medicina Nucleare, USL n. 4 Parma, Italy
T U E S D A Y
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
Indium 111 monoclonal antimyosin antibody scintigraphy has been shown to be highly sensitive ann specific for even very small areas of myocardial necrosis or sufferance. Uptake of this radio tracer was evaluated after coronary surgery (CABG) in 14 unformed and consenting consecutive patients without previous myocardial infarction, with uncomplicated surgical procedure and postoperative course, who underwent CABG for stable angina pectoris. Indium- 111 monoclonal anti myosin antibody (74 MBq Myoscint9 Centocor) was injected on third post-operative day; planar images in anterior, left anterior oblique 45 ~ and 70~ projections were obtained 24 and 48 hours later and analysed for myocardial uptake. Indium-I 11 anti myosin uptake was present in 10 out of 14 patients (71.4%); it was diffuse in 6 and localised in 4. The ratio of the maximal counts in the myocardium to the counts of adjacent lung background (HA, ratio) was measured and found elevated (1.94_+0.36). No good relation was observed between Indium-ll 1 antimyosin uptake or H/L ratio and Creatine kinase-MB isoenzyme (19_+15 ng/ml), AST (44+18 mU/ml) levels, duration of cardiopulmonaly bypass or aortic cross-clamp time and ST-T changes on ECG, while elevated serum myosin 13 heavy chain fragments (IRMA, Pasteur| were observed (1378_+238ng/ml). This preliminary study suggests that some degree of myocardial damage, though silent, is common after CABG.
Dynamic cardiomioplasty (CMP) is a new surgical procedure consisting in a long term elettrostimulation of a latissimus dorsi muscle wrapped around the failing heart. We evaluated by muitiple gated acquisition (MUGA) 10 males pts.(3 ischemic and 7 idiopathic cardiomiopathy; range 39-60 years). All pts. were evaluated before the CMP (TO), 8 at 6 ,7 at 12 months T1 T2 TO Left Vent.Ejection Fraction 29,5_+9,3 i LVEF in assisted cycles 24,1+11,4 27,9+12,2 LVEF without elettrostim. 26,2_+11,.4 25,6_+11,8 Peak Ejection Rate 1,15_+0,5 1,17_+0,6 1,24_+0,4 Peak Filling Rate 0,99_-+0,4 0,86_+0,4 0,84_-+0,1 There were no significant differences for variables considered before and after CMP. Follow up (NYHA functional class): 6 months 2 death 4 unchanged 4 improved 12 months 1 death 3unchanged 3 mproved Conclusions: good MUGA studies were obtained in all pts. despite difficulties in R wave synchronization; even if 6/7 pts. improved their NYHA class no significant modification was observed either in the systolic or in the dyastolic function at 6 and 12 months.
P M A P R I L
P 16-334
P16-336
DOES REST-REDISTRIBUTION THALLIUM-201 IMAGING PREDICT IMPROVEMENT IN LEFT VENTRICULAR FUNCTION AFTER AORTO-CORONARY BY-PASS SURGERY ?
T H A L L I U M - 199 S C I N T I G R A P H Y - IN EVALUATION OF CORONARY ARTERY DISEASE REVASCULARISATION
C Leblebici, V Sansoy, D Gezelsoy. Institute of Cardiology, University of Istanbul, Istanbul, Turkey.
Yu.Lishmanov, J.Vesnina, V.Chernov, A.Chernyavskiy, S h . A k h m e d o v , V.Pekarskiy. T o m s k Institute o f Cardiology, Russia
To test the hypothesis that rest-redistribution quantitative TI-201 imaging (RTI) would identify viable myocardium and predict improved myocardial function after coronary by-pass surgery (CBS) in patients with coronary artery disease (CAD), we studied 20 patients (mean EF: 0.27) before and 10 weeks after CBS by radiunuclide ventriculography and RTI. On the basis of quantitative analysis of defect severity, all segments showing more than 50% TI uptake on late images were consideredviable. By RTI criteria 84% of asynergie segments wore found to be viable. Sixty-one percent of viable segments functionally improved postoperatively, whereas only 36% of nonviable segments improved (p<0.03). When only adequately revascularized segments wore considered, the predictive value of a positive preoperative viability scan for functional improvement was 94%. The greatest improvement in global left ventricular function (LVF) after CBS occurred in patients with the greatest number of adequately revascularized asynergic segments classified as viable before surgery, In conclusion, preoperative RTI identifies viability in many asynergic segments in patients with CAD and depressed LVF and these segmentsfrequently improve function after CBS.
A i m o f this study was the scintigraphic e v a l u a t i o n of myocardial revascularisation in patients (pts) with c o r o n a r y artery disease ( C A D ) a n d myocardial infarction ( M I ) u n d e r w e n t the cardiomyoplasty ( C M P ) or c o r o n a r y bypass surgery (CBS) using short life nuclide 199T1 (T!/2=7.4h).37 C A D pts a n d 26 M I pts with successful t r o m b o l i t i c therapy u n d e r w e n t CBS. 18 pts with large left ventricular aneurysm u n d e r w e n t C M P .All the pts were investigated by means o f d y p i r i d a m o l e 199T1 scintigraphy before 1 a n d 12 m o n t h s after operation. It was demonstrated, t h a t CBS a n d C M P lead to considerable decrease in reversible defect size in all g r o u p o f pts. In M I pts after CBS decrease in persistent defect size was d e m o n s t r a t e d . After C M P we f o u n d reduction in 199T1 lung uptake. Those, 199T1 myocardial scintigraphy is an objective study for d y n a m i c evaluation myocardial perfusion after surgery treatment.
JOURNAL OF NUCLEAR CARDIOLOGY V o l u m e 2, N u m b e r 2, P a r t 2
Abstracts T u e s d a y afternoon, A p r i l 25, 1995
$85
P 16-337
P 16-339
O U T C O M E O F PATIENTS W I T H L E F T V E N T R I C U L A R DYSFUNCTION ~ R C O R O N A R Y A R T E R Y BYPASS GRAFTING,
CAN WE PREDICT THE FATE OF MAJOR WALL MOTION ABNORMALITIES FOLLOWING CORONARY ANGIOPLASTY ? USEFULNESS OF" ENO~MONE - THALLIUM" SCINqqGRAPHY
Giuseppe Gioia, Susan Iskandrian, Samir Pancholy, Kathleen Dileva, Jaekyeong Heo, Abdulmassih S Iskandrian. The Philadelphia Heart Institute, Presbyterian Medical Center, Philadelphia, PA.
G. L. Morgagni, *G. Fiorentini, C. Simoni, E. Pomarici, F. Rusticali. Dpt. of Cardiology &*Nuclear Medicine,GB Morgagni Hospital, Forli I
Previous studies suggest that the prognosis of patients (pts) with (CAD) and (LV) dysfunction is better with coronary artery bypass grafting (CABG) than medical therapy and that improvement is seen in pts with viable myocardium but not in those with nonviable myocardium. This study examined the outcome of pts with L V dysfunction (EF < 35%) who had CABG. The main indication for C A B G was angina pectoris ( N Y H A Class 2.4+0.9). Follow-up data were available in 269 of 349 pts operated between January '91 and June '94. There were 200 men and 69 women aged 65 + 10 years. The average number of grafts was 3.5 :l:0.8/pt. During a mean follow-up of 19 months there were 40 cardiac deaths (19 periopertive and 21 late) yielding an annual mortality rate of 9%. In the remaining 229 pts the symptoms improved in 192 pts (84%) and remained unchanged or worsened in 37 pts (16%). Thus, 77 pts (29%) either died or did not have symptomatic improvement. Thus, there is a fairly high mortality rate and/or lack of symptomatic improvement after C A B G surgery in unselected patients with severe L V dysfunction in whom the status of myocardial viability is unknown. Myocardial viability assessment is probably indicated when coronary revascularization is performed for the relief of angina pectoris.
We studied the value of a new test single photon emission computed tomography (SPECT) after administration of enoximone (E; 0.75 rng/kg IV over 10 min), in predicting reversal of major wall motion abnormalities (WMA) following PTCA. 15 unstressable pts with unstable angina, angiographically proven CAD and WMA were injected at rest with 3 mCi of 2~ (2olTI) either at baseline or after E. Injections were done at 2-day intervals in a randomised fashion; all pts underwent PTCA of the artery supplying the asynergic myocardial regions and were re-studied before discharge. 2~ uptake was visually assessed by two blinded independent observers who gladed the regions on a 4-point scale (0: normal ; 1,2, 3: mild, moderate, severe reduction in photon activity). PTCA was clinically and angiographically successful in all pts. At baseline 160 defects were detected (average 6.6/pt); among these, 100 were grade 2-3. After E, the number of defects decreased (n-96, average 1.6/pt) as well as their severity (24 grade 2-3). Following PTCA, there was a further decrease in the number of defects (n=64, average 0.8/pt) as well as in their severity (20 grade 2-3). Changes induced either by E or by PTCA were statistically significant compared with baseline, whereas no significant difference was found between the results after E and those following PTCA. After PTCA, WlvlA (assessed by 2-D echo) were judged greatly improved in all pts. We conclude that: 1) the decreased number of defects as well as their decreased severity, elicited by E, parallels with that observed after successful PTCA; 2) thus, in selected pts, this test has a high clinical value.
T U E S D A Y P M
P 16-338
P 16-340
Is Exercise Thallium-201 Imaging Helpful in Risk Stratifying Patients With Cardiac Transplant Coronary Artery Disease? R.A. Rodney, L.L. Johnson, M.L. Barr. Columbia University, New York, N.Y. Patients (pts) with (-) exercise (ex) SPECT thallium (Tt) scans have a favorable prognosis despite CAD by anglo. Pts with cardiac transplant (Tx) CAD have a high incidence of adverse events including silent MI and sudden death. Due to limited donor availability, risk stratifying pts with Tx CAD would be clinically useful. Thirteen pts (mean post-Tx time 40 mo) with anglo CAD underwent ex and 4hr red SPECT TI imaging. Ten pts had epicardial and small vessel CAD, two had small vessel CAD, and one had epicardial CAD. Scans were (+) in 10/13 (77%) pts, and (-) in 3 pts. There was no difference in ex mets or in CAD extent between the groups. At 20 mo follow-up 8/10 pts with (+)TI scans had graft failure or death vs 0/3 (0%) pts with (-)TI scans (p<0.05, Kaplan-Meier survival analysis). This preliminary data suggest that SPECT TI imaging may be of value in risk stratifying pts with Tx CAD.
LEFT VENTRICLE EJECTION FRACTION IN HEART TRANSPLANT PATIENTS. COMPARISON OF GATED MYOCARDIAL PERFUSION SPECT AND GATED PLANAR BLOODPOOLSCINTIGRAPHY P.C. Bameveld, A.J. van Dongen, N. de Jonge, P.P. van Rijk University Hospital Utrecht, the Netherlands With technetium-99m myocardial perfusion tracers gated myocardial SPECT studies have become feasible. In addition to myocardial perfusion, wall motion and left ventricle ejection fraction (LVEF) can be assessed. Aim of this study i s to compare LVEF from myocardial perfusion SPECT with planar bloodpool LVEF in a group of heart transplant patients. Nineteen male and 4 female heart transplant (HTX) patients, age 26-63, mean 52 yrs, post-HTX-interval 1-8 yrs, mean 3.9 yrs, underwent gated SPECT myocardial perfusion study and gated planar bloodpool LVEF study as part of the routine follow-up procedure. 700 MBq 99mTcTetrofosmin was injected at maximal exercise. Gated SPECT acquisition was performed one hour post-injection on a Picker Prism 3000 system. All studies were analyzed using Picker 3-D Perfusion/Motion Map TM software. Semi-automatic determination of endocardial surfaces was used to calculate the LVEF (EF1), and also wall motion was observed. Planar bloodpool LVEF, with 600 MBq 99mTc-pertechnetate. and myocardial perfusion SPECT study were performed with 5-17, mean 3, days interval. Acquisition was performed on an Elscint 409 round field of view camerasystem. Semi-automatic LV edge detection on enddiastolic and endsystolic images was used to calculate LVEF (EF2). The results of both studies were compared. Mean EF 1 was 55% (3867%), mean EF2 56% (32-75%). A paired T-test comparison showed no significant difference between the two methods. The mean difference was 1.4% (range +8 to -9). This indicates that there is no bias between these two methods. The correlation coefficient between them was 0.875. Global wall motion analysis showed agreement of both methods in 11 cases. Nine patients showed septal hypokinesia in gated SPECT probably due to traction of right ventricle on septum which was not visible in planar bloodpool scintigraphy. CONCLUSION: These preliminary results suggest that in heart transplant patients LVEF can be calculated simultaneously from routine gated SPECT myocardial perfusion study using 99mTc-myocardial perfusion agents.
A P R I L
$86
Abstracts Wednesday morning, April 26, 1995
P16-341
P16-343
AMBULATORY MONITORING OF LEFT VENTRICULAR FUNCTION IN CORONARY ARTERY DISEASE: EFFECTS OF REVASCULARIZATION.
PRIMARY ANGIOPLASTY AND REVERSE REDISTRIBUTION OF THALLIUM-201: A PROGNOSTIC ANALYSIS.
Antonio Nappi, Alberto Cuocolo, Massimo Imbriaco, Pasquale Sullo, Sergio Ferraro, Stefania Cardei, Leonardo Pace, Massimo Chiariello, Marco Salvatore. Universita "Federico ll" and lstituto Nazionale dei Tumori, Napoli, Italy. To assess the efficacy of coronary artery by-pass graft (CABG), 10 patients with multivessel coronary artery disease (CAD) were studied by Vest 8+2 days before and 15_+3 days after CABG. Left ventricular (LV) function was continuously monitored during physical daily activities, such as walking (140 yards) and climbing stairs (8 flights). Pre-CABG, walking induced a significant (p<0.01) increase in heart rate (HR) and no significant changes in ejection fraction (EF), stroke volume (SV) and cardiac output (CO). Pre-CABG, climbing stairs induced a significant (p<0.0t) increase in HR, associated with a decrease of EF (from 52_+8%to 47+11%, p<0.05) and no significant changes in SV and CO. Post-CABG, walking induced a significant increase in HR (p<0.01), EF (from 47+8% to 53_+10%, p<0.01), SV (from 47-+9% to 53• p<0.01) and CO (from 43• % edv/min to 53_+10 % edv/min, p<0.01 ). Post-CABG, climbing stairs induced a significant increase in HR (p<0.01), EF (from 47+8% to 52_+11%, p<0.05), SV (from 48_+8% to 56_+11%, p<0.01) and CO (from 45_+10 % edv/min to 61_+18 % edv/min, p<0.05). In conclusion, Vest allows to detect changes of LV performance during physical daily activities in patients with multivessel CAD following revascularization.
P M A P R I L
Jennifer H. Mieres, Bart S.Steinberg, Lawrence Y. C. Ong, Stephen. J. Green, Marc Levine, Jeffrey Snow, Stanley Katz. North Shore University Hospital-Comell Medical College, Manhasset NY. The pattern of Reverse Redistribution (RR) of Thallium-201(TI-201) at Stress Redistribution imaging is a frequent finding in patients(pts) following acute myocardial infarction(Ml) and is associated with a patent infarct related artery. However, the cardiac event rate in these pts is unknown. We retrospectively identified and obtained follow-up data on 45 pts who were treated with primary percutaneous angioplasty (PTCA) for MI. Group A, consisted of 21 pts with the finding of RR of T1-201 at predischarge submaximal stress testing(PSST). These pts were compared to Group B: 24 pts with fixed defects at PSST with TI-201. None of the 45 pts had evidence of reversible TI defects. The mean residual stenosis of the infarct vessel was 13+8 %.in Group A and 17+_5% in Group B. In Group A there were 13 pts with anterior wall MI with PTCA of the LAD and 8 pts with inferior MI with PTCA of the RCA or LCx. At PSST, 173 defects were identified as RR of TI-201.MI. In Group B, there were 11 pts with anterior wall MI treated with PTCA of the LAD, 13pts with inferior wall MI treated with PTCA of the RCA or LCx. At PSST, 251 fixed defects were identified, At 10+ 3 months follow-up, there were 6 cardiac events in Group A ; I MI and 5 unstable angina (UA) treated with repeat PTCA of the LAD. There were 4 cardiac events in Group B; 4 unstable angina; 2 treated with repeat PTCA of the LAD and 2 treated with CABG. The cardiac event rate in Group A was 28% and in Group B 16%(p= 0.1) These preliminary results suggest that the finding of RR in the setting of primary PTCA is associated with a higher cardiac event rate at 10 months.
P 16-342
Wednesday AM, April 26
DIPYRIDAMOLE THALLIUM IMAGING AFTER EMERGENCY CORONARY STENTING: INCREASED RESTENOSIS AT FOLLOW-UP IN PATIENTS WITH IRREVERSIBLE TRACER DEFECTS
S48-344 to $55-371 and P17-372 to P19-432
Roman Mura, Rainer Zimmermann, J6rg Zehelein, Harald Tillmanns, Wolfgang K0bler. Departments of Cardiology, Universities of Heidelberg and Giegen, Germany.
W E D N E S D A Y
JOURNAL OF NUCLEAR CARDIOLOGY March/April 1995, Part 2
Thirty patients underwent SPECT dipyridamole thallium-201 imaging at a mean of 10 _+4 days following successful emergency coronary stenting (Palmaz-Schatz stent). In all patients, indication for coronary stenting was an unstable dissection in the course of transluminal coronary angiogplasty. The target vessel was the RCA in 7, the LAD in 20, and the LCX in 3 patients. Quantitative angiographic follow-up (CASS II system) was performed 6 months later in 24 asymptomatic patients and at a mean of 116 days (range 15 to 194 days) in 6 symptomatic patients. Thallium scintigraphy revealed normal tracer uptake or reversible defects in 23 patients (Group I), and irreversible defects in 7 patients (Group II). Angiographic data were comparable in the two groups both before (Group I vs Group Ih 85_+10% vs 90+13%) and immediately after coronary stenting (1 9 _+7% vs 18 + 4%). At the time of angiographic follow-up, however, restenosis was significantly lower in Group I (32_+ 16%) as compared to Group II (63_+30%, P=0.014). The data demonstrate a significantly higher restenosis at follow-up in patients with irreversible thallium defects suggesting a possible association between diminished coronary perfusion and the occurence of restenosis.
$48-344 ASSESSMENT OF CORONARY ARTERY DISEASE SEVERITY IN HYPERTENSIVE COMPARED TO NORMOTENSIVE PATIENTS WITH ANGINA PECTORIS H.Hamdan,P.Jordan,M.Salih,R.Poyner, M.Wilson, C.Boivin,P. Mountford,WA.Littler. Queen Elizabeth Hospital, Birmingham Objective: To assess the anatomical severity of coronary artery disease using quantitative coronary angiography ,and the degree of myocardial ischaemia using quantitative exercise thallium-201 tomography (SPECT) in normotensive (NT) and hypertensive (HT) patients with chronic stable angina pectoris and no previous history of myocardial infarction. Methods: 37 patients with single vessel disease were studied. 18 had essential hypertension { 7 left anterior (LAD) coronary artery, 5 right coronary (RCA) and 6 left circumflex (Lcx) coronary artery} and 19 were normotnsives ( 11 LAD, 5 RCA, 3 Lcx). The extent and severity of myocardial ischemia was made from quantitative thallium SPECT using circumferential count profile. FIT Results: N__T .T . 169 + 2.3 p<0.001 Systolic Blood Pressure 125 + 3.8 95 + 1.4 p<0.00l Diastolic Blood Pressure 74 + 1.6 % Diameter stenosis 74 + 13% 68 + 9% p=NS 88 + 6% p=NS % Area stenosis 91 + 8% 21.3+4.1% p<0.01 Thallium extent defect 38 + 2.9% 1.5 + 0.4 p<0.01 Thallium severity score 3.6 + 0.4 In summary the anatomical severity of coronary artery disease was similar in normotensive and hypertensive patients, however the degree of real myocardial ischaemia appeared to be significantly less in hypertensives.
JOURNAL OF NUCLEAR CARDIOLOGY V o l u m e 2, N u m b e r 2, P a r t 2
Abstracts W e d n e s d a y m o r n i n g , A p r i l 26, 1995
$48-345
$48-347
PATIENTS WITH SILENT ISCHEMIA HAS LESSER JEOPARDIZED ISCHEMIC MYOCARDIUM THAN PATIENTS WHO DEVELOP CHEST PAIN DURING EXERCISE THALLIUM 201 SCINTIGRAPHY. ADEL ALLAM, ~ GAZAR., SI-II~,IF SHAKER., MOSTAFA EL SAYED, AHMED MOTAWAA., MOHAMED EL ASI-IKAR., MOHA.MED FARID., ABU BAKR TAMMAM., ABD EL RAHMAN SHARAF. AL AZHAR UNIV. ~CAIRO, EYGPT.
Significance of Tc-99m MIBI Lung Uptake in Patients with Known or Suspected Coronary Artery Disease Undergoing Exercise SPECT Myocardial Perfusion Imaging.
Previous studies that used thallium 201 (T1) seintigraphy to compare the amount of ischemie myocardium in patients (Pts) experiencing angina (CP) duringtreadmiL! testing versus (Vs) those who had no anginal pain (SI) used either planar (PI) or SPECT imaging, the disparity in results was explained by the fact that different modalities of imaging were used. In our study 70 consecutive patients with at least one unequivocal reversible defect on T1 was studied by combined PL and SPECT imaging. Of the 70 patients 67 were males, 68% had CAD, 54% had previous MI, 62% had typical CP on rest. Forty five Pts had CP during treadmill testing (Grl) and 25 Pts had SI (Gr2). Grl & Gr2 were identical regarding most clinical findings, except for incidence of typical chest pain at rest, 78% in Grl Vs 30% in Gr2 P>0.01. Exercise (Ex) ECG parameter: peak hear~ rate (PHR), doublepreduct (DP) duration of exercise (DEx),stage of exercise (SEx),I mm ST segment depression andalso TI scintigraphy findings; number of reversible defects (RD), grade of worst reversible defect (GD),and ischemia index (Ix) were compared in Grl Vs. G ~ PRR DP DEx SEx lmm ST,[. G r l 137+_17" 21:t:4(103)* 5.4• 2.2• 1814540%* Gr2 154:.+.17 24:L5(103) 8:1:3 2.8• 312512% RD PL RD SPECT GD PL GD SPECT Ix PL Ix SPECT G r l 4.9+_23* 5.4~2.3* .77~6"* .74+_6** 1.65:1" 126=LS* Gr2 3A:t:2.3 4• 1.08:k.7 1.21• 1.12.+-9 .82:L6 "** P<0.4 * P<0.01 compared to Gr2" Thus, beth Ex ECG parameters, and TI scintigraphy findings show lesser iachemia in SI Pts Vs CP Pts. Our results shows that both PL and SPECT yield similar results.
A. lain McGhie, Ping Wong, Toni Bransford, Edward Yah, Tom Beveridge, James T. Willerson. UT-Houston Health Science Center, Houston, TX. The significance of increased Tc-99m MIBI lung uptake (LU) in patients (pts) with coronary artery disease (CAD) is uncertain. We evaluated Tc-99m MIBI LU in 91 pts undergoing exercise SPECT perfusion imaging with known or suspected CAD. Tc-99m MIBI LU was quantitated using the heart-to-lung ratio (HLR). It was elevated in 21/91 pts (32%) including 13/40 pts (23%) with CAD. HLR was higher in pts with CAD (n =40) compared to normals, 0.38 __+0.08 vs. 0.29 -+0,05, p=O.002. HLR was greater in pts with myocardial infarction (MI), 0.40 -+0 96 vs 0.34 __+0.05, p =0.008. In pts with CAD, HLR did not correlate with maximal heart rate, systolic BP or pressure-rate product. No significant difference in HLR was found between pts with ischemic versus non-ischemic response to exercise, 0.35 --+0.08 and 0.39 -+0.09, respectively, p=NS. In pts with single and multi-vessel the HLR was 0.36 __+0.06 and 0.38 -+0.09, respectively, p=NS. HLR did not correlate with left ventricular ejection fraction. In conclusion, Tc-99m MIBI HLR was higher in pts with CAD, and in particular pts with prior MI. Tc-99m MIBI HLR was not related to functional capacity, presence of exerciseinduced ischemia, extent of CAD or systolic function.
$48-346
$48-348
DIAGNOSTIC ACCURACY OF EXERCISE M Y O C A R D I A L P E R F U S I O N S C I N T I G R A P H Y IN M E N COMPARED TO WOMEN
High incidence of scintigraphic myocardial uptake defects at rest and ~uring exercise in youw, ~runners
J a m e s R. L u c a s , J a m e s T o m , M i c h a e l W. D a e , Elias H. Botvinick, U n i v e r s i t y o f C a l i f o r n i a , S a n F r a n c i s c o W e e v a l u a t e d g e n d e r related a c c u r a c y o f e x e r c i s e m y o c a r d i a l p e r f u s i o n s c i n t i g r a p h y ( E M P S ) in 1 0 2 c o n s e c u t i v e p a t i e n t s (pts), 7 2 m a l e s ( M ) a n d 3 0 f e m a l e s (F), w h o u n d e r w e n t clinical EMPS within 3 months of selective coronary a n g i o g r a p h y (SCA). M a n d F did not d i f f e r in a g e , h i s t o r y o f p r i o r MI, n a t u r e or frequency of exercise induced symptoms or ST changes, a c h i e v e d d o u b l e p r o d u c t or w o r k l o a d . S C A r e v e a l e d c o r o n a r y d i s e a s e ( C A D ) in 7 9 % ( 5 7 / 7 2 ) o f M a n d 6 0 % ( 1 8 / 3 0 ) o f F (p<0.05). A m o n g b o t h M a n d F w i t h C A D , 34 pts h a d one, 24t w o a n d 17-three vessel C A D . M a n d F did n o t differ in C A D e x t e n t ( l , 2 or 3 v e s s e l C A D ) , o r l e s i o n s e v e r i t y ( 7 0 - 8 9 % , 808 9 % , 9 0 - 1 0 0 % n a r r o w i n g ) , n o r in the i n c i d e n c e o r extent o f fixed or reversible EMPS defects. M and F revealed no s i g n i f i c a n t d i f f e r e n c e in o v e r a l l ( 9 5 % vs 8 9 % ) o r p e r vessel sensitivity(68/100, 6 8 % vs 22/33, 6 7 % ) , o v e r a l l ( 6 0 % vs 7 5 % ) o r p e r vessel s p e c i f i c i t y ( 9 3 / 1 1 6 , 8 1 % vs 5 0 5 7 , 8 8 % ) , o r in sensitivities for single (24/26,92% vs 7/8,87%), double ( 1 8 / 1 9 , 9 5 % vs 4 / 5 , 8 0 % ) o r t r i p l e ( 1 2 / 1 2 , 1 0 0 % a n d 5/5, 100%) vessel C A D . T h e r e w e r e n o g e n d e r related d i f f e r e n c e s in pt. characteristics, exercise findings, CAD involvement, or accuracy of EMPS. T h i s a n d the l o w e r i n c i d e n c e o f C A D in F s u g g e s t s no g e n d e r related selection bias.
Bouvier 1F , Bergl~lnd B2, Brodin I.~ , Jorfeldt L3, Juhlin-Dannfelt A3, Nejat M , Saltin B , and Jensen-Urstad M .
l Department of Clinical Physiology, Si~dersjukhuset,2Department of lnternal Medicine, Karolinska Hospital, ~Department of Thoracic Physiology, Karolinska Hospital, and 4Department of Pharmacology and Physiology 111,Karolinska Institute, Stockholm, Sweden. In order to assess the usefulness of myocardial perfusion sclntigraphy in the evaluation of young, well-trained subjects with suspected heart disease we performed exercise stress and rest scintigraphy (SPECT) in 16 young, well-trained runners. T~eir ag~ and peak oxygen uptake were 25 + 1 years and 73 + i ml 0 2 9 k g " 9 rain" . There were no signs of myocardial hypertrophy or other pathology on echocardiography. A two-day stress-rest protocol using Tc-99m-sestamibi (Cardiolite) was used. Projection data were collected at 32 angles over a semicircular 180 degrees orbit. Reconstruction of polar maps were performed with and without attenuation correction. Emory Bullseye MIBI-normal male file was used for evaluation. Uptake defects were found in 10/16 subjects during exercise and in 11/16 at rest. Only 3/16 subjects had normal sclntigrams both at rest and during exercise when compared to the normal file. Uptake defects were concentrated (2/3 of the defects) to the diaphragmatic region of the left ventricle. Attenuation correction did not decrease the number of defects, instead the number, size, and severity of defects increased. The present data shows that if myocardial perfusion sclntigraphy is used for evaluation of young well-ta'ained patients with suspected heart disease, an age and activity matched reference population should be used. More sophisticated methods for attenuation correction such as transmission correction might also be valuable.
$87
$88
W E D N E S D A Y P M A P R I L
Abstracts Wednesday morning, April 26, 1995
JOURNAL OF NUCLEAR CARDIOLOGY March/April 1995, Part 2
$48-349
$48-351
DOBUTAMINE STRESS HAS LIMITED VALUE FOR ENHANCING FLOW HETEROGENEITY IN THE PRESENCE OF A MODERATE STENOSIS: IMPLICATIONS FOR TC99H-SESTAMIBI IMAGING JJ Yun, JC Wu, EN Heller, L Deckelbaum, DP Dione, YH Liu, FJTh Wackers, AJ Sinusas. Yale Univ., New Haven CT, USA Dobutamine (DUB} is used in conjunction with Tc99msestamibi (MB) imaging to produce flow {FL) hetergeneity. TO validate this pharmacological approach, we injected MB and radiolabeled microspheres (MS) in 6 open chest dogs during peak DOB stress {i0 ~g/kg/min) in the presence of a moderate (30 m ~ g gradient) LCX stenosis {STEN). MS were also injected at baseline (EASE), and during STEN Pre-DOB. Hearts were excised 20 min after MB injection, and cut into 96 or 192 segments for ganm~ well counting, for determination of MB activity and MS F L Coronary FL reserve in response to i.e. adenosine (18Zg) was 2.44• at BASE and 1.24• during STEN (p<0.05}. DOB increased heart rate (Pre-DOB:ll2• DOB:141• P<0.05), but did not change mean aortic pressure (Pre-DOB:80• DOB:95• p-ns). FL (ml/min/gm) and MB for nonischemic (NI) and ischemic (IS) regions were: (mean++SEM) IS FL NI FL IS/NI FL IS/NI M~ BASE 0.88+0,13 0.96• 0.93~0.02 --STEN 0.58f0.14 0,97• 0.59• --DUB 1.02i0.37 1.87• 0.5290.12# 0.70• ^ *p<0.05 vs STEN; #p-ns vs STEN; ^p<0.05 vs IS/NI EL DUB increased FE in both NI and IS regions. MB correlated with FL (MB-0.69FL+0.47,r=0.66) when FL was less than 1 ml/min/gm. At higher FL (i to 4.8 ml/min/gm) MB did not correlate with FL (MB=0.04FL+0.94, r-0.13). MB underestimated the FL deficit. Thus, DUB MB imaging may be of limited value, since (i) DOS does not augment FL heterogeneity in the presence of a moderate STEN, and (2) M B d o e s not correlate with FL at the higher FL induced by DUB.
W H O L E BODY E X E R C I S E T H A L L I U M I M A G I N G 1N HEAVY SMOKERS AND P A T I E N T S W I T H CORONARY A R T E R Y DISEASE Ph~ sDe Telher Christophe vasseur Dommioue Calhn MarieHelene Bourdrei Centre de Medecine Nuciealre me I'Artols Arras France
Whole body exercise thallium scintigraphy can detect silent i n t e r e x t r e m i t y a s y m m e t r y in a b o u t 60% of patients with coronary a r t e r y disease.The aim of this study was to determine the influence of age, smoking and coronary a r t e r y disease on the d i s t r i b u t i o n of thallium 201 at the level o f legs in 138 p a t i e n t s . In group 1 were included 14 heavy smokers ( more than 28 pack years ) with (n=51) or w i t h o u t coronary artery disease ln=23) anti in group 2 64 non smokers without coronary a r t e r y disease. I n t e r g r o u p comparison was made by Student's test for nonpaired serles, Patients of group I w e r e older than patients of group 2 ( 58_+9 versus 47.6_+II years, p
$48-350
$49-352
CORRELATIONS OF HEMODYNAMIC EFFECTS WITH MYOCARDIAL PERFUSION SPECT SESTAMIBI IMAGES DURING ARBUTAMINE INFUSION
P R O G N O S T I C VALUE OF H I G H D O S E D I P Y R I D A M O L E 9 9 M TC S E S T A M I B I S P E T IN U R E M I C P A T I E N T S W I T H O U T C A R D I A C SIGNS, S Y M P T O M S A N D D I A B E T E S ON THE WAITING LIST FOR RENAL TRANSPLANT.
J. David Ogilby, Jeffrey G. Kegel, Jeffrey H. Johnson, Joanne Reilley, Virginia Cave, Jaekyeong Heo, Abdulmassih S. Iskandrian, Philadelphia Heart Institute, Philadelphia, PA.
A.DE BERARDINIS, M.BACCEGA, W.MARTINY, R.ROPOLO, A.TORTORE, G.SEGOLONI, G.SQUICCIMARRO, M.CANPANA P.G.DE FILIPPI, M.CASACCIA.OSPEDALE NOLINETTE T O R I N O , ITALIA.
Hemodynamic effects of arbutamine (ARB), using a closed-loop delivery system, were studied in 14 pts with chest pain syndrome in the catheterization laboratory. The HR, aortic and pulmonary pressures, LV dP/dT, and thermodilution cardiac output (CO) were measured at baseline, peak stress, and during reeovery. Results: Coronary angiography showed >50% stenosis in 8 pts (Gpl) and 0-49% in 6 pts (Gp2). During ARB infusion, the 14 pts had a HR J" from 76:s to 115 • beats/rain (p=0.0001), aortic systolic pressure $ from 149:t:20 to 121+29 mmHg (p=0.0009), PCW mean $ from 13• to 9• mmHg (p=0.0022), LV dP/dT 1" from 1296• to 2357• mmHg/see (p=0.0001), and Total SVR $ from 1372• to 713a:278 dynes-sec-cm 4 (p=0.0001). In Gpl pts, cardiac output 1" from 6.3• to 9.2• L/min at peak ARB effect (p=0.0004). In Gp2 pts, COJ" from 7.4• to 12,2• L/rain at peak ARB effect (p=0.0047). Gp2 demonstrated a greater ~ in CO at peak ARB effect than Gpl (p=0.032). 8 pts in Gpl developed angina during ARB (p<0.002) but no significant ECG changes, Sestamibi scan was abnormal in 6/8 pts in Gpl and 1/6 pts in Gp2. Conclusions: ARe produces significant chronotropic (1" HR), inotropie (1" CO and LV dP/dT), and vasodilatory (4, Total SVR) effects in patients with and without CAD.
C o r o n a r y a r t e r y d i s e a s e (CAD) is the m a j o r c a u se O f m o r b i d i t y a n d m o r t a l i t y in c h r o n i c h a e m o d i a l y s i s a n d r e n a l t r a n s p l a n t (RT) p a t i e n t s ( p t s ) We e v a l u a t e d the p r o g n o s t i c s i g n i f i c a n c e o f myocardial per•177 imaging with high dose dipyrid a m o l e (DPM) 9 9 m T c S e s t a m i b i (MIBI). 121 c o n s e c u t i v e p t s on the w a i t i n g l i s t for RT w i t h o u t c a r d i a c s y m p t o m s and d i a b e t e s , m o r e t h a n 55 y e a r s o l d or 5 y e a r s of h a e m o d i a l y s i s w e r e p e r f o r m e d in 2 d i f f e r e n t d a y s w i t h i n 24 h o u r s from last dialythic treatment. Mean follow-up was 1 8 . 8 • months. G R O U P l ( n o r m a l scan) G R O U P 2 ( a b n o r m a l ) pts 93 28 RT 7 4 events 1 7 Probability of cardiac events: G R O U P 1 =6%; G R O U P 2 1 1 - 4 5 % . p : O . 0 0 1 ( c o n f i d e n c e i n t e r v a l 95%) C o n c l u s i o n : t h i s s t u d y c o n f i r m the p r o g n o s t i c v a l u e a n d the u s e f u l n e s s o f h i g h d o s e D P M M I B I S P E T in s c r e e n i n g l o w r i s k s u b j e c t s on the waiting list for renal transplant.
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday morning, April 26, 1995
$49-353
$49-355
THALLIUM REINJECTION IDENTIFIES "ISCHEMIC" SEGMENTS BUT DOES IT PREDICT EVENTS? N. Zafrir, S.T. Dahlberg, C.P. Reinhardt, J.A. Leppo, UMass, Worcester, USA; Beilinson Medical Center, Israel
PROGNOSTIC VALUE OF TL-201 REINJECTION (RJ) IN PATIENTS WITH CHRONIC MYOCARDIAL INFARCTION
Although thallium reinjection (REINJ) does enhance the detection of viable myocardium, its contribution to prognosis over stress/delayed redistribution (SDR) has not been clearly evaluated. Accordingly, we studied 366 consecutive patients (pts) with coronary artery disease who underwent SDR and REINJ thallium scintigraphy during mean follow up of 33+-12 months. Cardiac events (CE) occurred in 48 pts: 40 deaths, 8 MIs. Of the 366 original pts, 159 demonstrated ischemia by SDR but 107 of the remaining 207 pts showed ischemia by REINJ. Twenty pts (13%) with SDR had CE versus 33 pts (12%) with SDR and REINJ (p=ns). Pts with ischemia after SDR or after REIN J, as well as the number of segments with ischemia, did not demonstrate a univariate predictor for CE (Iogrank p=0.8). However, cox regression analysis utilizing various scan variables of ischemia, scar and abnormal segments showed that the number of abnormal segments was the most important independent prognostic factor (p=-0.002). Age, pulmonarythallium uptake and diabetes also had predictive value for CE. We conclude that thallium REINJ does not contribute to the prediction of CE compared to SDR. The number of abnormal segments (determined by the stress scan) is the best predictor for CE in pts with SDR and REINJ.
P.L. Pieri. A. Tisselli. G. Moscatelli. A. Spinelli. P. Riva "M. Bufalini" Hospital, Cesena, Italy This study was designed to assess the prognostic contribution of T1201 RJ in addition to Stress-Redistribution (S/RD) myocardial scintigraphy, with special regard to Fixed defects that become reversible after RI. We studied 122 pts with chronic MI (> 2 months) and suspected or known residual ischemia, with S/RD/RJ planar scintigraphy. Thallium scans were analyzed by 3 observers (3 segments/view; 5 points score) and classified as Normal (N). Fixed (F) and Reversible (R). The Lung/Heart rano was also calculated At a median F.U. of 47 months. 10 pts had hard events (4 deaths. 6 MI)(Group I), 12 pts had unstable angina (Group II), 12 pts underwent planned CABG or PTCA (Group III) and 88 pts had no events (Group IV). Results: 1) The presence of Fixed defects that became Reversible after RJ did not identify pts a! higher risk. 2) The n~ of Rev. defects a! 3 hr was significantly higller only in pts who underwent revascularization (Group Illk 3) Unstable angina was not predicted by any scintigraphic pattern: 4) The variables that were statistically related to hard events by nnivariate analysis were: increased lung uptake, reversibile cavity dilatation and the number of Fixed defects that remained F after RJ. By Cox multivariate analysis the strongest predictor of hard events was the number of Fixed defects that remained F after RJ as a marker of irreyersible myocardial damage. Conclusions: TI-201 Reinjection is a useful approach not only for detecting viable myocardium but also for risk stratification in pts with chronic MI.
$49-354
$49-356
PREDICTION OF RECOVERY AFTER REVASCULARIZATION WITH FDG; THE ROLE OF SPECT.
P O O R P R O G N O S I S IN P A T I E N T S W I T H N O R M A L TOMOGRAPHIC NUCLEAR IMAGES BUT ISCHEMIC E C G R E S P O N S E D U R I N G V A S O D I L A T O R STRESS TESTING
Jeroen J. Bax, Jan H. Cornel, Frans C. Visser, Paolo M. Fioretti, Otto Kamp, Arthur van Lingen, Cees A. Visser. Free University Hospital Amsterdam, The Netherlands. This study evaluates the predictive value for functional recovery after revascularization of FDG SPECT. We prospeCtively studied 25 patients (23 men; age 63+7; ejection fraction: 47_+i7%) scheduled for revascularization; all with regional wall motion (RWM) abnormalities on 2D echo. RWM was scored as: 0=normo-, l=hypo-, 2=akinesia, 3=dyskinesia. Patients underwent thallium (T1-201) SPECT at rest (to evaluate regional perfusion) and FDG SPECT during hyperinsulinemic glucose clamping. For comparison of SPECT and echo data, the myocardlum was divided in 5 segments: apex, anterior, lateral, inferior, septa!. Viable myocardium was defined by an increased FDG uptake in a T1-201 defect, scar tissue by a concordant reduction of FDG and T1-201 uptake. RWM was restudied 2-3 months after revascularization. Recovery was defined as RWM change _>1 after revascularization. Results: 14 patients had CABG and 11 PTCA. SPECT demonstrated 20 viable and 33 necrotic segments. The mean score of RWM pre-revascularization was comparable in viable and necrotic segments (2.7_+1.5 vs 3.1+1.6, NS). RWM score in viable segments decreased from 2.7-+1.5 to 1.2_+1.2 (p<0.001), and did not change in scar tissue: 3.1_+1.6 vs 2.9_+1,5. Improvement of RWM was seen in 16 (80%) segments identified as viable by SPECT. In contrast, 27 (82%) segments that were necrotic according to SPECT did not improve, These data suggest that FDG SPECT can predict recovery after revascularization,
$89
Elizabeth Klodas, T i m o t h y F. Christian, Todd D. Miller, R a y m o n d J. Gibbons, M a y o Clinic, Rochester, Minnesota, USA.
Normal tomographic (SPECT) nuclear images are associated with an excellent prognosis in patients (pts) u n d e r g o i n g exercise stress testing, r e g a r d l e s s o f E C G findings. The relative importance o f E C G findings in the setting o f normal S P E C T images during vasodilator stress testing is unknown. Over an 8 year period, w e identified 49 pts (46 w o m e n , 3 men) w h o underwent adenosine or d i p y r i d a m o l e stress t e s t i n g and had i s c h e m i a during infusion by E C G criteria ( > l m m ST d e p r e s s i o n ) , but normal SPECT images. During a mean follow up of 1.3 + 1.6 years, 9 pts (18%) e x p e r i e n c e d c a r d i a c e v e n t s including: 2 cardiac deaths, 2 myocardial infarctions, and 5 revascularization procedures. 54% o f the remaining pts required medical therapy for continued s y m p t o m s o f chest pain. Conclusions: Patients with normal S P E C T images but ischemia by E C G criteria during vasodilator stress testing are predominantly w o m e n who are at an increased risk o f s u b s e q u e n t cardiac events. A n i s c h e m i c ECG response during vasodilator stress testing is an important marker of poor outcome regardless o f imaging results.
W E D N E S D A Y P M A P R I L 2 6
$90
Abstracts Wednesday morning, April 26, 1995
$49-357
$49-359
Additive value of Thallium SPECT c l i n i c a l v a r i a b l e s for p r e d i c t i o n o f e v e n t s in s e l e c t e d h i g h c a r d i a c s u b m i t t e d to a b d o m i n a l aortic ( A A )
imaging over perioperative risk p a t i e n t s surgery.
THE USE OF STRESS MYOCARDIAL PERFUSION IMAGING IN RISK ASSESSMENT IN THE MEDICALLY TREATED ELDERLY PATIENT WITH DOCUMENTED CORONARY ANATOMY.
J. Machecourt, D. Fagret, G. Vanzetto, D.Blendea, J.L. Magne, F. Gattaz, H. Guidicelli., Centre Hospitalier Universitaire - Grenoble France.
Melco T. Perez, Seydi Aksut, Samir Pancholy, Virginia Cave, Tamara Sfivka, Jaekyeong Heo, Abdulmassih S. Iskandrian. The Philadelphia Heart Institute, Presbyterian Medical Center, Philadelphia, PA.
Diverging results have been reported about both the predictive value of thallium and selection critera for patients for thallium evaluation before AA surgery. Out a group of 517 consecutive patients referred, 134 had two or more clinical or ECG cardiac risk variables and were operated after thallium SPECT reinjection study. Results : Twelve pts (9%) had major perioperative events (cardiac death or non fatal M.I.) and 18 pts had other cardiac events (unstable angina, congestive heart failure, or ventricular tachyarrhythmia).Were correlated with the occurrence of events, fn univariate analysis: history of M.I. (p<0.05), presence (p<0.001) and number of segments with thallium reversible defects (p<0.001), and in multivariate analysis history of M.I. and the number of segments with reversible defects. When all the cardiac events were considered, all the previous variables, as well as Q waves and ST segment anomalities were predictive. Conclusion : When performed on clinically selected high cardiac risk pts undergoing AA surgery, thallium SPECT demonstrates significant prognostic value for cardiac events over that provided by clinical variables alone.
This study examined the predictors of hard events (MI) in 160 medically treated elderly patients (10ts) (> 70 years) with documented coronary anatomy by angiography. All pts (83 men and 77 women, aged 74 + 4 years) had stress SPECT perfusion imaging (exercise or pharmacologic). Of those, 38 pts had prior Q-wave MI, 77 pts had hypertension and 27 pts had diabetes mellitus. There were 22 hard cardiac events (15 death and 7 nonfatal MI) during a mean follow-up of 35 months~ The event rate was five times higher in the pts with abnormal images (5%/~ear vs. l%3Jear). Using multivariate survival analysis on important clinical, stress, SPECT and coronary angiographic descriptors, the following variables were independent predictors of events: size of perfusion abnormality (X2=6, P=0.02); number of diseased vessels (X2=4, P=0.05). Life table analysis showed more events in those with large defects ( > 15% of myocardinm) than small defects ( 17% vs. 5 %, P < 0.01). The SPEC'r image results contain most of the information. Thus, stress perfusion imaging is useful for risk assessment in medically treated patients by providing independent and incremental information to clinical and coronary angiographic results.
$49-358
$54-360
Incremental clinical and in p a t i e n t s comparison
p r o g n o s t i c v a l u e o f S P E C T TI o v e r exercise electrocardiogram variables e v a l u a t e d for e q u i v o c a l chest pain : of s u b m a x i m a l w i t h m a x i m a l tests .
P. Long~re,J. Machecourt,*D. Fagret, G. Vanzetto, *M. Comet, B. Denis. Service de Cardiologie, *Service de Medecine Nucltaire CHU Grenoble France.
W E D N E S D A Y P M A P R I L 2 6
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
1121 patients (sex ratio M/F=68/32) were followed 34 + 10 months after an exercise electrocardiogram (EE) with T1; EE was considered as maximal if ST segment depression 1 m m occured or > 85 % max predicted heart rate was achieved, submaximal if < 85 % MPHR with no segment depression occured. T1 was considered as abnormal if there was one or more segments with fixed or reversible defect. Results : with multivariate Cox analysis, were predictive of future CV deaths : a previous MI (F=4.2), a submaximal EE (F=8.6) and an abnormal T1 (F=6.5) and were predictive of major events (death or MI) : male gender (F=4.1), a previous MI, a submaximal EE and an abnormal T1. 238 EE were positive : tl was abnormal in 208 pts (2 deaths, 8 MI at Fup) and normal in 30 (0 death, 0 MI). 636 EE were negative : tl was abnormal in 383 (2 deaths, 7 MI) and normal in 293 pts (1 death, 2 MI). 247 EE were submaximal : d was abnormal in 190 (12 deaths, 8 MI), and normal in 57 pts (0 death, 1 MI). C o n c l u s i o n : an abnormal SPECT T1 has an incremental prognostic value for predicting major events, either after a maximal EE (RR =10) or after a submaximal EE (RR = 7 ).
RADIONUCLIDE ANGIOGRAPHIC ASSESSMENT OF REPAIR VS REPLACEMENT FOR MITRAL REGURGITATION D We~r.ker, JS Borer, C H~rdter, P Supino, R Devm~ax, M Roman, P Kfigtidd,ComellMedicalCent~, NY, NY, USA To define late postop course of left and right ventricular (LV, RV) size and function after mitral valve repair (MVr) vs replacement (MVR) for mitral regurgitation (MR), 28 pts who had MVR or MVr underwent rest (r) and exercise (ex) radionuclide cineangiography and rest echocardiography preop and 4-7 years postop (po). RVEF (r: 37% to 47%; ex:33% to 47%) and contractility (ESS/ESVi) (2.1 to 2.5) improved and LV diastolic dimension (6.4 to 5.5 cm) decreased (all p<.01); LVEF and ESS were unchanged. In 18 of the 28 pts (EFr,n=18, ESS/ESVi, n=15), additional early (< lyr) po values were obtained: MV-Replacement (n=l 1) i MV-Repair (n=7) LVEFr(%) LVEFex(O/o) RVEFr(%) RVEFex(~ ESS ESS/ESVi 4. =
p <
0.05,
.,v 48 36 34 80 2.1 .=
9 -*~ ns 44 , 43 9 44 9 118 ns 2.1
ns "~'* 152 ns 48 i50 n~ 45 i39 * 48 i30 ns 109 i86 ~ 2.1 il.5
G ns * ~ ,~ 9
51 - ns 49 ns 48 ns 46 ns 74 ~s 2.0 r~
53 55 50 49 81 2.3
p<0.005
MVr causes a more rapid and complete normalization of LV performance and contractility than MVR, while the two left heart procedures affect RV performance similarly.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday morning, April 26, 1995
$91
$54-361
$54-363
RESULTS OF GATED PERFUSION SPECT IN PATIENTS WITH PREVIOUS MYOCARDIAL INFARCTION CATEGORIZED BY FDG PET.
PROGNOSTIC VALUE OF MENTAL STRESS INDUCED SILENT LEFT VENTRICULAR DYSFUNCTION IN CORONARY ARTERY DISEASE Diwakar Jain, Matthew Burg, Robert Soufer, Barry L Zaret. Yale University, New Haven & VAMC West Haven CT, USA Studies carried out in our institution have shown that mental stress (MS) can induce silent left ventricular (LV) dysfunction in nearly half of patients ( pts ) with coronary artery disease (CAD). We have previously observed this phenomenon to be associated with a 3 fold increase in cardiac events (myocardial infarction or unstable angina ) over 1 year follow up period. To determine the prognostic significance over a longer period of time, 30 male pts (age 43-75 yrs) with stable CAD and reversible myocardial perfusion abnormality on stress TI-201 imaging underwent MS testing under continuous LV function monitoring using a miniature radionuclide detector (VEST). Pts were followed for 2 years for adverse cardiac events. At the time of MS, baseline LV ejection fraction of the entire group was 0.55; 13 pts had old MI. Fifteen pts showed significant LV dysfunction (>_0.05 EF fall lasting _>2.0 rain ) ( Gp I ) and the remaining 15 pts had no LV dysfunction ( Gp II ). Both Gps had comparable clinical characteristics, extent of perfusion abnormalities on stress TI-201 imaging, and antianginal medication. A total of 14 pts had cardiac events (myocardial infarction- 4, unstable angina requiring hospitalization and or revascularization - 10 ) over 2 yr period. In Gp 110/15 pts. (67%) experienced cardiac events, vs only 4/15 (27%) in Gpll (p=.025). These preliminary results suggest in CAD pts with ischemia on stress TI-201 imaging, mental stress induced LV dysfunction continues to be predictive of adverse cardiac events up to 2 years. Further studies in larger pt population are warranted
MP Larock, Th Benoit, M. Gods, V. Legrand, H. Kulbertus, P. Rigo. C.H.U. SART-TILMAN, Liege, Belgium. In this study we have attempted to evaluate the ability of G SPECT to detect regionai abnormal myocardial wall thickening (W]) at rest. We have studied 27 patients : 20 with previous single myocardial infarction (MI) and 7 with previous multiple MI as defined by history, ECG and angiography. Data were recorded using a dual head camera (180 ~ rotation and 32 projections), one hour after injection of 925 MBq of Sestamibi. Functional results were compared to the FDG PET and perfusion patterns. Abnormal WT was detected by G SPECT in all match transmural MI patterns (13/13) and in 91% (10/11) of mismatch hibernating myocardium patterns. In non transmural match patterns, abnormal WT was only present in 13% (1/8). WT was preserved in 85% (39/46) of non occluded arteries but false positive were observed in presence of combined RCA and LCx lesions. Septal wall motion artefacts were frequent when analysing wall motion rather than myocardial WT. In conclusions, G perfusion SPECT represents a promising technique to document abnormal WT and could help stratify different viability patterns after MI.
$54-362
$54-364
PREDICTION OF ENDICATIONS FOR VALVE REPLACEMENT IN PATIENTS WITH AORTIC REGURGITATION
STRESS-INDUCED LNCREASE IN GLOBAL AND REGIONAL LEFT VENTRICULAR EJECTION FRACTION AFTER SUCCESSFUL REVASCULARIZATION
JS Borer, C Hoehreiter, E Herrold, P Supino, M Aschermann, D Wencker, RB Devereux, M Roman, M Szulc, P Kligfield, OW Isom, CornellMedical Center,New York, NY
Isabel Coma-Canella, Maria del Val G6mez, Luisa Salazar, F61ix Gallardo. La Paz Hospital, Madrid, Spain
Optimal criteria for valve replacement (AVR) are unclear in asymptomatic/minimally symptomatic (sx) pts with chronic aortic regurgitation (AR) and normal left ventricular (LV) ejection fraction (EF) at rest (r), To test the hypothesis that noninvasively measured LV size, performance and/or contractility assessed at r and exercise (ex) can predict the development of operable sx, subnormal LVEFr or sudden death in such pts, LVEFr/ex and endsystolic wall stress (ESS) r/ex were assessed annually in 104 pts using radionuclide cineangiography (KNCA) and echocardiography During av 7.3 year follow-up, 39/104 pts died suddenly (4), or developed subnormal LVEFr (13), or operable sx only (22) [progression rate=62%/yr]. By multivariate Cox model analysis, change (A) in LVEF from r to ex normalized for AESS r to ex was the only independent objective predictor of progression to any endpoint and, univariately, best predicted sudden death alone. The ALVEFAESS tercile at highest risk progressed to endpoints at a rate of 13.3%/yr; the lowest risk tercile progressed at 1.8%/yr (p<.0002). In AR, development of indications for AVR, as well as of sudden death, can be predicted most efficiently by ALVEF-AESS definable by combined RNCA and echo.
To assess the changes in global (GEF) and regional (REF) left ventricular ejection fraction after revascularization, equilibrium radionucline angiography (RNA) was performed in 16 patients who suffered acute myocardial infarction and had periinfarct redistribution (observed in stress-rest thallium SPECT). REF was the ejection fraction of the asynergic region at rest, which corresponded to the infarct plus periinfarct area. Both thallium (Ti) and RNA were performed at rest and during stress with dobutamine, up to a maximal dose of 40 gg/Kg/min. The same studies were repeated 9• months after successful revascularization (9 coronary angioplasty, 7 bypass surgery. The table shows the results before and after revascularization: before GEF(%) 45• REF(%). 27• Tiscore 6•
Rest after 46• 36• 3•
~ ns 0.002 0.004
Dobutamine before after o-49• 35• 12•
63• 56• 4•
0.001 0.001 0.001
Conclusions: Rest REF of postinfarction asynergic regions with periinfarct ischaemia improves after successful revascularization, while TI defect size decreases. With dobutamine both REF and GEF are significantly higher after (vs beforel resvascularization.
W E D N E S D A Y P M A P R I L 2 6
$92
Abstracts Wednesday morning, April 26, 1995
$54-365
$55-367
A S S E S S M E N T OF LV F U N C T I O N IN CAD BY DOBUTAMINE RADIONUCLIDE VENTRICULOGRAPHY. M J. Garcia-Velloso, A. Huelmos, A. Maldonado L. Rubio, E. Alegrfa, J. Richter. Clinica Universitaria de Navarra. Facultad de Medicina. Universidad de Navarra. Pamplona. Spain. It has been suggested that dobutamine (DOB) may stimulate hibernating but viable m y o c a r d i u m and can thus differentiate it from infarted myocardium. The aim of this study was to determine if improvement in LV function with DOB and equilibrium radionuclide v e n t r i c u l o g r a p h y (ERV) correlates with an i m p r o v e m e n t in L V f u n c t i o n afer b y p a s s surgery. ERV at baseline conditions and during DOB infu-sion at 5 mcg/Kg/m was performed in 12 male patients (P) with CAD and LV dysfunction. ERV was repeated six months after surgery. Mean baseline ejection fraction (EF) was 42,1_+7,9 and in 8 P DOB induced an increase o f 5-25%. Six months after surgery, mean baseline EF was 51,6_+ 15,6 (p<0.04), with an 6 - 2 5 % improvement in 6 P, in which DOB had induced an E F i n c r e a s e greater than 10%. I m p r o v e m e n t in 45% o f the abnormally contracting LV segments was seen during DOB, and 76% of these segments also improved their function after surgery. In conclusion, in this group of patients EF increase with DOB correlates with a better LV function 6 months after surgery and this examination test may be useful in assessing coronary surgery in patients with poor LV function.
C O M P A R I S O N A N D R E P R O D U C I B I L I T Y OF ECHOCARDIOGRAPHIC AND RADIONUCLIDE LVEF: C L I N I C A L I M P L I C A T I O N S Niels van Royen, Conrad C. Jaffe, Harlan Krumholz, Kevin M. Johnson, Donna Natale, Patricia Atkinson, Paul deMan, Frans J. Th. Wackers. Yale University, New Haven, CT, USA.
P M A P R I L
Both 2D-echocardiography (ECHO) and equilibrium radionuclide angiocardiography (ERNA) are commonly used for assessment of left ventricular ejection fraction (LVEF) and are presumed to be interchangeable. We compared and assessed reproducibility of LVEF by ECHO and ERNA in 73 patients who had both studies <72 hrs interval. Three echocardiographers and 3 nuclear technologists assessed LVEF twice with l week interval. Mean LVEF by ECHO was 0.42-+0.18 and by ERNA 0.44_-t-0.19(p=ns). Range of individual correlations(r) and SEE are : Correlation LVEF ECHO vs. ERNA Intra observer ECHO Inter observer ECHO Intra observer ERNA Inter observer ERNA
r ran~,e .75-.82 .92-.96 .85-.90 1.0 all .99-1.0
SEE range .07-.09 .03-.05 .05-.07 .0l all .01 all _
Clinically unacceptable differences (A) of repeat LVEF (i.e. A>. 15, or: one <.40, other>.40 and A>.t0, or: one<.50, other>.50 and A>. 10) occurred in 8-26% of studies for ECHO and in 0% for ERNA. Thus, because of ERNA's superior reproducibility, ERNA is the method of choice for assessment of LVEF when precisely reproducible value is required for clinical decision making.
$55-366
$55-368
Myocardial Viability and Function After Acute l.~w-flow Ischemia Treated with a Membrane Stabilizing Agent.
COMPARISON BETWEEN 99mTc MIBI GATED-SPET AND CINE-MR IMAGING: PRELIMINARY REPORT.
Nicul PD, Narula J, Lopez L, Guerrero LJ, O'Donnell SM, Strauss /-IW, Khew BA. Allegheny General Hospital, Pittsburg, PA., Northeastern University & Massachusetts General Hospital, Boston, Ida.
W E D N E S D A Y
JOURNAL Or NUCLEAa CARDIOLOGY March/April 1995, Part 2
Acute onset of significant but not complete coronary occlusion has similar therapeutic and prognostic implicatious as acute myocardial infarction, and constitute an important indication for mechanical or surgical reperfusion (liP). Therefore, myocardial viability after low flow ischemia (LF1) were studied in 15 open chest dogs with intracuronary (ic) antimyosin Fab (AM) radiolabeled with 2 different isotopes, at 30 and 60 rain atler RP. The LAD pressure at 30-40 mm Hg was maintained for 2.51-1, 15 rain alter liP, 10 dogs received 150 lsg/kg ic tritluorperazine (TFP) and 5 were used as controls (C). The coronary sinus was drained during AM injection providing a single pass delineation of the necrotic myocardium. Mean infarct size in g (MIS:tSD) by computer planimetry of C heart slices increased from 29.2:k-9.72g to 41.1:1:7.64g (p<0.01) between 30 and 60 rain. MIS of TFP treated hearts was unchanged (35.0+10.7 to 34.2:t:12.2g). Myocardial functional preservation by TFP, was assessed by M-mode eehocardiography in a double blinded 6I-I LFIRP study (n=6). Four TFP-treated dogs had a mean 8.4% reduction in the hypokinetic segment length (I-Ir~.). MIS was 31.1:t:16 to 28.5 +12,7g at 1/2 and 6 H. In 2 controls, Hr~ increased 11.0% and MIS i n c r ~ from 27.2g to 30.2g. Therapeutic potential of membrane stabilizing agents in the preservation of myocardial integrity in reperfused ischemic myocardium is indicated.
Gaetano Tanzilli, Gianluca Valentini, Giuseppe Rubini, Valerio Todino, C Greco, Ernesto Brianzoni, Sergio Ancidei, Stefano Gobbi, Alfonso Berbellini, Claudio Palapacelli, Massimo Nardi, PierPaolo. Campa. II~ Dept. Rome University, ITALY. G-SPET analysis is based on counts variation between diastolic and systolic phases. The aim of our work was to evaluate the correlation between counts variation measured by G-SPET and left ventricular wall thickening variation evaluated by CineMagnetic Resonance (CINE-MR). We selected 10 Pts (mean age: 54 years) enrolled in a multicenter study on G-SPET. GSPET images were acquired by using a single head gammacamera (acquisition at 1.5 h after injection, 1100 MBq 99mTcSestamibi, LEHR collimator, orbix 180 ~ 64x64 matrix, 32 steps, 50 sec/step; 8 frames/cicle). Semiquantitative analysis based on systolic-diastolic bull's eye images and circular profile analysis system were used. The ECG-GATED, multislice SpinEcho sequences with an echo delay time (TE) of 20 ms and repetition time (TR) of 80% R-R interval were used first. CINEMR was obtained by using gradient-echo sequence. We compared the segmental variation of counts between diastolic and systolic phases with variation of regional wall thickness (milimeters). We found a high correlation between counts and thickness variation in lateral (r=0.91) and septal wall (r=0.88), but a lower value to inferior wall (r=-0,74). These regions have a greater thickness than the inferior wall, where partial volume effect and attenuation are more evident.
JOURr~AL OF NUCLEAR CARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday morning, April 26, 1995
$55-369
$55-371
INTRACORONARY DOPPLER GUIDE WIRE ADENOSINE INDUCED HYPEREMIA VERSUS SPLIT-DOSE THALLIUM201 DIPYRIDAMOLE IMAGING FOR ASSESSMENT CORONARY BLOOD FLOW RESERVE.
When Is Addition of Dobutamine-Atropine MIBI SPECT to Echocardiography Useful in Risk Stratificating Patients with Chest Pain? ML Geleijnse, A Elhendy, JH Cornel, EP Krenning, PM Fioretti. Departments of Cardiology and Nuclear Medicine, University Hospital Dijkzigt and Erasmus University Rotterdam, NL.
Edoardo VERNA, Luca CERIANI, Luca GIOVANELLA, Battistina CASTIGLIONI, Alberto LIMIDO, Salvatore CAICO and Sergio REPETTO - Ospedale Multizonale, Varese - Italy Methods: We prospectively evaluated coronary blood flow velocity reserve 0BFVR) during Adenosine-induced (A) hyperemia using an intracoronary Doppler (ID) guide wire in 10 patients undergoing diagnostic coronary angiography. Regional flow velocity profiles were obtained at baseline and after 18 meg of intracoronary A. BFVR was then calculated as the percent increase of flow velocity at peak hyperemia. All patients subsequently underwent split-dose Thallium201 dipyridanole imaging (SD-T1). Two separate injections of 1.5 mCi of Thallium-201 followed by imaging were performed at baseline and immediately after i.v. Dipyridamole administration (0.56 rag/Ks in 4 rain.). The percent increase in regional activity obtained during pharmacologic testing was calculated as an index of coronary flow reserve. Results: Mean coronary blood flow reserve was 194+/-60% by ID-A and 183+/-53% by SD-T1 (n.s.). There was a significant correlation between ID and SD-TI in the assessment of regional coronary blood flow reserve ( Y= 0.97X + 4.7 r=0.85, p<0.0001). Conclusions: Quantiative analysis of SD-TI scintigraphy may be used to accurately assess regional coronary blood flow reserve.The expected limitation in Thallium-201 uptake at increased blood flow rates seems to be not relevant at the range of coronary flow usually obtained with Adenosisne mediated stimuli.
$93
Aim of the study was to assess the prognostic value of dobutamine-atropine stress echocardiography (DSE) and MIBI SPECT (DSS) alone and in combination. 244 consecutive patients (pts) with chest pain, who were unable to perform an adequate exercise test, were studied simultaneously with DSE and DSS. Mean age was 60 • 11 years, 141 were men and 129 pts had a previous myocardial infarction. A test was considered positive in presence of a new or worsening wall motion abnormality or a transient perfusion defect respectively. Five options of stress testing were examined. Option A: each pt only DSE, B:each pt only DSS, C: each pt DSE and DSS only in normal DSE and D: each pt DSE and DSS only in submaximal normal DSE. DSE was positive in 94 pts and DSS in 109 pts (agreement 75%, kappa 0.49). During an average follow-up of 27 months, 30 pts had hard cardiac events: 17 cardiac death and 13 nonfatal myocardial infarction (MI). Predictive odds ratios (95% CI) were, respectively: DSE DSS Cardiac Death Death or MI Option A: 244 0 3.2 (1.1 - 9.0) 4.4 (1.8 -10.5) Option B: 0 244 3.2 (1.1 - 9.5) 3.1 (1.3 - 7.4) Option C: 244 150 3.0 (0.9 - 9.4) 3.5 (1.3 - 9.2) Option D: 244 28 4.0 (1.3 - 12.2) 5.6 (2.2 -14.7) Conclusions: In estimating prognosis DSE should be the first choice since it provides similar information at lower cost. Adding DSS to DSE is only useful in pts with a submaximal normal DSE.
$55-370
P 17-372
DOBUTA/vlINE STRESS TESTING IN CORONARY ARTERY DISEASE: COMPARISON OF TC-99m TETROFOSMIN IMAGING WITH ECHO IN HIGH-RISK PATIENTS Roxy Senior, Sanjiv Kaul, Heinz Sochor, Usha Raval, Sumit Basu, Avijit Lahiri. Northwick Park Hospital, Harrow, UK
NITRATE TC-99M-SESTAMIBI SPECT FOR THE PREDICTIONOF POSTREVASCULARIZATIONOUTCOMEIN ASYNERGICTERRITORIES.
The purpose of this study was to compare perfusion imaging with Tc-99m tetrofosmin (TET) and echocardiography (2DE) during dobutamine (Dob) infusion in high-risk patients with coronary artery disease (CAD). Accordingly, 48 patientS with CAD [41 (85%) with multivessel disease] and 12 normals underwent TET (SPECT) and 2DE during dob infusion (5-40 mcg/kg/min). Each of 12 segments of the left ventricule was assessed blind for detection of CAD and inducible ischaemia. In addition, 131 segments with resting dysynergy were assessed for viability. The sensitivity, and specificity for CAD detection was 96% and 75% for TET and 88% and 83% for 2DE (p=NS) and no differences were noted for each of the 3 vascular territories. The sensitivity and specificity for detection of ischaemia was 94% and 75% for TET and 81% and 92% for 2DE (p=NS) and no differences were noted for each of the vascular territories. Combining the two techniques improved prediction of CAD (p<0.001) and inducible ischaemia (p<0.005) compared to either test alone. Of the 131 dysynergic segments TET and 2DE showed viability in 112 (85%) and 121 (92%) segments respectively. Concordance between the two techniques was 88% (kappa = 0.77) for detection of viable/non-viable segments. Thus in a high risk population Dob stress with TET and 2DE have synergistic value for detection of CAD and inducible ischaemia and offer similar information for the assessment of viability in dysynergic segments.
Nitrate (N) administration during tracer injection reportedly improves the detection of hibernating myocardium in perfusion imaging. The aim of this study was to verify the reliability of N Tc-99m-sestamibi SPECT. We studied 34 patients with left ventricular dysfunction. Before revascularization (rev.) they underwent rest (R) and N Tc-99msestamibi SPECT on separate days. SPECT was analysed quantitatively using the comparison with a data base of normal controls. R and N defect extent in each coronary territory was estimated and the N-induced changes expressed in % of the R extent. There were 64 territories with suspect hibernating myocardium (group A: pre-rev moderate or severe asynergia) and 38 viable territories (group B: pre-rev, minimal asynergia or normokinesis). After rev. 20 group A territories showed a wall motion improvement (At) and 44 were unchanged (A2). In R SPECT there were 68 significant uptake defects: 59 in group A and 9 in group B. In N SPECT a -> 10% decrease in the extent of R defect was found in 31 territories: 24 in group A (I9 in A1 and 5 in A2, p < 0.000001) and 7 in B. The finding of a > 10% decrease on N SPECT was related in 26/31 cases to the presence of viable myocardium. In group A, this finding had 79% positive and 97% negative predictive value for the post-rev, outcome. Therefore, N administration improves Tc-99m-sestamibi capability to recognise viable myocardium and makes R-N Tc-99m-sestamibi SPECT an useful tool to predict the postrev. outcome of asynergic territories.
R. Sciagrh, G. Bisi, G.M. Santoro, P.F. Fazzini. Nuclear Medicine, University of Florence; Florence, Italy.
$94
Abstracts Wednesday morning, April 26, 1995
P 17-373
P 17-375
CGP 12177 IS A BETA-BLOCKER WITH INTRINSIC SYMPATHOMIMETIC ACTIVITY.
CMNICAL DEMAND IN NUCLEAR CARDIOLOGY.
Hrric Valette, Andr6 Syrota, Chantal Fuseau. SHFJDRIPP-CEA, Orsay, France. l l C - C G P 12177 is used to assess myocardial betaadrenergic receptor density. During PET experiments in anaesthetized dogs, we observed an increase in heart rate following injection of CGP (ll.tg/kg) suggesting that CGP has an intrinsic sympathomimetic activity (ISA). Changes in left ventricular ejection fraction (LVEF, gated blood pool studies), fol!owing infusion of CGP (0.51~g/kg, lbtg/kg, 1,5 lag&g) or propranolol (Pro: 0.17mg/kg, 0.34 mg/kg, 0.68 mg/kg) which is devoided of ISA) were compared in 5 dogs.These doses of Pro have beta-blocking effects without increasing plasma norepinephrine concentration. Results (heart rate: HR): baseline 1st dose 2nd dose 3rd dose CGP HR 122+30 151+19 154+21 158+23 LVEF 68+11 82+5 82+12 91+8 Pro HR 126+28 116+28 115+18 113+15 LVEF 71+15 63+17 60_+10 58+11 ANOVA showed that the changes in HR and LVEF were different for the two drugs (p<0.003 and p<0.0001, respectively). Blood pressure and plasma norepinephrine remained unchanged with both compounds. These results strongly suggest that CGP has ISA. Therefore, CGP could be used rather safely in patients with left ventricular dysfunction.
P M A P R I L
Pieduigi Rossini, Raffaele Giubbini, Elisa Milan, Aurora Vaccari, Arturo Terzi, Mautfzio Bestagno. Nuclear Medicine Dpt, Civic Hospital, Brescia -Italy. Our Nuc. Cardiology Lab. is located in a 2000 bed University Hospital and it is a reference lab. to the Cardiology Dpts of 7 Community Hospitals in an area with over one million inhabitants. The clinical demand exceeds the maximum output of our lab. (approximately 2000-2500 studies per year). For this reason Cardiologists have to limit their requests to pts with mandatory indications for nuclear studies. From our database we extract on a yearly basis the indicalions to nuc. cardiology grouped in the following categories: 1990 1991 1992 1993 1994(normalised) CADdiagnosis 35.9%
502Y,
22.7%
24.8%
26.2%
Functionalaesessmentand risk stratificationof post.M/ pts 11,8%
'12.3%
9.2%
8.4%
8.2%
Functionalassessmentof coronarylesions
13.0%
10.0%
12.3%
9.8%
9.7%
1Q.8%
8.6%
14.5~
12.9%
1~,1%
9.0%
21.5%
25.7%
23.0~
19.7~
15.6O/o
21.1%
22.1%
3.3:1
2.6:1
2.6:1
2.5:1
2d :1
12:1
Evaluationof pts treatedby PTCAor by-passsurgery
Func~onalaeseesmentof LV performance
Vlablllty assessment 5.2~ I'12% MalM:emale 2,~;1
3.6:1
Exerclse/dlpyrldamole 2~4:1
_ 3:1
We conclude that in the last 5 years we have observed a progressive reduction of diagnostic tests (now approximately 25% of the overall demand) in favour of the functional evaluation of CAD pts, especially viability (4x) and vessel patency assessment after revascularization. The number of radionuclide angiographies and of studies performed for nsk stra~fication in the post MI pts is stable as well as the male/female ratio; the number of pham'acological stress tests is increasing in comparison to exercise.
P 17-374
P 17-376
THE RABBIT IS A CONVENIENT SMALL ANIMAL TO S T U D Y M Y O C A R D I A L N O R E P I N E P H R I N E UPTAKE AND STORAGE WITH PET.
IMPROVED DETECTION OF CORONARY ARTERY DISEASE BY PLANAR TC-99M TETROFOSMIN COMPAREDTO THALLIUM-201IMAGING R S Khattar, J CW Crawley, U Raval, B S Sridhara, and A Lahiri. Northwick Park Hospital, Harrow, UK
Hrric Valette, Christian Loc'h, Bernard Mazi~re, Chantal Fuseau, Andr6 Syrota. SHFJ-CEA, Orsay, France.
W E D N E S D A Y
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
The drawback of the use of rats and dogs for the study of myocardial norepinephrine (NE) uptake - storage is the high (20%) extra-neuronal uptake. Dae has suggested, using 123I-MIBG scintigraphy and the neurotoxin 6-O1-I dopamine that the rabbit has a low uptake-2. In the present study we confirm these results using the bromoderivative of MIBG (76Br-MBBG). Three groups of 6 rabbits were studied: control, desipramine (40mg/kg) and 6-OH dopamine (50mg/kg). Animals were injected with 100~Ci in an ear vein and they were killed 30rain later, the heart rapidely removed, the left ventricle dissected and the radioactivity counted. Results: Control: 0.28+0.02 % ID/g/kg; Desipramine: - 92%; 6-OH dopamine: - 93%. These results confirm the low uptake-2 in this species. Three rabbits (mean weight: 4kg) were imaged for one hour using a human brain scanner (CT1953B/31). Injected doses were 300 to 6001.tCi. Myocardial uptake of MBBG was high with a plateau from the fifth minute after injection to the end of the experiment. Lung uptake showed a rapid wash-out of the tracer. Rabbits appear to be a convenient animal for the study of myocardial NE uptake - storage in viva.
Tc-99m tetrofosmin (Tet) is a new perfusion imaging agent which has advantages over TI-201 including superior image quality and dosimetry. The results of stress studies using planar Tat were compared with T1-201 by a blinded observer, in 38 patients with suspected coronary artery disease (CAD). Defects were allocated to the left anterior descending (LAD), right coronary (RCA) or left circumflex (LCX) arteries using a polar map with 3 levels of severity. Receiver operating characteristic (ROC) curves were plotted using angiographic data and the area under the ROC curve was used as a measure of diagnostic accuracy. ROC curves were created for the presence of CAD, multivessel (MV) and single vessel (SV) disease as well as for the three main arteries. Area under ROC curve 50% stenosis CAD MV SV LAD RCA LCX Tel 0.80 0.55 0.50 0.69 0.77 0.55 TI-201 0.67 0.55 0.58 0.70 0.66 0.53 70% stenosis Tet 0.85 0.55 0.55 0.75 0.57 0.55 T1-20I 0.58 0.55 0.55 0.75 0.55 0.45 This data suggests that there is an overall improvement for the detection of CAD by TeT compared to T1-201. Howeverthere is no difference in the localization of disease.
Abstracts Wednesday morning, April 26, 1995
JOURNAL OF NUCLEAR CARDIOLOGY
Volume 2, Number 2, Part 2
P17-377
P17-379
DETECTION OF MYOCARDIAL VIABILITY:TRANSDERMAL NITRATES COMBINEDWITH EARLY THALLIUM REINJECTION
EVALUATION OF Tc-99m TETROFOSMIN AS A ROUTINE MYOCARDIAL IMAGING AGENT FOR THE ASSESSMENT OF CORONARY ARTERY DISEASE.
G.Cannizzaro,G.Calsamiglia,CAprile,O.Zoccarato,L.Tavazzi Fondazione Clinica Lavoro- Montescano (Pv)- italy One hundred eighteen pts with CAD and >_ 5 segments with perfusi0n defects in the stress (ST) scintigraphy underwent Thallium ST study - early reinjection (just after ST imaging) and 4 hrs. scintigraphy, They were randomly allocated to transdermal administration of Nitrocor| 20 m9 15 rain. after Thallium-ST inj. (61 pts=group A) or control (57 pts=group B). The two groups were homogeneus for clinical, ECG, echo and ST scintigraphic variables. The number of reversible defects was 124/417 (29.7%) in the group A and 1311458 (28.6%) in the group B (n.s.).
P.J. Thorley, K.L. Sheard, U.M. Sivananthan Killingbeck Hospital, Leeds, UK
Conclusion: Nitrates joined to early reinjection of Thallium seem to improveviablemyocardiumdetection.
Recent trials in selected patients have shown that Tc-99m Tetrofosmin is a suitable agent for myocardial perfusion imaging. We have performed Tetrofosmin imaging in 316 patients routinely referred for diagnosis and assessment of coronary artery disease (CAD). SPECT imaging was performed 45-60 mins. post injection using a two-day protocol. 204 patients were stressed on a treadmill and 112 using Dobutamine. Comparison with angiography was possible in 80 patients, 65 with CAD and 15 with normal coronary arteries and low likelihood of cardiac disease. The sensitivity for the detection of CAD was 94%, 93% for exercise stress and 95% for Dobutamine. Taking both the 15 normal patients and the normal arteries in the patients with coronary disease gives an overall specificity of 85%, 87% for exercise stress and 80% for Dobutamine. We conclude that Tetrofosmin appears to be a highly sensitive and specific agent for the detection of CAD using both exercise and Dobutamine stress.
P 17-378
P17-380
ENHANCED DETECTION OF MYOCARDIUM VIABILITY WITH EARLY POST-EXERCISE THALLIUM-201 REINJECTION AFTER SUBLINGUAL NITROGLYCERINE
THALLIUM- 199 SCIN TIGRAPHY EVALUATION OF CALCIUM CHANNEL BLOCKERS EFFECT IN CORONARY ARTERY DISEASE.
Results : outcome of severe ST defects: p GROUP A GROUP B SEVERE ST D E F . 221/417/53% ) 2101458(46%) n.s. NONREVERSIBLE 135 {61%) 168 {80%) <.001 REVERSIB.(VIABLE) 86 (39%) 42 (20%) <.001 patient's analysis: GROUP A GROUP B p REVERSIBILITY 49/61(80%) 37/57(65%) <.001 RELEVANT REV (>2sgts) 36/61(59%) 24157(42%) <.001
Evangelos Georgiou, Athanassios Antonopoulos, Michael Kyriakidis, Margarita Pagou, Pavlos Toutouzas, Charalambos Proukakis. Athens University Medical School, Athens, Greece. In order to evaluate the efficacy of an early Thallium-201 (71) reinjection and imaging protocol after sublingual nitroglycerine (SNTG) for reducing the need for conventional (4 hr) redistribution imaging (CRI), we compared the results of immediate postexercise TI reinjection and imaging after SNTG with those of CRI in 62 consecutive patients (pts), aged 55_+8 yrs (mean _+ SD) who were assessed for myocardial ischemia. Immediately after the completion of the initial postexercise imaging (PSI), 0.8 mg SNTG followed by the reinjection of 1 mCi of TI was administered and two further sets of images were acquired 1 (IRI) and 4 (CRI) hrs later. A total of 1488 segments was analysed. On PSI 305 (61%) segments demonstrated defects of which 198 (65%) showed enhanced TI uptake, 97 (32%) did not change and 10 (3%) showed reverse redistribution on IRI. Of the 97 persistent defects only 17 (6%) showed fill-in of TI on CRI while 12 (4%) segments showed reverse redistribution. In only 5 (8%) pts the diagnosis changed from myocardial necrosis to ischemia after analysis of the CRI. In conclusion, early postexercise reinjection of TI after SNTG followed by 1 hr image acquisition may be useful for a comprehensive and convenient assessment of myocardial viability.
V.Chernov, V.Mordovin, Yu.Lishmanov, J.Vesnina, S.Triss, E.Kolomin, R.Karpov. Institute of Cardiology, Tomsk, Russia. The aim of the study was to assess calcium antagonists (CA) effect on myocardial perfusion in CAD pts using short life nuclide 199TI(T1/2=7.4h). Study was performed in 9 l-vessels disease (VD), 13 2-VD, 8 3-VD and 5 X-syndrome pts. The initial scintigraphy was performed after bicycle exercise testing. The repeat one was after CA treatment at the same level of exercise. Significant decrease in reversible defect size was found in 20 cases (7 I-VD, 8 2-VD, 4 3-VD and I X-syndrome pts), in 7 cases perfusion data were without considerable changes (2 1-VD, 2 2-VD, 1 3-VD and 2 X-syndrome pts) and 10 patients showed increase in defect size (3 2-VD, 3 3-VD and X-syndrome pts) may be, as result of "steal". Thus, 199T1 myocardial scintigraphy is a new perspective method for dynamic evaluation of ischemic zone size in antianginal treatment. Calcium antagonists is more effective in one-vessel disease pts.
$95
$96
Abstracts Wednesday morning, April 26, 1995
P 17-383
Correlation of mismatched uptake of beta-methyl fatty acid analogue and thallium in infarcted myocardium with coronary stenosis and regional wall motion abnormality
1-123 IPPA KINETICS IN NORMAL VOLUNTEERS AND PATIENTS WITH CORONARY ARTERY DISEASE:
SPECT with thallium (T1) and fl -methyl fatty acid (BMIPP) was performed in 131 patients with myocardial infarction to investigate the clinical implications of mismatched uptake of myocardial fatty acid and perfusion. Reduced BMIPP uptake relative to TI perfusion (mismatch B) was observed in 54% to 59% of 155 infarcted segments, whereas reduced TI perfusion relative to BMIPP uptake (mismatch T) was less frequent ( --~t 7%). In an anteroseptal segment, type B was most frequently observed compared to no mismatch or type T; 64% vs 29% vs 6%, respectively. The incidence of type T was relatively high in inferior and posterolateral regions ( 1315%). Severe coronary stenosis was observed in 78% of type B segments and 70% of no mismatch segments but only in 44% of type T segments. Asynergy was observed in 90% or more of type B or no mismatched regions but only in less than 60% of type T segment. In conclusion, ischemic lesions are more closely related to type-B mismatch but not necessarily to type-T mismatch, probably because of TI attenuation in inferior and posterolateral regions.
A P R I L
Jaekyeong Heo, Joseph Powers, Raffael Giubini, David Cassefi, Joseph Russell, Virginia Cave, Abduimassih S. Iskandrian. The Philadelphia Heart Institute, Presbyterian Medical Center, Philadelphia, PA. We previously reported that rest-redistribution SPEC'r 1-123 IPPA imaging can be used to detect viable myocardium based on initial uptake 4 mill after injection and wash-out 30 rain later. This study compares the biokinetics of rest-redistribution 1-123 IPPA in 20 patients with coronary artery disease(CAD) and left ventricular dysfunction from Phase t and 2 trials) to 10 normal volunteers. Count densities from regions of interest were derived from initial and 30 rain. images. In the normal volunteers, there were no regional variations in wash-out: 30 5: 5% on the anteroseptal region, 29 + 6% in the inferior wall and 31:1: 4% in the lateral wall. In the 20 patients, with CAD, there were 15 normal vessels and 45 diseased vessels. The wash-out in the normal vessels (31 + 10%) of the patients with CAD was similar. The wash-out was less in territories of diseased vessels (25 + 11%, P = 0.01). There was a moderate correlation between percent diameter stenosis and wash-out (r = 0.39, P = 0.005) and between the initial tracer uptake and wash-out ( r=0.39, p=0.003). An abnormal initial uptake ( < 80% of mean normal) or abnormal wash-out ( < 1 SD of mean normal) was seen in 39 of 45 (87%) diseased territories. Thus, the use of normal IPPA file allows quantitative assessment of tracer kinetics in patients with CAD. Most diseased vessels have abnormal uptake or wash-out.
P17-382
P 17-384
TETROFOSMIN: A NEW MYOCARDIAL PERFUSION TRACER. OUR EXPERIENCE.
IMPROVEMENT OF LEFT VENTRICUI.AR FUNCTION IS PREDICTED BY THALLIUM INFUSION SCINTIGRAPHY.
Michele Sicolo, Guerrino Zuin, Claudio Barizza, Ricoardo Vangelista. Nuclear Medicine Service, Mestre-VE ITALY.
P M
March/April 1995, Part 2
P17-381
Akiyoshi Hashimoto, Tomoaki Nakata, Kazuhiko Nagao Kunihiko Hirasawa, Hitoko Ogata, Naoya Matsuura, Hirohtsa Yamashita, Tamio Aburano, Takeshi Kobayashi, Masayori Fumdate. Sapporo Medical University and Hokkaido Myocardial Metabolic Imaging Study Group, Japan.
W E D N E S D A Y
JOURNAL OF NUCLEARCARDIOLOGY
~mTc-Tetrofosmin (Myoview-Amersham) is a new radiopharmaceutical agent for myocardial perfusion imaging. 50 patients(20F, 30M, age 60+7) with suspected coronary artery disease were studied. The aim of our study was to test this new tracer: 1) All patients were fasted : post tetrofosmin injection half patients had a normal breakfast and the others had a fat meal like patients studied with MIBI: the latter showed less radioactivity uptake in gallbladder. 2) 5 patients underwent a total body scan to evaluate the mioview biodistri-bution: a major uptake of parotid glands, thyroid, myocardium, liver and muscles was observed. 3) another 10 patients underwent a dynamic study post tetrofosmin injection (60frames/1 min) with a LFOV gamma camera to evaluate with activity/time curves the myocardial, liver and lung uptake: after 15 minutes myocardial uptake reached a stable good uptake, but the best target to non-target ratio is at 40-50 min. 4) 10 tetrofosmin kits were submitted to chromatho-graphic analysis until 6-7 hours after reconstitution with ggmTC: the radiochemical purity was never less than 97%. 5) in 4 patients SPET-tetrofosmin acquisition was compared with MIBI: no differences were observed in blind tdals by two operators. 6) No adverse reactions were observed. 7) More-over the method of labelling is simple and without boiling. For all these aspects Myoview can be considered an ideal agent for studyng the myocardial perfusion defects.
R.M. lwanochko, L. Wright, R.J. Bums. The Toronto Hospital, Toronto, Ontario, Canada. Thallium (1"1) "input" using a bolus (2mCi) and infusion (lmCi/2hr) for rest scintigrapby leads to reversibility of severe, conventionally fixed defects which is predictive of TI uptake after revascularization (RVS). We examined whether such uptake is predictive of increase in LVEF after RVS in 12 "possibly hibernating segments" (PHS) in II patients (age 60-+9 yrs,7 male, 8 with prior Q-wave MI,I with LBBB) without other significant defects.PHS were characterized by severe (<50% normal segment activity), conventionally fixed stress SPECT TI defects and concordant wall motion abnormality.Semiquantitative SPECT TI uptake was analyzed for reversibility (infusion vs. conventional delayed images). LVEFwas measured pre- and post-RVS. Reversibility preRVS using TI infusion was associated with important mean increase (20.7-+16.0% vs. 2.8-+3.2%; p=0.03) in LVEF. 111 Infusion LVEF Pre-RVS LVEF Post-RVS Reversibility 35.5 • 16.8 % 56.2 • 6.4 % No Reversibility 41.1 -+ 13.1% 44.3 • 2.9 % _Conclusions: Similar to flow-metabolism PET TI infusion scintigraphy predicts increased LVEFpost RVS.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday morning, April 26, 1995
P 17-385
P 17-387
ASSESSMENT OF MYOCARDIALVIABILITYWITH GATED SPECT Tc-99m SESTAMIB! IMAGING DURING ADMINISTRATIONOF SUBLINGUALNITROGLYCERIN Mark I. Travin, Steven D. Herman, David G. Wolinsky, John Miskewicz, Gary V. Heller. RogerWilliams Medical Center, Providence, Memorial Hospital, Pawtucket, Albany Associates, NY, and BrownUniversitySchool of Medicine, RI.
CLINICAL USE OF 1-123 METAIO~BENZYLGUANIDINE OilBG) MYOCARDIAL $CINT1GRAPHYFOR THE EVALUATIONOF CARDIAC, SYMPATHETICNERVE DISTURBANCES IN PATIENTS W~TH CHRONIC RENAL FAILURE(CRF)
To assess whether NTG induced wall motion(WM)improvement on gated SPECT sestamibi (MIBI) imaging is helpful in assessingmyocardialviability, 18 patients undergoingexercise MIBI scintigraphywere studied. Baseline(BL)post stress and post NTG gated SPECT image pairs were read side-by-side, blinded, in random orientation, to detect differences in wall motion in the ant., lat., sept., inf., and apical segments (5/patient). Differencesin WM between BL and NTG gated images for the 90 segments were correlated with reversible perfusion defects in the stress/rest perfusion images. 10/27 (37%) reversiblesegmentshad WM improvementafter NTG, compared with 1/12 (8%) fixed segments, and 2/51 (4%) normal segments (p<0.001). Of 11 defect segments that had improvedWM after NTG, 90% were ischemicdefects. CONCLUSION: Nitroglycerin induced wall motion improvementas detected by gated SPECT sestamibi imaging in a segmentwith a perfusiondefect predicts stress ischemiain that segment. This technique may obviate the need for rest imagingand help to detect myocardialviability.
Hajime Miyanaga, Yoneyama $atoshi, Kamitani Tadaaki, Takahashi Toru, Kunishige Hiroshi Patients with chronic renal failure,especially treated under hemo-or ~ritoneal dialysis often suffered autonomic disturbances such as orthostatic hyDotension, or abnormal perspiration. We performed MI~ scintigraDhy in the initial stage (15min after i.e.) and delayed stage (4h after i.e.) and Dower spectral analysis (PS/O of RR fluctuation~ of the ECG in I0 controls(group 1), 8 CRF patients (~ts) without autonomic nerve disturbances (group 2), and 9 CRF Dis with autonomic nerve disturbances (group 3).The ratio of mean counts of the ROI located in Heart and mediastinum was significantly lower in group 3 than in group 1(1.9 -t- 0.3vs2.4 • O.4,D
P 17-386
P 17-388
DO HIGHER WASHOUT RATES OF 99~TCTETROFOSMIN REQUIRE CHANGES IN PROTOCOL OF MYOCARDIAL SPECT STUDIES IN COMPARISON TO 99"TC-SESTA-MIBI?
EXERCISE Tc-99m TETROFOSMIN CARDIAC TOMOGRAPHY IN THE DIAGNOSIS OF CORONARY ARTERY DISEASE
G. Graf, H. Vogt, P. Heidenreich Zentralklinikum Augsburg, GERMANY 99mTc-Tetrofosmin myocardial scintigrarns at rest and during exercise show significant higher washout rates in comparison with 9'~"Tc-Sesta-MIB[. Myocardial count rates of MIBI studies decrease nearly constant by to about 70% of initial counts at 3 hours p.i.. Using ~ l ' c Tetrofosmin, we found a very high initial washout to 75% during the first 90 minutes p.i.. Afterwards the washout is similar to MIBI for both rest and exercise studies, with a reduction of activity to about 65% aider 3 hours. The initial high washout rates of Tetrofosmin are in contradiction to the steady state requirements of SPECT studies, therefore the acquisition should not be started before 90 minutes p.i.. Furthermore, in general washout rates of both radiopharmaceutieals need adequate corrections especially using single head gamma cameras having normally acquisition times of more than 20 minutes.
$97
Pasquale Sullo, Alberto Cuocolo, Emanuele NicoPai, Leonardo Pace, Antonio Nappi, Michele Klain, Stefania Cardei, Fiorenzo Squame, Marco Salvatore. Universit& "Federico I1" and tstituto Nazionale dei Turned, Napoli, Italy, The aim of this study was to investigate the usefulness of exercise Tc-99m tetrofosmin tomography in the diagnosis and localization of coronary artery disease (CAD). We studied 47 patients (44 men, mean age 53_+8yrs) with suspected CAD: 39 with previous myocardial infarction (MI) and 8 without MI. Two patients had normal coronary vessels, 21 one-vessel, 12 twovessel and 12 three-vessel disease (>_50% coronary stenosis) on coronary arteriography. A total of 141 coronary vascular territories were quantitatively analyzed. Tc-99rn tetrofosmin imaging was normal in the 2 patients with normat coronary arteries and abnormal in all patients with CAD. The overall sensitivity, specificity and predictive accuracy for detection of stenosed vessels were 79%, 91% and 84%, respectively. Sensitivity, specificity and predictive accuracy were 83%, 91% and 85% in the left anterior descending coronary territory, 78%, 96% and 87% in the left circumflex coronary territory and 74%, 88% and 81% in the posterior descending coronary territory. Sensitivity, specificity and predictive accuracy for detection of stenosed vessels were 79%, 90% and 83% in patients without MI and 79%, 92% and 85% in those with previous MI. In conclusion, exercise Tc-99m tetrofosmin tomography is accurate in evaluating the presence and localization of CAD.
W E D N E S D A Y P M A P R I L 2 6
$98
Abstracts Wednesday morning, April 26, 1995
P17-389
P17-391
1-123 PHIPA SCINTIGRAPHY IN CHRONIC CORONARY ARTERY DISEASE: A COMPARATIVE STUDY WITH TL-201
2OlThailium (Ti) reinjection (RI) after sublingual nitroglycerin administration (S-NGA) could improve sensitivity of rest (R)-redistribution (RD) TI imaging to detect myocardial viability.
J6rg Zehelein, Bernd Bubeck, Michael Eisenhut, Johannes Hoffend, Rainer Zimmermann. Departments of Cardiology and Nuclear Medicine, University of Heidelberg, Germany. 13-(p-[1231]iodophenyl)-3-(p-phenylene) tridecanoic acid (PHIPA) is a radiolabeled synthetic long chain fatty acid with prolonged myocardial retention (biological half life up to 70 hours). The trapping mechanism most probably relies on inhibition of r~-oxidation by the p-phenylene group in the alkyl chain. In 10 patients with stable angina pectoris, 180 ~ SPECT images were acquired 30 min after injection of 160 MBq PHIPA at stress. Three days later, separate rest studies were performed (identical imaging protocol). The regional activity in each of 32 myocardial segments per patient was compared to that of stress/redistribution thallium-201 images performed within 1 week following the PHIPA studies. The number of abnormal segments after stress was similar with PHIPA and thallium-201 (16+5 vs 18_+4 segments per patient, 75% agreement). Reversibility on rest images was obtained in only 3.0 _+2.6 segments per patient with PHIPA, but in 6.1 _+3.9 segments with thallium-201 (P< 0.05); 69% of those segments with abnormal thallium-201 uptake at stress were abnormal even at rest with PHIPA. The data indicate decreased free fatty acid uptake in the majority of myocardial areas with stress induced perfusion abnormalities. Furthermore, due to its long myocardial retention, PHIPA appears to be a suitable imaging agent for the detection of alterations in fatty acid utilization with SPECT.
W E D N E S D A Y
P M A P R I L
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
E. Zerbib, C. Chauvel, A. Cohen, F. Carrat, S, Askienazy, J.Valty. M. Nucl6aire, Cardiologie, Hal St-Antoine, Paris. We investigated if S-NGA followed by TI RI could improve sensitivity of R-RD T1 imaging. 12 patients were included (11 M/I F, mean age: 65 years, mean ejection fraction 37 + 1 1 % ) . 3 SPECT were performed: R, 3-4 hours RD and T1 RI (40 MBq) after S-NGA (0.4 to 1.6 mg). Left ventricle was divided in 13 segments and TI fixation was analyzed in a semi-quantitative mode: 0 = normal, 1 = mild, 2 = medium, 3 = severe.
Rest
RD
S-NGA - RI 2=-
5=n
12
mean fixation score 18.25+ 3.5
1=0
7= 0
2--+ 6 ~1=0 16.60+ 4.0 (*) 15.75+ 3.3 (*)
= d e c r e a s i n g score (reversibility) ; 0 = no effect ; + = increasing score ( w a s h out). ( * ) : p < 0,05 vs rest score
Variance analysis showed a significal difference between R and RD or RI. Reversible T1 fixation was detected on 11 patients after S-NGA versus 5 with only RD study. The score after Rt was lower than RD but the difference did not reach statistical signifiance.These results suggest T1 RI after S-NGA should increase sensitivity of R-RD T1 imaging.
P 17-390
P18-392
INFLUENCE OF SYMPATHETIC NERVE ACTIVITY ON 1-123 MIBG SCINTIGRAPHY IN NORMAL VOLUNTEERS.
GENERAL EXPRESSION FOR EVALUATION OF THE FALLING RIGHT VENTRICLE (RV): RADIONUCLIDE STUDY.
Takashi Yano, Hiroshi Yamabe, Masanori lwahashi, Susik Kim, Hideki Fujita, Kazumi Maeda, Mitsuhiro Yokoyama. Kobe Univ. 1st Int. Med, Kobe, Japan
Richard P. Spencer. Univ. Connecticut Health Center, Farmington, CT. USA
Although the increased washout rate (WR) and decreased uptake of 1-123 MIBG are markers of impaired sympathetic function in congestive heart failure, the precise mechanism is not well known. We studied whether exercise induced sympathetic nerve activation can increase WR and decrease uptake of 1-123 MIBG in normal volunteers. Seven male volunteers underwent rest MIBG scintigraphy at first, then they underwent MIBG scintigraphy with ergometer exercise after MIBG injecaon. Heart to mediastinum ratio (H/M) and WR were calculated from the planar images. Serum norepinephrine (NE) concentration was also measured just before imaging. Results: H/M 4hr. WR (%) NE (pg./ml) rest 2.14+0.09 18.2+6.0 172_+52 exercise 2.07_+0.17 26.3+5.3* 541_+118" * p<0.01 rest vs exercise WR and NE concentration was higher in the exercise study than the rest study. NE concentration significantly correlated with WR. HAM in exercise study tended to be smaller than rest study but not significantly. These results indicate that sympathetic nerve activation play a role in the increased WR of MIBG in normal volunteers.
The Starling law (Frank-Starling principle) is not applicable to the failing heart. A general descriptive equation is needed for processing data (volume versus EF) from the RV. We know that as EF falls, ventricular cavity tends to dilate. We thus set the specific rate of change of RV cavity size equal to the negative rate of change of the EF. For analysis, we utilized 20 sets of data gathered from the literature on end diastolic volume (EDV) and end systolic volume (ESV) versus EF, in myocarditis or healed myocardial infarction. Results were as follows. 1) In each series, of In ESV vs In EF (or in EDV vs in EF), the ESV line had a much steeper slope. 2) The best correlation in each series was between ESV (rather then EDV) and E ~ 3) The lines extrapolated backward to a nonzero point at which EDV=ESV and cardiac action may cease. The description appeared to be robust for population based data, but might have to be used with caution with values gathered from the heart with possible stunned or hibernating myocardium.
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday morning, April 26, 1995
P 18-393
P18-395
Failure to label red blood cells adequately in daily practice using an in vivo method : clinical considerations. A.SMambye,A.Vervaet,L.Knaepkens,1LVandemaeiren,J.Vanclevivcae. MiddelheimGeneralHospital,Antwerp,Belgium.
L E F T V E N T R I C U L A R FUNCTION IN INSULIND E P E N D E N T A N D IN N O N INSULIN-DEPENDENT PATIENTS: R A D I O N U C L I D E A S S E S M E N T
In vivo labellingof RBCs to perform a GBP study can resultin low labelling efficiency(LE) and/or suboptimalimage quality (IQ), thoughboth conditions am not necessarilyassc~'iated. In a group of 737 patients, we found 4.9% low LE (<65% bound fraction), and 11.9% suboptimalIQ. Subclassifyingthe patientsaccordingto theirclinical condition, three groups were clearly identified. Group I (n=385) comprised patientsreferred for GBP within 24h. of coronary angiography.Frequencyof low LE was 2.8%. Suboptimal IQ was never found without poor LE. An obvious influence of intravenous beparin on the LE was noted. Group II (n=128) consistedof patients treated with chemotherapy(mostlyanthracycline). Low LE was noted in 4.7% (P=NS vs group 13. 17.2% showed suboptimal IQ (P<0.001 vs group I) despite a borderline normal binding (80-90%). Group HI (n=224) comprised elderly patients referred for evaluation of left venlricular function because of acute oncmmdor chronic heart failure.,dyspnoea..Low LE was found in 8.9% (p=0.002 vs first two groups),esw~ciallyin patients with severe acute disease,such as sepficaemia(p<0.C(X)I),with normalisationof the LE after improvement of the clinical condition.Suboptimal IQ was noted in 16.1%, lX~-ticularlyin patientswith tuna! failure,regardlessof their haematocritand haemoglobinvalues (P=0.001). In vivo labellingof RBCs is thus a good method in most cases. However,in elderlypatientswith severeacute diseaseor renal failtre, and in patientsUeatcd with chemotherapy,we recommendto use an in vitrotechnique.
Ettore Astorrl, Paolo Fiorlna, Annallsa Astorrl, Gllberto Gavaruzzl*, Gluseppe
Magnatl Cattedra dl Cardlologla, Unlversltb dl Parma, *Servlzlo di Medlcina Nucleate, USL 4, Parma, Italy Aim of this study was to compare by gated radionuclide angiography systolic and diastolic ventrieular function in insulin-depondent 0DDM) and in non insulin-dependent (NIDDM) diabetic patients, without overt cardiovascular disease, Study population eonsinted of 20 IDDM patients (15 m - 5f; 40.7 + 10.3 years) and of 14 NIDDM patients (9 m - 5f; 47.0 + 7.5 years). The duration of diabetes (DD) and glycosyhted hemoglobyn (HbA m ) were higher in IDDM patients. Ventricuhr ejection fraction (EF) and peak ejection rate (PER) were assessed by gated mdionuclide left ventficulography and were similar in the two groups of patients, while peak filling rate (PFR) resulted lower in NIDDM patients compared to IDDM patients. The PFR/PER ratio was near to the normal value (= 1) in IDDM patients, while in NIDDM patients it was reduced, HbAlc (%) ~D (yrs) IDDM NIDDM
PER s"t
PFR s "t
PFR/PER
9.5+1,3 8.2+1,7
15.9+8.7 61.3+7.7 3.45.'0.8 6.4+_3.6 57.6_+6.7 3.1+0.2
EF (%)
3.3+0.1 2.6_.~.8
0.99:t'0.16 0.84:s
p < 0.02
p < 0.001
n.s.
n.s.
p < 0.05
p < 0,02
The systolic performance was substantially similar in both IDDM and NIDDM patients. The ventricular diastolic filling was impaired in NIDDM patients, as shown by the decrease of PFR and particularly of the PFR/PER ratio. Our radionuclide data suggested that NIDDM versus IDDM patients, had a prevalent abnormality of ventricular diastolic performance, althought IDDM patients had higher values of DD and HbAlc.
P18-394
P 18-396
COMPARISON OF REGIONAL WALL MOTION AND GLOBAL LVEF ANALYSIS IN 99mTc-SESTAMIBI GATED SPECT, 99mTc-RBC MUGA AND VENTRICULOGRAPHY T. Leitha, M. Pruckmayer, M. Gwechenberger, A. Staudenherz, H. Bailer, G. I~onik; Univ. Clin. Nuc. Med. Vienna, LKA Krems
R E S P I R k ' F O R Y \'APdATIO.'," L","C O N S T R I C T I V E P E R I C A R D I T I S A S S E S S E D BY IL.kDION-t_TCLIDE .M\-GIOGP,,-K PHY
The correlation between ~ T r sestamibi gated SPECT (GSPECT) at rest (3-head LFOV gamma camera (Picker PRISM 3000), 360 ~ 20 steps, 6~ UHRPAR collimator, 64 x 64 matrix, 16 intervals, R-R acceptance • 10% base line value), planar 99"Tc-RBC multigated scan (MUGA) at rest (single-bead LFOV gamma camera (GCA901A Toshiba), 64 x 64 matrix, 24 intervals, R-R acceptance • 10% base line value) mad ventriculography (VG) during coronary angiography was assessed in 27 patients with CAD (15/27 patients had MCI, 13/27 patients had a positive stress test). Analysis of GSPECT was performed using the ,,3D Perfusion/Motion Map Software (Southwestern Medical Center, University of Texas), MUGA was processed by the New GMS software (V5.0; Toshiba Corp.). Visual analysis was performed independently for all studies by rating regional wall movement (3 = normal, 2 = equivocal, 1 = abnormal, 0 = severely abnormal) of eight myocardial segments (excluding the apex). Reliability analysis for the regional and global wall motion assessment by different observers was performed and revealed reliability coefficients for the intra-observer assessment of > 0.8 and > 0.95, respectively. Assessment of the regional and global wall motion in GSPECT correlated well with MUGA (LVEF: r = 0.68; p < 0.001) and VG (LVEF: r = 0.66; p < 0.001). 99~rc sestamibi gated SPECT analysis provides reliable data about left ventricular performance and information about regional myocardial perfusion in one single investigation and may replace planar 99~Fc-RBC multigated scanning at rest.
S99
Ian P. Clements. Lyle J, Olson, Mayo Clinic, Rochester. XlN" 17SA The purpose of IlLs study ~ a s to determine if l.espil-atol3, v,'u-iations in left ventricular filling could be detected in patients with constrictive peficarditis by r a d i o n u d i d e vemficulography. Using a nasal respirometer and additional electronics, eight patients, before and after peficardiectomy for constrictive peficm'ditis, had a gated blood-pool ventriculogram acquired during 200 first cardiac cycles after the onset of inspiration (INSP) and another with similar aquisition after the onset of expiration (EXP). Peak filling rate (PFR. end-diastolic volumes/sec), and time to PFR (lnsec) were measured. BEFORE AIa'TF, R
e~'se
z~
t\'sP
,i
l~.,a,
PFR '19+__.8+ 2.9+.7 3.4___6 ] ~ 6+1.3 TPFR 103+_27"+ 169+39 152+_20 ] 153_-57 p=,02 * firation vs explratlorl, v e vs after tTonchlsions: 1) With modification, radionuclide ventriculoo_raI)h~ can detect l'espirato~T variation in !el! ventrictdar fiflil{g in constrictive peficarditis. 2) T~is variation is seen as a shortened TPFR in inspiration. 3) Pericardiectomy abolished this variation.
W E D N E S D A Y P M A P R I L 2 6
S100
Abstracts Wednesday morning, April 26, 1995
JOURNAL OF NUCLEAR CARDIOLOGY March/April 1995, Part 2
P18-397
P 18-399
IMPROVED CONTRACTILITY OF VIABLE M'YOCARDIUM AFTER REVASCULARIZATION M E A S U R E D BY R A D I O N U C L I D E I M A G I N G
Withdrawn
Wemer Benzer, Heinz Fritzsche*, Manfred Kargl*, Department o f Cardiology and Department of Nuclear Medicine*, Landeskrankenhaus Feldkirch, Austria We studied the effect of revascularization procedures on hypoperfused akinetic but viable myocardium and their contribution to the ejection fraction (EF) after reperfusion. 12 consecutive patients had a significant coronary a r t e ~ stenosis with akinesia in the corresponding segment. Viable myocardium was formal with 201-T1 reinjection in each of these segments. Radionuclide ventriculography (RNV) was used to measure global and segmental EF at rest and during stress. Then revascularization procedures were performed (6 ACBP, 6 PTCA). After 10+/-3 months RNV was repeated. In 10 patients both global EF increased at rest and during stress (from 33+/-12% to 42+/-11% and from 31+/14% to 44+/-16%, p<0,02) and segmental EF in the viable segments (from 28+,'-18% to 38+/-21% and from 29+,"19% to 41+/-25%, p<0,05). Our results indicate that contractility of viable myocardium in hypoperfused segments improve after revascularization. This has also a significant effect on the global EF.
P 18-398
P 18-400
LEFT VENTRICULAR VOLUME CALCULATION. AUTOMATED TECHNIQUE APPLIED TO MULTIGATED RADIONUCLIDE ANGtOGRAPHY.
PRONOSTIC VALUE OF THE LEFT VENTRICULAR EJECTION FRACTION (EF) MEASURED BY RADIONUCLIDE ANGIOGRAPHY (RNA) DURING 1SOPROTERENOL (IPNA) STIMULATION IN DILATED CARDIOMYOPATHY (DCBA)
F. Godinho, G. Cantinho Instituto de Medicina Nuclear. Fac. Medicina de Lisboa, Hospital Santa Maria. Lisboa, Portugal
W E D N E S D A Y P M A P R I L
Although radionuclide imaging is a non invasive method widely used for evaluation of ventricular function and regional wall motion, left ventricular volumes are not determined routinely due to the additional steps required. We developed a count proportional method, based on the work of T. Massardo et at. for the measurement 0 f / e f t ventricular volumes applied to multigated radionuclide attgiography (R.NA). The equation Vt = 1.38 M~ R~a relates total chamber volume (Vt) to the area of a pixel (M) and the ratio of total counts within the chamber to the counts within the hottest pixel in the chamber. We investigated the accuracy of this method by comparing the left ventricular ejection fraction (LVEF) obtained from the telediastolic and telesystolic volumes to the LVEF automatically calculated in RNA, a parameter widely validated. We studied 100 patients. LVEF was also determined in 55, by echocardiography. The correlation value of LVEF derived from volumes with the automate LVEF was r = .88, and for echo LVEF r = .62. The mean values of LVEF from the 3 methods were: 42+12% (volumes LVEF); 44+13% for automated LVEF and 51+ 14% for ECHO LVEF. These results allow us to conclude that the automated determination of volumes by this method appears to be accurate, besides being quick, easy and with the advantage of not requiting blood sampling.
Ph, Przard, D. Obreja, J. J. Lejeune, Ph.Geslin, A. Tadei, P. Jallet, CHU Angers, France. Left ventricle performance changes during IPNA stimulation were monitored by RNA ~.n68 Patients (pts) with DCM an d E.F < .35 at rest ( mean : 23 _+8 %). During a mean follow-up of 3.8 • 3.3 years (1 to 12 years), 24 pts died, 4 pts had cardiac transplant, 2 pts were missed. Results : Univariate analysis : 3 variables were positively related to mortality : end diastolic Volume at rest (p < i001), EF during IPNA stimulation (p < .O31 ) and EF change between rest and IPNA (p < .05). Mortality was not related to aetiology of DCM and age. Multivariate analysis : the value of EF during IPNA stimulation was the unique signii:,cant variable related to mortality (Chi2 : 13.35, p < .(.~-I01) All pts with EF < .20 during IPNA stimulation but one died within 2 years. No pts with EF > .35 during IPNA stimulation died before 5 years. Pronostic value of EF during IPNA may be related to the fact that this indiee depend upon 3 factors : Value Of EF at rest (or severity of DCM), left ventricle contractile reserve presence and absence of severe ischaemia.
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday morning, April 26, 1995
S101
P18-401
P18-403
A "GEOMETRI(' - (:OLNI" BA~ED" (GCB) h~TI-IOD pI~I)R QUANTIFICATION OF LEFT VENTRICIJ~AR \;()LL~MES
EFFECTS OF REST AND EXERCISE ON CARDIAC VOLUMES DETERMINATIONS BY COUNT-BASED METHOD FROM Tc-99m-HSA AND Tc-99m-RED BLOOD CELLS GATED VENTRICULOGRAPHY
M. Veljovic, V. Bosnlakovic, D. Markovic. D. Sobic, S Pavlovi4, N K 6 ~ Y 6 ~ C T S ~ i c . Institute of Nuclear M6dicine, CCS, Belgrade, Yugoslavia 'An orimnal method for quantification of left ventricular (LV) voltan6" based on rhdionuclide ventricum~apny was developed. COunt based data were combinea with the geome[ric based ones assuming a prolate ellipsoid LV shape (with identical short axes). The following equation for computing LV volume was developed. V = 2 * M 2 9 D * Ccot/Cmax
(1) where:
V = LV volume (cc) M = Calibrated pixel size (cm): Ctot = Total counts in LV ROI (cts)3 Cma.x ='Maximum pixel counts in LV ROI (cts); D = "ROI" drawn short axis of prolate ellipsoid in LAO 45 (cm). Physical experiments wit5 heart shaped phantoms were used to compare OCB with the method assuming a ball LV shape CBLV) developed by Massardo et al. The true volumes of cylindrical and ellipsoid phantoms of t 12.5 cc and of 190.5 co, were computed to be 114 cc and 196 cc by GCB and 168 cc and 180 cc by B L V . respectively. Seveh normals (EF=61.14 _+ 3.02%) and 6 pt.4 wit,/ dilatd~d cardiomvopathy (DClvl) (EF=31.3 :_~ 7 . 6 % ) w e r e studied. Mean values of end diastolic LV volume (EDV), stroke volume (SV) and cardiac output (CO) in nonfials aS cardiac indices (C I) were found to be 60.85 • 5.93 ml /mz : 36.85 _+ 4.48 ml/m2 and 2.35 ~_:(3.52 1/mimm2 . respectivelv.in DCM pts CI values ofEDV. SV and CO were: 1"14.2 +_4 3 7 ml m2 , 32.'8 +_ 13.5 ml/m2 and 2.64 • l/min/m2 , respectively A good correlation of (GCB) method was obiainedwith gated Blood pool SPECT (r=090, tot EDV) and contrast ventricuk~graphy (r=098, for EDV).
Topuzovic N, Rusic A, Brlosic R, Krstonosic B, Karner I Dept. Nuclear Medicine, Clinical Hospital, Osijek, Croatia The aim of this study was to investigate the changes in blood activity dudng rest, exercise and recovery penods and its influence on cardiac volume. 13 patients underwent radionudide ventdculography with Tc-99m-HSA (Group I), and 17 patients with Tc-99m-labeled red blood cells (Group II) for clinically indicated rest-stress studies. Left ventncular volumes were determined by a count-based method using corrected counts rate in blood samples obtained dunng rest, peak exercise and after recovery. In Group I at stress, the blood activity decreased 12.6 + 5.4 % (p< 0.05) compared to the rest level, and increased 25.1 + 6.4 % (p< 0.001) above resting in Group II. This had a profound effects on cardiac volumes determinations if only rest blood aliquot was used: during exercise the cardiac volumes Significantly decreased adiflcially in Group I (22.1 + 9.6 %, p<0.05), but in Group II was signit'r overestimated (32.1 + 10.3%, p< 0.001). The changes in blood activity between the stress and recovery were not significantly different for both Group. In conclusion, taking only one blood sample as aliquot in rest-stress studies lead to erroneous estimation of cardiac volume due to significant changes in blood radioactivity dudng exercise.
P18-402
P18-404
CONTINUOUS MONITORING OF LV FUNCTION DURING EXERCISE: A PRELIMINARY STUDY OF REPRODUCIBILITY. Cioglia G, L a i C, M e r c u r o G, M a n c a MR, Cherchi A. I n s t o f C a r d i o l o g y , Univ of Cagliari, Italy The cardiac response to exerclse was assessed with an ambulatory ventricular function monitor (VEST), in 13 patients with stable angxna pectoris. Data recording started while the subjects sat quietly o n b i c y c l e ergometer a n d c o n t i nued during maximal symptom-limited exercise. After 1 hour of rest, the stress test was repeated. In 9 subjects the exercise was repetead the day after. We studied left ventricular e3ection fraction (EF), r e l a t i v e end diastolic and systolic volume (EDV, ESV), relative cardiac output (CO). rest 20% 40% 60% 80%100% 2R 5R EF exl 49 51 52 51 48 45 59 59 ex2 51 53 54 55 53 47 59 61 day a 48 51 53 50 47 41 59 59 day b 47 52 55 54 52 42 58 62 No statistically significant differences were observed between EF measured during the first and the second exercise a n d in d i f f e r e n t days.
R A D I O I S O T O P I C E V A L U A T I O N O F A D R U G E F F E C T O N LEFT VENTRICULAR FUNCTION:
Does peHndopril improve the left ventricular function in pa//ents with congestive heart failure ? A.E.Deamrgah M.D.*, t, Bernay M.D. *, T.Ba~o~hi M.D.*, E . Oncel M.D. ** O. SaC.an M_D.**. Departmmts of Nuclear Medicine*~d Cardiology**, Facility of Medicine, Ondokuzmayxs University, S ~ , TURKEY The aim of this study was to investigate the effe~ of perindoprfl which is an ansiote~asin-convertin 8 enzyme inhibitor on lea't ventrioalar function in patients with congestive heart failure (CH:F). A total of 15 patients with CHF ( New York H e , ~ Association Class 2 - 3 ) (range: 36 - 68 yrs : mean age: 52.3 :t: 4.2 yrs ) were exmnmed using radionuclide ventriculography (RNV) and edaoc~dibsraphy (EC) . /Mter a baseline RNV and EC were madeataken , the patients Were treated with 75 nag ( 3 x 25 m 8 ) pea'indopril orally per day. EC and RNV were repeated eight to twelve weeks after the onset of the therapy. The calculated mema left ventrioxlar diastolic attd systolic fimctlon values on RNV before ~ald a f ~ treatment Were ; Ejection fractlon (%) 35.14 • 1.54 to 36.5 :t: l.86 ( normal values = >= 50 % ) , Peak filling rate ( E D V / s e c ) 1.44 • 0.16 to 1.84 • 0A8 ( normal values = 3.3 • 0.6) , Time to peak filling ( msec ) 330 • 7.1 to 280 • 18 ( normal values = 136 • 22), Peak emptying r u t e ( E D V / s e c ) 1.707 :e 0.071to I.77 • 0.13 ( n o r m a l v a l u e s = 2.7:i:0.5), Time to peak emptying ( ~ ) 280 • 7 to 260 • 5 ( normal values = 182 • 44 ) . The ejection fraction values measured on EC were : 31.57 9 2 . 2 1 % to 32.45 -i: 2.64 % . There was not a signific,,mt ditference between the pre- sad post-treatment ejection fraction values with both methods ( p > 0.05 ). The peak filling and eantayin 8 p~ameters measured on RNV before mid after treatment were also not si~aificsmtly different ( p > 0.05 ) . In conclusion, both RNV and EC deanonstrated that there was no lmprovemaent in left ventr~.cular ejection fraction aRer perindopril treatment. The systolic ~md diastolic peak filling parameters calculated by RNV confirmed the absence ofldt ventricul~ function improveanent.
S102
Abstracts
JOURNAL OF NUCLEAR CARDIOLOGY
W e d n e s d a y m o r n i n g , A p r i l 26, 1995
P 18-405
P18-407
PRESSURE-VOLUME LOOPS OBTAINED AT EQUILIBRIUM BY SIMULTANEOUS ACQUISITION OF LEFT VENTRICULAR PRESSURE CATHETERISATION AND GATED BLOOD POOL RADIONUCLIDE DATAS.
C O R R E L A T I O N B E T W E E N L V E F D E T E R M I N E D BY G A T E D EQUILIBRIUM RADIONUCLIDE VENTRICULOGRAPRY AND FIRST-PASS R A D I O N U C L I D E A N G I O G R A P H Y U S I N G A N E W TWO-REGION-OF-INTEREST METHOD AND A M U L T I C R Y S T A L CAMERA.
Adolfo Facello, Andr6 Constantinesco, Luc Mertz, Laurent Tritsch, Jean-Pierre Monassier, Joseph Elias, Bernard Brunet, Pierre Bareiss. Hopital E. Muller, Mulhouse, FRANCE. Pressure-Volume (PV) relationship is an important element to appreciate LV function, XRay angiography has some technical limitations and cannot be used routinely in this way. We developed an instrumentation to obtain PV loops using a double system o f simultaneous acquisition. LV P values are measured using an intraventricular pressure probe connected to an analog to digital converter board in a PC. At the same time, LV V values are obtained by a standard LAO gated blood pool radionuclide technique at a temporal resolution of 20 msec/frame. Both acquisitions are simultaneously triggered to the same ECG signal using an acceptance window of +/- 5% of mean RR interval. Absolute LV end diastolic V, measured by blood pool GSPET, is used to normalise LAO V curve. Overall procedure takes about 40 min and averages 400-600 cardiac cycles. We applied this technique in pts with CAD. Good quality and reproductible PV loops were obtained in 6 pts. This methodology could be a promising technique to explore LV function.
P M A P R I L
S. Jones, T Sateman, C. Sarnhart, M. Sanders, J. O'Keefe. Univ of Missouri at Kansas City, Kansas City, MO, USA. Quantitative LVEF measurements from multiple gated equilibrium radionuclide (MUGA) scans are accurate, reproducible, and highly useful clinically. A portable multicrystal (MC) camera (Scinticor) has the potential for measuring LVEF more rapidly (first-pass (FP) technique) and in diverse situations (peak exercise). However, MCFP-LVEF has been shown to underestimate MUGA-LVEF. To determine whether a new quantitative algorithm using separate end-diastolic and end-systolic regions of interest could overcome this shortcoming, 79 consecutive pts (57 males, mean age 63 yrs, 62 known CAD, 48 prior MI) underwent a rest FP study immediately followed by a 6-minute 45 ~ LAO MUGA scan (Siemens Orbiter interfaced to Microdelta computer). MUGA-LVEF ranged from 16% to 63% (mean 43+12%) vs MCFP-LVEF 24% to 76% (mean 51• The correlation coefficient was 0.87 with slope 0.77 and y-intercept 4.3. MUGALVEF was slightly lower than FP-LVEF in all but 3 patients. CONCLUSION: In comparison to MUGA-LVEF, MCFPLVEF using a 2-region-of-interest method is strongly correlated and slightly higher at all levels of left ventricular function.
P18-406
P18-408
ACCURACY OF LVEF DETERMINATION AND LONGTERM MONITORING OF LEFT VENTRICULAR FUNCTION WITH A NON-IMAGING DETECTOR
Mats Sensen-V,'st~%~ ~orglu-d 2 , Fr~0rio Bouvior ~, ~,mart ~oreeldt 3 ,
(CARDIOSCINT).
W E D N E S D A Y
M a r c h / A p r i l 1995, P a r t 2
Tommi Be Lindhardt, Niels Gadsb~ll, Biger Hesse. Rigshospitalet, University of Copenhagen. Agreement between LVEF determined by radionucleid angiography(RNA) and LVEF measured with the Cardioscint probe was assessed in 26 p a t i e n t s w i t h a w i d e r a n g e of L V E F v a l u e s . Also, c o n t i n u o u s longtime monitoring (186 m i n . ; 5 3 - 2 4 5 m i n . ) of L V E F were performed in 17 p a t i e n t s w i t h s t a b l e ischaemic heart disease. Results: The regression equation between LVEF_NA a n d LVEFcardiescin t w a s : Y = 1 . 0 5 X + 0 . ~ 2 ; R = 0 . 8 5 ; SE = 0 . 0 9 . During longtime monitoring fluctuations in L V E F a 0 . 1 0 w e r e r a r e . L o w e s t L V E F values were recorded a r o u n d 12 a . m . Conclusion: LVEF can be determined with reasonable accuracy using the non-imaging Cardioscint system. Longterm monitoring with the Cardioscint suggest a diurnal variation in L V E F w i t h a t r a n s i e n t early afternoon decline in L V E F .
HEMODYNAMICRESPONSESTO EXERCISEIN RUNNERS Anders3 Juhlin-Dannfeit , Mohsen Nejat , Bengt Saltin , and Lars-]kke Bredin 9 ]Departments of Clinical Physiolggy, Si~ders]ukhttset,188 83 Stockholm, 2 I nernal t Medicine, Karolittska Hospital, ~Thoracic Physiology, Karolinska Hospital. and 4pharmacology and Physiology IlL Karoliaska I~tilute, Stockholm, Sweden. We have studied the hemodynamic responses to exercise by means of nuclear angiocardiography. Fifteen elite middle- and long-dlstance runners were studied at rest and during incremental exercise. H e m rate increased linearly during exercise. Ejection fraction (EF) was 64 % at rest and increased to 70 % at the transition to exercise (100 W). There was an additional increase in EF with rising work intensity to 74 % at 200 W. Left ven~cular end-dins:nile volume (LVEDV) increased 17 % at the transition from rest to exercise. Together with EF values this resulted in an increase in stzoke volume with 27 %. With increasing work intensity, LVEDV
tendedto decreasewith the 200 W valuebeing 5.4 % lowerthanthe I00 W value.As EF increasedabout the same magnitude with risingwork intensity,strokevolume was preservedwithsimilar100 and 200 W values. Consequently,cardiacoutput(strokevolume 9heartrate)increasedlinearly with increasing work intensity. As the increase in stroke volume at the transition from rest to exercise was paralleled by an increase in LVEDV it could be due to the Frank-Starling mechanism. During increasing exercise intensity LVEDV decreased. Nevertheless EF increased keeping stroke volume constant. The increased EF must consequently be due to a true increase in myocardial contractility, probably related to increased catecholamine levels. Due to high EF values at rest, 5 of 15 athletes did not fulfil the conunonly used criterion of a 5 % increase in EF during exercise. This shows that concern must be taken to resting values and evaluation cannot solely depend on changes between rest and exercise values.
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday morning, April 26, 1995
P18-409
P18-411
Hea~ rate performance curve, heart ratethreshold, la~ate anaerobicthreshold and LVEF measured by RNVS
LEFT VENTRICULAREJECTION FRACTION AND PARAMETERS AT STRESS AND REST IN PATIENTSWITH DIFFERENT HEART DISEASES
S103
Traute Mende,S Conrad P. Hofmann, R. Pokan, K. Preidler, H. Leitner, B. Eber, M. Schumacher, F. Fruhwald, R. Zweiker, W. Klein. Inst. Sports Sciences, University of Graz, Austria
Clinic of Nuclear Medicine,MartinLuther University HalleWittenberg,FRG
The heart rate/performance curve (HRPC) is usually S-shaped but flattening at the top is not always the rule. By means of radionuclide ventricular scintigraphy, the left ventdcular ejection fraction (LVEF) as well as the behaviour of HRPC was investigated in graded cycle ergometry. A significant negative correlation (r=0.673, P<0.01) was found between the existence and extent of the HRPC deflection and the stress-dependent myocardial function, expressed as the deflection from the LVEF/performance curve. Heart rate threshold (HRT) and the drop of LVEF were both significantly related to lactate turn point. Due to the absence of a deflection of HRPC, HRT could not be obtained in all cases. This absence of a HRPC-deflection was related to a diminished stress-dependent myocardial function.
The aim of our investigationswas the search for differences of typical values of ejection fraCtion(EF)andits parametersin different heart diseases.We investigated 148 patients,38out of them suffering from myocardial infarction(MI),64from chronic coronary disease(CCD)and 12 from dilatativ cardiomyopathy(CMP).Ejectionfraction (EF) and parameters were measured by means of gated radionuclide ventriculographyat stress and rest. Most messagedparametersare besides EF,peak filling(PFR)and ejection rate(PER) also activ and passiv filling time(AF,PF).AF and PF show the most significant differences in all groups of diseases. TABLE 1: EF,AF and PF in patients with MI,CCD and CMP. Parameter MI CCD CMP rest stress rest stress rest stress n 38 14 64 40 12 5 EF(%) 55 56 59 68 50 52 AF(ms) 139 139 176 137 164 128 PF(ms) 285 234 307 225 278 258 ConclusionThe estimation of EF and their parametersmay be helpfull in the diagnostics of MI,CCO and special of CMP.
P18-410
P18-412
RNVS MEASURED EXERCISE DEPENDENT LVEF RELATED TO AEROBIC AND ANAEROBIC THRESHOLD IN PATIENTS AFTER MYOCARDIAL INFARCTION AND HEALTHY SUBJECTS
RESPONSES OF EJECTION FRACTION TO DYNAMIC AND STATIC EXERCISE:EVALUATION BY RADIONUCLIDE VENTRICULOGRAPHY ~.Stamenkovi~ ,N.Dra~ni~ ,M.Prvulovi~,Lj.Stefanovi~ and S.Gruji~ Institute of Cardiovascular Diseases,Faculty of Medicine Novi Sad,Yugoslavia In twelve patients with normal coronarography performed with suspicion to coronary occlusive diseases,the global ejection fraction of the left ventricle (GEFLV) in static (handgrip) and d ~ c exercise test on the bicycle and Isuprel (isoprotorenol) was followed up. In twenty-one patients with coronary occlusive disease, six of them with aorto-coronary by-pass grafts, GEFLV changes were followed by the same exercise principle. In persons with normal coronarography at the exercise test on the bicycle GEFLV increased for 8% (rarge from 6% to 12%). After the application of Isuprel it increased for 9% (range from 7% to 13%). GEFLV did not vary with static exercise. In patients with coronary occlusive disease GEFLV significantly decreased both in static and dynamic exercise. At dynamic exercise test on the bicycle GEFLV decreased from approx. 53.2% to approx. 41,1%. When Isuprel was applied by infusion in patients who could not undergo the exercise test on the bicycle the similar results were obtained. In six patients, five of them were operated on and suffered from the same anginal discomforts, GEFLV decreased from approx. 56.5% to 46.7%.
R.Pokan, P.Hofmann, F.Beaufort, K.Preidler, M.Schumacher, F.M.Fruhwald, R.Zweiker, B.Eber, R.Gasser, P.Schmid, D.Brandt, and W.Klein. Dept. of Int. Med., University of Graz, Austria 21 male patients (MI) after myocardial infarction were compared to 17 healthy control subjects (C) of the same age and 15 young sports students (S). LVEF increased continously from resting values up to anaerobic threshold (ANT) both in S and C. Between AnT and maximal work performance (Wrn=,) S showed a plateau and C showed a decrease in LVEF, contrary to MI who showed an increase from resting values (46+10%) up to aerobic threshold (AeT) (54+11%), a plateau between AeT and AnT (51+13%) and a decrease down to 46+15 at Wr,=. This change at AnT was independent of groups at the same percentage of Wm,x. LVEFrnaxvalues were measured during the first 90 seconds of recovery in MI (61+16%) as well as in C and S, which are not representative for load dependent myocardial function. A significant ST-segment change with exercise was only found in MI in six cases. Corresponding W to ST-segment changes were significantly related to W at AnT. For an entire evaluation of a patients exercise dependent myocardial function a LVEF-measurement is recommended at rest, at AeT (50% W ~ ) , AnT ( 75% Win=,) and 100% Win==.
S104
Abstracts Wednesday morning, April 26, 1995
P19-413
P19-415
EXERCISE THALLIUM-201 SCINTIGRAPHY IN HYPERTROPHIC CARDIOMYOPATHY J Candsll, J Pslet. J Castell*, S Aguadd*. P Blanch. B Romero. E Galve, A Garcia-Burillo*. J Soler Soler. Servicio de Cardio|og[a. Servicio de Mediclna Nuclear*. Hospital General Universitari Vail d'Hebron. Barcelona.
Comparison between fatty acid metabolism and myocardial perfusion in patients with hypertrophic cardiomyopathy.
Some studies nave suggested that the finding of ischasmia in exercme perfusion scintigraphy could be predictive of unfavourable outcome in hypertrophic cardiornyopathy. To assess such hypothesis; 73 consecutive patlents with hypertrophic cardiomyopathy were investigated. }n all of them echo-DooDler study and perfueion scintigtaphy had been performecl. Hotter monitoring, radionuclide ventriculography and cardiac catheterization w=th coronary angl0graphy were performed n 60, 47 and 18 patients, respectively. The mean follow-uo time from the diagnosis was 6 years {'~-24~ Results: 4 2 % of patients had perfusion defects [anteroeeotal in 15. apical in 10 and inferoposterior in 22). There was no significant difference in clinical parameters and the remaining studies between patientes with and without perfus{on defects. 201TI + ( n = 3 1 ) 201TI- (n=42) V. ~sot: EF V I < 5 0 11 (35 % ) 18 (43 %) Holter: Vent. Tach 3 (10 %) 3 ( 7 %) VPC/24h>5OO 6 (19 %) 3 ( 7 %) A-V Block 1 ( 3 %) 1 ( 2 %) Echo-Doppler: Obstruction 14 (45 %) 2 0 (48 %) Clinical Parameters: Dispnea 21 (68 %) 31 (74 %) Angtna 8 (25 %) 7 (17 %) Syncope 3 (10 %) 2 ( 5 %) Card. failure 3 ( 1 0 %) 6 (14 %) Infarction ' 2 ( 6 %) 1 ( 2 %) Death 3 (10 %) 1 ( 2 %) Coronary Angio: 10 ( 2 4 %) Normal 5 (16 %) Abnorma 2 (6%) 1 ( 2 %) Conclusions: In patients with hypertrophic cardiomyopathy, there are no differences in clinical data and data from other studies between those with scintigraphy perfusion defects and those without.
W E D N E S D A Y P M A P R I L
JOURNAL OF NUCLEAR CARDIOLOGY March/April 1995, Part 2
Y Ohtake, A Moriguchi, I Adachi, I Narabayashi, M Suwa, Y Hirota, K Kawamura. Osaka Medical College, Japan. Both TI-201 exercise loading myocardial scintigraphy and 1-123 BMIPP myocardial scintigraphy were performed in 28 patients with hypertrophic cardiomyopathy(HCM) including I obstructive type, 15 asymmetrical hypertrophic type, 10 al~ical hypertrophic type and 2 dilated stage The radioactivity in the five segments (anterior, septaL apical, posterior and lateral) was assessed qualitatively. The results from both T1-201 exercise loading myocardial images(EX and RE) and 1-123 BMIPP myocardial images (BM) are scored according to the following scales: 0, perfusion defect; 1, notable defects~ 2, clear but modest defects; 3, normal; 4, hypertrophic uptake. BM showed modest defects in all cases without perfusion defects at both EX and RE. BM showed large and notable defects in 5 cases, in spite of perfusion defects at EX only in 6 cases. In 17 cases of perfusion defect at both EX and RE, BM had larger defects than that of EX or RE in 11 cases. Totally defect size of BM is larger than that of EX(17/23, 74%) and RE (11/17, 65%). And BM shows modest defects or notable defects with or without the evidence of myocardial perfusion defects in EX or RE (28/28, 100%), independently of the type of HCM. These data suggests that (1) there is a slight or marked decline in the fatty acid metabolism in all patients with HCM, (2) decreased fatty acid metabolism takes precedence over the myocardial ischemia.
P19-414
P19-416
CLINICAL IMPLICATIONS OF ABNORMAL SEPTAL UPTAKE OF 123I_ BMI PP IN PATIENTS WITH HYPERTROPHIC CARDI OMYOPATHY
Pseudo-normalization of Diastolic Function Detected in Ventricular Volume Curve is the Significant Predictor of
Ta tsuya Kamada, Motoi Morota, Me gumi Matsumoto, Ichiro Harada, T a k e s h i Watanabe, Y a s u h i k o Kobayashi, Y o s i k a z u Nagai, C h i h a r u Ibukiyama. Tokyo Medical College, Tokyo, JAPAN .
H Kobayashi,R Asano, K lmamura, Y Ikkatai, K Kusakabe S Hosoda, Tokyo Women's Medical College. Tokyo, Japan
Reduced patients
septal uptake of I~3I-BMIpP in with hypertrophic cardi omy opa %by HCM) was investigated in relation to is 9hemia. z23I-BMi PP scint igr aphy, exercise 2~ sc int igr aphy, echoc a r d i o g r a p h y and c o r o n a r y a r t e r i o g r a p h y (CAG) were p e r f o r m e d on 14 HCM patients presenting with asymmetric Septa i hyper trophy (ASH) . De f ect BMIPP scores (D S) Were calculated from images, r e v e r s i b l e d e f e c t scores (KS) from TI images and s q u e e z i n g scores (sqs) from CAG. The p a t i e n t s Were d i v i d e d into two groups, group N w i t h o u t low septal u p t a k e 'of BMIPP and group P w i t h low septal uptake, and RS, septal wall t h i c k n e s s a n d SqS were compared between them. Abnormal septal u p t a k e of B M I P P was n o t e d in 9 patients. Re, septal wall t h i c k n e s s a n d SqS were all significantly higher in group P than in group N. There w a s a p o s i t i v e c o r r e l a t i o n b e t w e e n DS on the one h a n d a n d KS a n d SqS on the other. The r e s u l t s of this study suggest that m y o c a r d i a l ischemia is a s s o c i a t e d w i t h abnormal septal u p t a k e of B M I P P
Poor Prognosis in Patients with Dilated Cardiomyopathy
To assess the prognostic value of pseudonormalization of diastolic function in patients with dilated cardiomyopathy (DCM), left ventricular volume curves of radionuc de ventriculography were analyzed i n 5 3 DCM patients with LVEF<30%. All cases were studied radionucl de ventriculo-graphy in medically controlled Condition. 1/3 I ng fraction (I/3FF) were evaluated in left ventricular volume curve, and patients were divided into 2 gi,oups accord ng to the 1/3FF results; Group A: i/3FF>35%, psedo-normalization of left ventricular diastolic function (N=23), Group B: 1/3FF<35%, decreased left ventricular diastolic function (N=30). Survival curve
was analyzed using Kaplan,Meier method. Prognostic value of 1/3FF was compared with other prognostic indices: X-ray cardi0-thoraCic ratio NYHA grade, LVEF, echocardi0graphic M mode data. Mean survival duration n group A (1.8=~-0.6 years) was significantly shorter than that in group B (5.0-*0.7 years). One year and 2 year survival rate in group A were 42% and 25%, respectively: Degree of mitral valve regurgitation was not correlated with I/3FF. I/3FF was the most valuable prognostic predictor in these prognostic ~indiCes. Conclusion: Pseudo-normalization of diastolic function detected in ventricular volume curve is the significant predictor of poor prognosis in patients with DCM.
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday morning, April 26, 1995
$105
P19-417
P!9-4!9
EVALUATION OF CARDIAC SYSTOLIC AND DIASTOLIC FUNCTIONS IN PATIENTS WITH AMYLO!DOSIS
b123 MIBG MYOCARDIAL UPTAKE AND WASHOUT IN PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY (HCM): COMPAR!SON OF TWO TyPES OF HCM.
E. Ozalp, NO. Kt~tik, H. Ya~oo~lu, E ibis, A. Akin, G. Efl~ay Ankara Unive~ity Faculty of Medicine DePartment of Nuclear Mcdicfne 06100 ANKARA/TI]RKiYE
Hirotaka Maruno, Sugao Ishiwata, N0buyuki Komiyama, Masahisa Onoguchi, Hajime Murata. Toranomon Hospital, Tokyo, Japan.
It was reported that amyl0idosis (ALD) cor!mionly involv~ .the heart besides involvement of different organs a,ld Cardiac involvement is the cause of death in about 50% of patient (pts). Rest Radionuclide Ventriculography (RV) Echocardiograpby (ECHO) were pedbrmed in i4 pts(mean age:39.7+_8) with ALD and 6 n0rmaJ'volunteers (mean age:35.6-+7) without any cardiac or systemic disease to evaluate of the systolic (Ejection Fraetion-EF, wall motion) and diastolic (Peak Filling Rate-PFIL Time to Peak Filling-TPF)functions. Wail motion was found normal in 11 pts with ALD and ta normal volunteers while abnormal m 3 pts with ALD, on both of RV and ECHO. The systolic and diastolic parameters were obtained as in fbllowingtable: Cn-oupl(n:6) Group2(n:l l) Group3(n:3) EF 57.1+_4.4 O4.1+10.7 36.6_+1.5 PFR 3.37_+0.8 297+063 1.97_+0.32 TP 119.6+'tL2 155.7_+29 1606_+19 (,(iroupI:nomla~%~hol~p2!Al.l) witlx~ut":,allmotitvnabnormalttics,(~up3:Al.I)v,lth wall motionabnorn!a!itl::~). As seen ~ the table, there are significantlyprolonged TPF and decreased PFR in pts with ALD (p<0.01). It is concluded that, in pts with ALD, diastolic functions are impaired before than systolic functions, and evaluauon of diastolicfunctions w~thRV is very sensitivetbr detection of early cardiac involvement in pts with ALD
Myocardial SPECT images using 1-123 metaiodobenzylguanidine (MiBG) were assessed in tWO types Of HCM(14 patients With asymmetric septal hypertrophy ( A s ~ and !0 patients with apical hypertrophic cardi0myopathy (APH)) and normal control subjects (n=8). After injection of I-!23 MIBG, SPECT imaging was performed 15 minutes (early image) and 4 hours (delaye d image) later. The left ventricular (IV)wall was divided into5 segments and myocardial uptakes were scored Visually (0:absent, hseverely reduced, 2:moderately reduced, 3:mildly reduced, 4:normai). Washout rate o f myocardium from early todeiayed images was calculated using bull's eye method. All patients and control subjects underwent TI-201 SpECT or C-11 acetate PET and no peffusion defect was found at rest. O n early images in APH, uptake score in the hypertrophied apex was lower than those in the other segments 0.30 vs. 3.50-3.80), however, in ASH, uptake score in hypertrophied septum was not reduced. Washout rate (WR)of entire LV myocardium was significantly increased in ASH compared with APH (42.7+18.2% vs. 29.9 +8.61%, p<0,05). In ASH, WR was increased in both hypertrophied and nonhypertrophied segments (39.8• vs. 34.74-21.5%, NS): in contrast, in APH, the WR in hypertrophied apex was much increased(43.7+10.4%) but WR in n0nhypertrophied segment was similar to that in normal control (12.8+9.24% vs. 11.3 49.18%, NS). These results suggest that APH is different from ASH with respect to cardiac sympathetic nervous dysfunction.
P19-418
P19-420
DISTINCTION MYOCARDIAL ROLE OF
BETWEEN PHYSIOLOGIC AND PATHOLOGIC HYPERTROPHY IN ATHLETES: POSSIBLE m IN-ANTIMYOSIN ANTIBODY STUDIES.
Ignasi Carri6, Ricard Serra-Grima, Maite Subirana, Lluis Berne, Montserrat Estorch, Antonio Bay,s. Hospital de Sant Pau, Barcel0n a. Ventrlcular wall thickness within a range compatible with patho!ogic cardiac hypertrophy is sometimes seen in h~ghly trained athlete s . In this case, differential diagnosis between physiologic and pathologic forms of myocardial hypertroPhy may be difficult. Identification O f myocardial damage could provide a clue for the final diagnosis of pathologic hypertrophy, We performed HIIn-antimy0s!n (AM) studies 9in 12 athletes with left ventricular Wall thickness >-13 nun at echocardiography. Twelve athlete s With wall thickness in the range o f physiologi c ~ardiac hypertrophy (11,12 nun) compOsed a Control group. In addition, !UIn-AM studies Were performed i n I0 patients with hypertrophic cardiomyopathy. In the Control group, AM studies Were normal in 10 athletes and showed minimal antimyosin uptake in 2. Heart to lung ratio (HLR) was 1.47• In the group of athletes with ventricular wall thickness >13 nun, AM studies were normal in 2 athletes and showed positive AM uptake in i0 (p<0.01). HLR was 1,70• (p<0.01). Positive AM uptake was observed in all patients with hypertrophic cardiomyopathy. HLR was 1.87+0.16 (p<0,001). A M studies may be helpful in distinguishing between physiologic and pathologic forms of myocardial hypertrophy.
123I-BMIPP S P E C T I M A G I N G IN H Y P E R T R O P H I C CARDIOMYOPATHY IN R E F E R E N C E TO SEPTALFREE WALL JUNCTION OF LEFT VENTRICLE M a t s u m u r o A, Miyao K, Kuribayashi T, Hibino Y, K a w a h a r a A, T a n a k a T, Tsuji H, Kitamura M Kyoto S e c o n d R e d Cross Hospital, Kyoto, Japan Fatty acid myocardial imaging using 12Sl-betamethyl-iodophenyl pentadecanoic acid (BMIPP) w a s performed o n 18 patients with asymmetric septal h y p e r t r o p h y (ASH), 12 with apical h y p e r trophy (APH), a n d i0 with hypertensive heart disease (HHD). O n the short-axis SPECT, w e addressed attention to the defect in the anterior a n d posterior junctional areas (AJ & PJ) in addition to the rout~_ne 9 segments (seg). In the 9 seg, the defect w a s mainly o b s e r v e d in apical (67%) a n d inferobasal (61%) seg of ASH; in apical seg (100%) of APH; a n d in <30% of e v e r y seg of HHD. As to the junctional areas, the defect w a s predominantly distributed there in A S H (73% of AJ, 61% of PJ), but lass in A P H (42% of AJ & P J) a n d H H D (13% of AJ, 30% of PJ). In general, the defect of B M I P P w a s larger than that of 2~ in these diseases. T h e characteristic defect of B M I P P in A S H m a y reflect the pathologic finding that disarray is most m a r k e d in the AJ a n d PJ in A S H ( A m J Cardiol 1992;70:1333).
S106
Abstracts W e d n e s d a y m o r n i n g , A p r i l 26, 1995
P19-421
P 19-423
POSITIVE INDlUM-III-MONOCLONAL ANTIMYOSIN IMAGING IN DILATED CARDIOMYOPATHY PREDICTS A FAVORABLE OUTCOME
THE CHARACTERISTICS OF 1231-MIBG SCINTIGRAPHY APPLIED TO LEFT VENTRICULAR PRESSURE OVERLOAD DISEASES Y Ikkatai, H Kobayashi, K Niki, K Kusakabe, S Hosoda Tokyo Women's Medical College, Tokyo, Japan
d. Nanas, J. Lekakis, Z. Margari, V. Prassopoulos, L Palazis, N. Kouvelas, E, Agapitos, P. Kostamis, S. Moulopoulos. "Alexandra" UniversityHospital,Athens,Greece.
W E D N E S D A Y P M A P R I L 2 6
JOURNAL OF NUCLEAR CARDIOLOGY M a r c h / A p r i l 1995, P a r t 2
The purpose of the study was to identify the relation of positive antimyosin scan to myocardialfibrosis (MF) and responseto medical treatment. Seventeenpatients (pts, 13M/4F)43• yrs sufferingfrom idiopathic cardiomyopathy diagnosed by endomyocardial biopsy, underwentantimyosinscan, clinical and hemodynamicevaluationand quantitative estimation of the MF. In 9 pts (group A) the antimyosin uptake ratio in the cardiac and right lung regions (H/L) was >_1.6 (2.0+0.35) and in 8 pts (group B) <1.6, (1.43+0.05, p<0.005). The durationof heart failure symptoms in group A was 30+34months and in group B, 18+19 months (p=NS). There was no clinical or hemodynamicdifferencebetweenthe 2 groups. The proportion of MF was 7.6+5.3% in group A and 3.6+2% in group B (p=NS). NYHA functional classwas reducedby medical treatmentby 1.5+1.2in group A vs 0.4+0.5in group B (p<0.05).Therewere 2 deathsin group B and none in group A. In conclusion, these data suggest that even long standing dilated cardiomyopathy might give a positive antimyosin imaging independentof the level of MF. A positive antimyosin scan predictsfavorableresponseto medicaltreatment.
The purpose of this study was to clarify the characteristics of 1231-MIBG scintigraphy(MIBG) in left ventricular pressure overload diseases. Method: MIBG scintigraphy was applied to 11 pts with aortic stenosis (AS), 15 pts with hypertrophic obstructive cardiomyopathy(HOCM), 11 pts with hypertrophic cardiomyopathy (HCM), and 10 controlled pts(C). Initial myocardial uptake (%MU), myocardial clearance (MC) and heart to mediastinum activity ratio(H/M) were observed in delayed planar image. Results: %MU was higher in AS (1.92+ 0.46%) and HOCM (2.27+ 0.47%) groups than in HCM (1.61+ 0.29*/,) and control (1.60• 0.21%) groups. MC was higher in the AS (39• HOCM (37•176 and HCM (28• groups than in the control group (19• H/M of AS, HOCM, HCM and C were 1.87• 2.09• 1.98• and 2.29• respectively. %MU therefore was higher in the pressure overload state pts (AS and HOCM). In the case of AS,positive correlation was observed between pressure gradient (PG) and %MU.(r=O.618, IO<0.05). .~onclusion : %MU of MIBG was increased in the case of left ventricular pressure overload state.
P19-422
P 19-424
Venous Control in Patients with Hypertrophic Cardlomyopathy H L Thomson, S S Lele, J J Atherton, J Ganes, A Britten, W J McKenna, M P Frenneaux. Royal Brisbane Hospital Australia and St George's Hospital U.K
M Y O C A R D I A L B L O O D F L O W AND A R R H Y T M I A S IN H Y P E R T R O P H I C C A R D I O M Y O P A T H Y R Lorenzoni, R Gistri, L Choudhury, M Ryan, F Cecchi, G Chiriatti, PG Camici. MRC Clinical Sciences Centre, RPMS, Hammersmith Hospital, London, UK.
Background. We have previously demonstrated abnormal control of the resistance vessels in non exercising vascular beds during leg exercise in patients with hypertrophic cardiomyopathy (HCM). We hypothesised that a failure of venoconstrietion in patients with HCM might also occur and contribute to the substrate for haemodynamic collapse. Control of the venous capacitance system was evaluated during exercise and during central volume unloading in patients with HCM and compared to resistance vessel control Method. 34 patients with HCM and 20 age and sex matched controls were evaluated. Forearm vascular resistance (FVR) was assessed at rest and at peak semi erect cycle exercise. The forearm pressure-volume relationship was evaluated using a nuclear technique as an index of venous tone before and during the application of sub-hypotensive lower body negative pressure (LBNP) (20 mm Hg). Splenic venous volume was assessed at rest and at maximal erect cycle exercise. Results. During exercise FVR increased by 49+109% in the patients vs 128+100% in controls(p< 0.0001). Changes in exercise splenic venous volume were abnormal in patients vs controls ( -12+11% vs -41+10% respectively: (p<0.0001) and assessment of changes in central venous pressure in a subset of 4 patients and 4 controls suggested this was due to abnormal control of venous tone rather than increased venous pressure. Splenic venoconstriction was inversely related to % change in FVR during exercise(p=0.005, r=0.6). Forearm venous tone increased a similar amount during subhypotensive LBNP in patients and controls Conclusions. Control of the venous capacitance system in patients with HCM is abnormal during exercise. Resistance vessel and splenic volume changes are inversely related. Abnormal control of venous tone as well as systemic vascular resistance may contribute to haemodynamic collapse.
Often pts with hypertrophic cardiomyopathy (HCM) complain of chest pain despite normal coronaries and a reduced coronary vasodilator reserve (CVR) has been found with PET. Sudden death is frequent in these pts and ventricular tachycardia (VT) on Holter monitoring is a risk factor. The aim of this study was to investigate the relationship between the presence of VT on Holter monitoring and myocardial blood flow (MBF, ml/min/g) at baseline (Bas) and after dipyridamole (DipMBF, 0.56 mg/Kg, iv over 4 mins) in pts with HCM. We studied 84 HCM (62 males, age 42+12 yrs) and 26 controls (C, 17 males, age 43+14 yrs, p=NS) with O15-water or N13-ammonia and PET. CVR was calculated as DipMBF/BasMBF. BasMBF was similar in HCM and C while DipMBF and CVR wwere lower in HCM. HCM C BasMBF 0.84+0.30 0.95+0.18 p=NS DipMBF 1.51+0.62 3.21+1.09 p<0.01 CVR 1.8+0.6 3.4:t: 1.1 p<0.01 BasMBF, DipMBF and CVR were similar in the 26 HCM pts with and the 58 without VT on Holter monitoring. VT non V T BasMBF 0.78+_0.30 0.88+0.30 p=NS DipMBF 1.37+0.62 1.58+_0.61 p=NS CVR 1.8+_0.7 1.8+_0.6 p=NS In conclusion: 1) The present study confirms, in a larger population of HCM pts, that CVR is severely blunted; 2) No relationship could be demonstrated between the impairment of MBF and the presence of VT.
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday morning, April 26, 1995
P 19-425
P 19-427
M Y O C A R D I A L BLOOD F L O W DISTRIBUTION AND VENTRICULAR T A C H Y C A R D I A IN PATIENTS WITH HYPERTROPHIC C A R D I O M Y O P A T H Y
MYOCARDIAL PERFUSION THALLIUM TOMOGRAPHY CARDIOMYOPATHY.
R Gistri, R Lorenzoni, F Cecchi, G Chiriatti, PG Camici. CNR Institute of Clinical Physiology, University of Pisa, Italy. Ventricular tachycardia (VT) on Holter monitoring is a risk factor for sudden death in pts with hypertrophic cardiomyopathy (HCM). To test whether regional and/or transmural inhomogeneity of myocardial blood flow (MBF, ml/min/g) is related to VT, MBF at baseline (Bas) and after dipyridamole (Dip; 0.56 mg/Kg iv), was measured in 56 HCM pts (39 males, age 44_+13 yrs) using N13ammonia and PET. The coefficient of variation (CV, SD/mean) of MBF was used to assess its homogeneity of distribution at Bas and Dip. The subendocardial to subepicardial flow ratio (Endo/Epi) was calculated in the septum (>25 mm thickness) of 12 pts to assess transmural MBF distribution. The CV increased from 0.18_+0.07 at Bas to 0.21+0.08 after Dip (p<0.05) and the Endo/Epi decreased from 0.93_+0.04 to 0.83_+0.17 (p<0.05). The CV and the Endo/Epi ratio were not different in pts with and without VT, both at Bas and Dip. VT (5) no VT (7) BasCV 0.19+0.07 0.17_+0.08 P=NS Dip CV 0.20-+0.08 0.21_+0.09 P=NS Bas Endo/Epi 0.93_+0.05 0.93_+0.03 P=NS Dip Endo/Epi 0.87_+0.16 0.81_+0.19 P=NS In conclusion, the results of the present investigation indicate that 1regional and transmural MBF distribution becomes more inhomogeneous in pts with HCM during Dip stress; 2- No differences were found between pts with and without VT on Holter.
ASSESSED IN THE
S107
BY EXERCISE HYPERTROPHIC
Alain Le Helloco. Daniel G r a s , Anne Devillers, Marc Bedossa, Jean-Claude Daubert, Claude Almange,University Hospital Rennes. PR. To determine clinical features of hypertrophic cardiomyopathy (HCM), 27 oatients (pts) with mean age 52,1 ~ 13,6 divided in ~roup I (10 pts) with myocardial ischemia (septal or apical defect) and zroup 2 (17 pts) with normal thallium myocardial scinti~raphy (SPECT) underwent exercise test, SPECT after exercise and angiocoronaro~raphy. Age, septal thickness (S.T), non sustained ventricular tachycardia (NSVT) and left ventricular end-diastolic (LVED) and end-systolic volumes were studied in 2 groups. Group 1 (I0) GrouD 2 (17) Age S.T. NSVT LVED
39 Z 7,7 25,6 ~ 2,4 4 pts 62 ~ 7 ml/m 2
61.3 ~ 8,8
17,6 ~ 2,3 81 ~ 19ml/m 2
o 40,0005 D < 0,0001 ~ = 0,08
Myocardial ischemia in NCM is associated with younz pts, higher S.T., potentially lethal arrhythmias (VT) and low LVED.
P 19-426
P19-428
RELATIONSHIP BETWEEN POSITIVE GALLIUM-67 SCINTIGRAPHY AND ENDOMYOCARDIAL BIOPSY RESULTS IN PATIENTS WITH CLINICALLY SUSPECTED MYOCARDITIS
DIMINISHED CARDIAC MIBG UPTAKE IN CHILDREN WITH IDIOPATHIC DILATED CARDIOMYOPATHY.
Romuald Wojnicz, Ewa Kozielska, Barbara Ku~nierz, Jan Wodniecki, Zbigniew Ka,dziola, Jerzy No~fiski, Tomasz Kukulski, Michal Tendera. Silesian Centre of Cardiology and 2nd Department of Cardiology, Silesian Medical Academy, Zabrze, Poland.
Pascal Merlet, Philippe Acar, Laurence Iserin, Daniel Sidi, Andr6 Syrota, Jean Kachaner. Cardiologie infantile C H U Necker, Paris and SHFJ, CEA, Orsay, France.
Gallium-67 citrate imaging (Ga-67) has been proposed to detect cellular infiltration in myocarditis (MCI) and idiopathic dilated eardiomyopathy. In order to assess the relationship between positive Ga-67 myocardial imaging and endomyocardial biopsy results we performed prospective study of 29 pts with clinically suspected active MCI: 14 lots with positive Ga-67 myocardial imaging (gr. A: 9M, 5P, aged 18 to 54, means 35,9) and 15 pts without Ga-67 scan (gr. B: 8M, 7F, aged 21 to 50, mean 37,2). All pts underwent right ventricular endomyocardial biopsy. The time between Ga-67 scintigraphy and biopsy was 7+3 days. A minimum of four samples was independently examined by two investigators according to Dallas and Fenoglio classifications. Cardiac scans were obtained on planar gamma camera (93 keV and 184 keV, low energy collimator) in three views: AP, LAO-45 and LL, 48 hours after the injection of 3,55mCi of Ga-67 citrate. The uptake of the radiolabel in the heart was graded as negative (uptake less or equal to that in the sternum and less than liver) and positive. The results are shown in the table: Classification Gr. A (n=14) Gr. B (n=15) p Dallas active 9 (64,3%) 4 (26,7%) 0.026 borderline 5 (35,7%) 3 (20%) NS no 0 (0%) 8 (53,3%) 0.002 Fenoglio acute 2 (14,3%) 2 (13,3%) NS chronic 11 (78,6%) 6 (40%) 0.02 no 1 (7,1%) 7 (46,7%) 0.01 These results indicate that the using of Ga-67 imaging may enable more appropriate selection of patients with clinically suspected myocarditis for endomyocardial biopsy.
T h e norepinephrine (NE) reuptake function, i.e.the main means o f inactivating the NE at the synaptic level, is altered in adults with c o n g e s t i v e heart failure (CHF). 1-123 metaiodobenzylguanidine (MIBG) imaging can assess non invasively cardiac N E reuptake function. In adult patients with CHF, a diminished M I B G uptake appears as a potent prognostic indicator in comparison with other recognized indices. The present study was undertaken to evaluate the N E reuptake function in 7 children (age=4+2 years) with C H F due to idiopathic dilated cardiomyopathy (echographic fractional s h o r t e n i n g = l 1+3%) in c o m p a r i s o n with 5 patients (age 6+4 years) with normal systolic function (fractional shortening=42_+9%). Cardiac M I B G uptake was assessed as the heart-to-mediastinum activity ratio on the planar image obtained 4 h after IV injection o f 0.5 to 1 mCi o f MIBG (in the chest anterior view). A 47% decrease in cardiac MIBG uptake was found in C H F patients compared to patients with n o r m a l systolic f u n c t i o n (137+12 vs 2 5 5 + 1 5 % , r e s p e c t i v e l y , p<0.05). T h u s , a d r a m a t i c d e c r e a s e in myocardial NE reuptake function occurs in children with idiopathic dilated cardiomyopathy, comparable to that present in adults. T h e s e findings may have therapeutic and prognostic implications.
S108
Abstracts
Wednesday morning, April 26,
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
1995
P19-429
P19-431
HETEROGENEOUS SYMPATHETIC INNERVATION IN GERMAN SHEPHERD DOGS WITH INHERITED ARRHYTHMIA AND SUDDEN DEATH Michael Dae, Philip Ursell, Randall Lee,Carole Stilson, Michael Chin, N. Sydney Moise. University of California at San Francisco; Cornell University, Ithaca, NY.
Prognostic value of exercise radionuclide angio graphy in patients with dilated cardiomyopathy. S 0 StrSmblad,B Andersson, K Caidahl,M Lomsky & F Waagstein, Div of Card,Sahlgrenska University Hospital,Gothenburg, SWEDEN
A colony of German Shepherd dogs with spontaneous ventricular arrhythmias and sudden death has been identified. To test for an abnormality of myocardial innervation, we studied 7 of these dogs. Three of seven were severely affected (frequent VT on holter), two were mildly affected, and two had no arrhythmias. We imaged myocardial sympathetic innervation and perfusion using 1-123 metaiodobenzylguanidine (MIBG) and thaUium201 respectively. Nerves were evaluated morphologically by immunocytochemical localization of tyrosine hydroxylase. Perfusion was homogeneous, however there was a regional decrease in MIBG uptake ranging from 10% to 45% of the left ventricle. Immunocytochemial studies confirmed regional denervation. Two of three dogs with severe arrhythmia showed either extensive denervation or a steep gradient in MIBG uptake, while only one of four of the mildly affected or dogs without arrhythmias showed extensive denervation. We conclude that there is abnormal heterogeneous sympathetic innervation in this population of dogs with spontaneous naturally occuring ventricular arrhymias and increased incidence of sudden cardiac death.
P 19-430
P19-432
I N D I U M - I l l ANTIMYOSIN UPTAKE IN CONGESTIVE HEART FAILURE (CHF) AND CORONARY ARTERY DISEASE (CAD)
Withdrawn
D. Jaeger, M. van Doorn-Kaivers, A. Vogel, A. Machraoui, B. Lemke, S. v. Dryander, V. Wiebe, J. Barmeyer. Dept. of Cardiology, University of Bochum, FRG
W E D N E S D A Y P M A P R I L 2 6
28 patients enrolled in a double-blind study evaluating metoprolol in dilated cardiomyopathy and 9 patients treated openly with metoprolol was assessed using resting and exercise radio-nuclide angiography before start of treatment. Patients with a decrease in ejection fraction and/or increase in endsystolic volume of more than 5 % were considered to have a pathological response to exercise. Regardles of treatment in the following 12 months patients with a pathological response had a significant increase in mortality and/or need for heart transplant. 5 of the 11 patients with a patho-logical response died (4) or were accepted for transplantation (i) in contrast to the fact that 1 of 26 patients with this response died. P less than 0.05. These findings indicate that exercise radio-nuclide angiography might be used as a tool for selecting patients with dilated cardiomyopathy and poor prognosis for intensive treat-ment as well as possibly the use of heart transplantation.
Indium-Ill monoclonal antimyosin antibody imaging will be used detecting myocyte damage in case of myocarditis, ischemia or transplant rejection. Antimyosin uptake was quantified by heart to lung ratio (HLR, normal value <1.6) in 10 patients (P) with CHF (NYHA IV) in comparison to 10 P with CAD (NYHA IV). CHF HLR PCWP (mmHg) Cl (I/minimz) EF (%) SVR (dyn*s*cm"5)
1.89 28.0 1.60 23 1969
CAD (+0.17) (+8.7) (+_0.26) (+4) (+_407)
1.90 22.0 1.81 25 1927
(+_0.15) (+5.2) (+_0.20) (+_9) (+293)
PCWP = pulm. capillary wedge pressure; CI = Cardiac Index; EF = left ventricular ejection fraction; SVR = periph, vascular resistance. Conclusion: Increased antimyosin ratio will be found as an unspecific indicator of myocyte damage in P with severe heart failure (NYHA IV) caused by CHF or CAD without any difference. Chronicly increased antimyosin ratio will be a nuclear indicator in discussion about heart transplantation.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday afternoon, April 26, 1995
Wednesday PM, April 26
$60-435
S60-433 to S65-452 and P20-453 to P22-501
QUANTITATIVE A N A L Y S I S O F R E G I O N A L W A L L THICKENING BY Tc-99m MIBI GATED SPECT: COMPARISON WITH REGIONAL WALL MOTION
$60-433 Accuracy of gated technetium-99m-sestamibi SPECT for the detection of coronary artery disease Qinghua Zhou,Wanyi Qu,Ruipin Yang,Tiangko Gao Zhongguo Ran,Beijing HospitaI,Beijing,P.R.China Technetium-99m-sestamibi has photon energies and radiation dosimetry which allows imaging by gated single photon emission computed tomography (SPECT).In order to test the hypothesis that gated SPECT perfusion imaging with Tc-99m sestamibi is super to ungated SPECT imaging in 'the dectaition of coronary artery disease (CAD).40 patients and 24 normal (nl)s were studied.Coronary arteriography was performed in all patients.The normals were not subjected to coronary arterography but had a 5% likelihood of coronary artery disease by Bayesian analysis.Exercise gated imaging was performaned at 8 frams/cardiac cycle.Segmental perfusion was asessed semiquantitatively from long and short axis sections.High quality tomographic myocardialc images were obtained in all patients.The overall sensitivioty for the detection of CAD was 94% (33/32) and 84% (24/34) by gated and ungated SPECT,respectiviely.Overall specoficlty for CAD was 88% and 88% by gated and ungated SPECT,respectively.The normalcy rate ( in 24 nls) was 100%.The sesitivity for individual disesed arteries was 75% by gated SPECT and 62% by ungated SPECT (P< 0.05) and specificity for nornal coronary arteries was 95% by gated SPECT and 95% by ungated SPECT.Thus,gated SPECT with Tc-99m-sestamibi allows accurate assessment of regional myocardial pertusion and more accurate detection of significant coronary stenosis compared to ungated SPECT imagmg.
$109
Naoya Hattori, Nagara Tamaki, Seiji Shirakawa, Takashi Kudoh, Madoka Tateno, Eiji Tadam-ura, Tatsuo Torizuka, Yoshiharu Yonekura, Junji Konishi. Kyoto University, Kyoto, Japan Tc-99m MIBI gated SPECT permits assessment o f regional wall thickening (WT) on the basis o f count increase from e n d - d i a s t o l e (ED) to e n d - s y s t o l e (ES). W T w a s quantitatively c a l c u l a t e d in 42 patients s u s p e c t e d o f ischemic heart disease to c o m p a r e regional wall motion (WM) by first-pass ventriculography. % W T ((ES-ED)/ED) and % W T m a x ( ( E S - E D ) / E D m a x ) were calculated from ED and ES counts in each pixel to create bull's eye map display. W M was scored with 4 grades in apical, anterior, and inferior regions. Apex Alt WM %wr %WFmax%~T %W'Fmax %WT %WTmax 1 19.1~.17.0 ~ 6.7-~5" n/a tYa nfl tYa 2 362M2.2' 21555.5* 18Ydd0.9 119&_7.6 21.1-'+9.3 13~ttfi.8 3 472:t.16.1 34.7+_11.8" 21fi:tS.2* 158:!5.8" 25.7"~.7" 162t:hS.5* 4 51.L+J2.8 362:~.8 37.4fJ0.(7' 28fi:~8.5. 392d:10.8" 265:!:7.2" WM; l=akinesis, 2=severe hypokinesis, 3=mild hypokinesis, 4=normokinesis, * p < 0.05, Mean~_+S.D. %WTmax correlated with WM better than %WT particularly in the areas o f severe wall motion abnormality. In conclusion, MIBI gated S P E C T permits regional wall thickening quantitatively. % W T m a x is considered to be a better index o f regional function.
$60-434
$60-436
DOES GATED 99mTc-SESTAMIBI SPECT IMPROVE CHD DETECTION IN COMPARISON TO UNGATED SPECT?
IMPROVEMENT IN LV FUNCTION AFTER BALLOON VALVULOPLASTYIN MITRAL STENOSIS: ASSESSEMENTWITH RADIONUCLIDEANGIOGRAPHY.D. Le Guludec,G. Gdmon, M.C. Peker, M. Faraggi,M.S.Slama, HGp.Bichatand B~cldre,France. The determinantsof LV dysfunctionoccuring in 30 to 50% of pts with pure mitral stenosis are unknown. The LVEF (%), peak ejection and filling rates (PER, PFR, s-1) and end-diastolicvolume indexes (EDV) were prospectivelystudied using equilibiumradionuclideangiography in 18 pts, before and 3 days after successful balloon valvuloplasty (BV). The study population was 36+10 years old, in sinus rythm before and after BV, free of coronary or other valvular disease. 9 pts had a baseline LVEF impairment< 55% (G1), and 9 pts had normal LVEF (G2). Echographicmitral valve area (MVA, cm2) were similar in the 2 groups before and after BV, reaching 2.21+0.3 (G1) and 1.99• pm-BV HR LVEF EDV PER PFR k.~/A G 1 7~12 47+8** 150+_22 2.53~.8 1.87~.5" 1.06~.2 G2 67+11 63~7"* 156-~32 3.19~.8 227~.3" 1.01~.2 * p< 0.05, ** p<0.0005 betweengroups. Before and after BV, MVA was correlatedwith PFR (r=0.51, p<0.05) but not with LVEF. After BV, no significantchanges in HR and EDV were observed,but LVEF (58+7, p<0.0005),PER (3,15+0,5, p<0.05), and PFR (2,46+0.6, p<0.0005) improved significantly only in G1. Conclusion: successful mitral balloon valvuloplasty increase LV function in pts with systolic dysfunction, independantly of the improvementin filling parametersand preload.
T. Leitha, H. Bailer, A. Staudenherz, M. Gwechenberger, M. Pruckmayer, G. Kronik; Univ. Clin. Nuc. Med. Vienna, LKA Krems Gated 99'~l'c-sestamibi SPECT (GSPECT) (3-head LFOV gamma camera (Picker PRISM 3000), 360~ 20 steps, 6~ UHRPAR collimators, 16 intervals, R-R acceptance • 10% base line value) at rest and after bicycle stress was performed in 24 CI-ID patients. Ungated SPECT studies were derived from the original gated SPECT by adding corresponding intervals prior reconstruction of selicos in three planes and bull's eye analysis. Analysis of GSPECT was performed using the ,,3D Perfusion/lVlotion Map Software" (Southwestern Medical Center, University of Texas). Visual assessment was performed independently for all scintigraphic studies by rating regional perfusion (3 = normal, 2 = equivocal, 1 = abnormal, 0 = severely abnormal) of eight myocardial segments (excluding the apex). These data were compared to regional perfusion as assessed by coronary angiogmphy (3 = 0-39, 2 = 40-59, 1 = 60-79, 0 = 80-100% stenosis). Reliability analysis for the regional perfusion assessment in GSPECT was performed for stress and rest studies and revealed reliability coefficients of 0.9060 and 0.8977, respectively. GSPECT showed the best correlation for regional perfusion assessment (correlation coefficients r ranging from 0.0697 - 0.8061) followed by bull's eye analysis (r: 0.1309 - 0,6745) and the evaluation of myocardial sclices in three planes (r: -0.3215 - 0.6683). However, the proximal lateral segment showed the weakest correlation with angiogmphy in all analyses. Gated 99"q'c-sestamibi SPECT improves the detection of CI-ID in comparison to angated SPECT, even if the additional information about regional wall motion is not considered.
$110
Abstracts W e d n e s d a y afternoon, April 26, 1995
$60-437 LEFT VENTRICULAR EJECTION FRACTION ASSESSED BY GATED 99mTc-MIBI SPET (GSPET): CORRELATION WITH CONTRAST LEFT VENTRICULOGRAPHY (VCG). A. Fikrle, A. Haldemann, D. Liischer, P. Koranda, ,L Kinser, H. Ledermann, M. Sulzer, K. Schinke. Inselspital/~lniversity of Berne, CH-3010 Berne
W E D N E S D A Y P M A P R I L
JOURNAL OF NUCLEAR CARDIOLOGY March/April 1995, Part 2
$61-439 SIGNIFICANCE
OF
INCREASED LUNG DOBUTAMINE
THALLIUM UPTAKE DURING THALLIUM-201 SC1NTIGRAPHY
C R a g h a v a n , P V a d u g a n a t h a n , Z X He, G Guidry, JJ Mahmarian, M S Verani. Baylor College o f Medicine, H o u s t o n , TX, U S A
The aim of this study was to compare the left ventricular ejection fraction(EF) assessed by 99mTc-MIBI-GSPET and VCG. Using a 2day protocol, stress and rest GSPET was performed with MIBI on a 3-head camera in 57 consecutive pts referred for evaluation of myocardial perfusion. VCG was performed within 2 weeks of the scintigraphic study. The ,,scintigraphic" EF was obtained independently by 3 observers from GSPET performed in rest, 45min. after stress MIBI-injection(S-EF) and on the following day, 60min. after MIBl-injection at rest(R-EF). The scintigraphic EF determination was performed using the 3-D Perfusion/Motion MapTM Software (with a 3D model derived from an automated surface detection algorithm) on the Picker Odyssey computer. The mean EF of all pts was: VCG-EF=58.2+14; S-EF=52.9_+11.7; R-EF=53.8+_9.8%. The difference VCG-EF vers. S-EF and VCG-EF vers. R-EF was significant (p<0.05) and S-EF vers. R-EF was non-significant. The correlation found in 57 pts was VCG-EF vers. S-EF: r=0.81; VCG-EF vers. R-EF:r=0.87; S-EF vers.R-EF:r=0.93. The best correlation was found for VCG-EF ,~0-60%, followed by VCG-EF<40% and VCGEF>60%. No significant difference was found between the 3 observers (W-test). The assessment of EF with the MIBI-GSPET using 3Dsurface method is highly reproducible, reveals good correlation with VCG, although it systematically slightly underestimated the EF in comparison to VCG. This method provides clinically useful quantitative information regarding systolic function and permits simultaneous assessment of myocardial perfusion and function.
calculated the lung-to-heart ratio (LHR) in 73 pts (38 males, mean age 63-~13 years [SD]) who underwent DOB T12~ planar and SPECT imaging. Fifty six pts had a perfusion defect size <5% of the left ventricle (group l), 8 pts had a defect _>5 and <20% (group 2) and 9 pts had a defect ->20% (group 3). The LHR was 0.36• for group 1, 0.384-0.08 (p=NS) for group 2 and 0.54-.0.18 for group 3 (p<0.05 vs group 1 and 2). In a subgroup of 18 pts with coronary angiography, 4 with no significant CAD, 5 with single vessel and 9 with multivessel CAD, the LHRs were 0.36• 0.354-0.06 and 0.504-0.22, respectively (p=0.08 vs SVD, p=0.11 vs normal). Thus, increased lung uptake during DOB TI2~ scintigraphy is a marker of extensive perfusion abnormalities, often due to multivessel CAD.
$60-438
$61-440
EFFICACY OF SIMULTANEOUS FUNCTION AND PERFUSION IMAGING ON Tc-TETROFOSMIN MYOCARDIAL SCINTIGRAPHY
COMPARISON BETWEEN DIPYRIDAMOLE AND ADENOSINE IN DETECTION OF CORONARY ARTERY DISEASE WITH 201-THALLIUM IMAGING. R.Taillefer, R. Amyot, S. Turpin, R. Lambert, C. Pilon, M.Jarry, J. Lfveill4 R. Essiambre. Nuclear Medicine Deparlment, HOtel-Dieude Montreal, Canada
Kamon Imai, Kihiro Asano, Hirotsugu Hoshino, Youichi Honda, Hidehiko Kashiwagi, Yasuhiro Ishii, Jyunichi Mogi, Makoto Mutou, Takahiro Shibata, Hiroshi Ogawa, Youichi Kubouchi, Toshinobu Horie, Saitama Cardiovascular Center, Saitama, JAPAN The aim o f this study was to determine whether the diagnosis for coronary artery dmease (CAD) with Tc-tetrofosmin (Tf) myocardial seintigraphy (MS) was improved by the combination o f function image (F) and perfusion image (P) as compared with P alone. Tf-MS was performed with one-day protocol (stress / rest) in 51 patients (pts) (CAD:31, Non-CAD:20). F was obtained by first pass method, and P by SPECT simultaneously. Number o f diseased vessels was 14 in right coronary artery (RCA), 18 in left anterior descending (LAD), and 12 in left circumflex (LCX). Isehemia was diagnosed by 2 different criteria; 1) defect with fill-in on P alone, 2) both defect with fillin on P and stress-induced wall abnormality on F. Data are expressed as sensitivity / specificity (accuracy), respectively. Location of disease RCA LAD LCX Perfusion alone 79 / 41 (51), 89 / 97 (94), 58 / 97 (88) Perfusion+Funetion 50/92(80), 78/97(90), 33/100(84) By addition o f function image, accuracy and specificity of O diagnosis in area o f R C A improved from 51 O~Ato 80JA, and from 41% to 92%. Thus the addition of function image in Tf-MS would be useful to improve the diagnosis, especially in region o f RCA.
Increased lung TI TM u p t a k e after exercise or vasodilator pharmacologic stress is a m a r k e r o f extensive coronary artery disease ( C A D ) b u t has not been evaluated during dobutamine ( D O B ) stress. Thus, w e prospectively
Both dipyfidamole (DIP) and adenosine (ADE) are widely used as pharmacologic stressors with 201T1 (2"1) imaging for detection of CAD. The purpose of this study was to directly compare DIP and ADE T1 imaging in patients with proven CAD. Fifty-five patients were submitted to two planar T1 studies: one with DIP and the other with ADE. The time interval between the 2 studies varied from 2 to 7 days and the order was randomly assigned. Three standard planar views were obtained at 10 rain. and 4 hours after injection of 3 mCi of TI. Administration of DIP was as follows: 0.142mg/kg/min during 4 rain., slight exercice and injection of TI. The infusion of ADE was as follows: 0.142/mg/kg/min. during 6 min. with injection of TI after the third minute of infusion. Patients were asked to give their preference considering the number, severity and duration of side effects on a scale form 0 (worst) to 5 (best). Reading was done by 2 experienced observers. The heart was divided into 3 segments view. The change in systoUc blood pressure was - 12_+11 mmHg for ADE and -5_+10 for DIP (p<0.001) and the change in heart rate was +18_+10 bpm for ADE and +8_+7 bpm for DIP (p<0.001). Using regions of interest, ischemic/normal wall ratios were determined: 0.79_+0.06 for ADE and 0.83_+0.08 for DIP (p=0.005). ADE detected 301 normal, 173 ischemic and 21 scar segments while DIP detected 333, 137 and 25 respectively. Patients prefered ADE (4.3+-.1.0 for ADE vs 3.8+--I.5 for DIP, p=0.04) mainly because of the short duration of side effects. In conclusion, this preliminary study shows that the use of ADE with 201 TI imaging may have some advantages over DIP.
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday afternoon, April 26, 1995
$61-441
$61-443
CLINICAL DETERMINANTS OF H E M O D Y N A M I C AND SYMPTOMATIC RESPONSES IN 1,934 PATIENTS DURING ADENOSINE SCINTIGRAPHY
Exercise ECG and Thallium 201 SPECT in patients with left main coronary artery disease. J.M. SCHOLL, F. VlGONI, V. ARJA, O CENDOYA, A. BLASCO, P. WAGNIART. Centre Cardiologique du Nord, Saint-Denis, France.
DL Johnston, DO Hodge, MR Hopfenspirger, RJ Gibbons Mayo Clinic, Rochester, Minnesota, USA.
Slll
There is individual variability in the hemodynamic and symptomatic responses during adenosine perfusion scintigraphy. To assess whether certain clinical conditions are responsible for this variability, change in hemodynamics and number of symptoms were correlated with multiple clinical variables in 1,934 patients (pts) receiving adenosine. Pts received adenosine 140 ~gm/kg/min x 6 rain or a graduated dose (50/75/100/140 ~tgmNg/min) x 7 rain. LV ejection fraction (EF) was available in 890 pts. The following clinical variables were associated with significant (p <.02-.001) responses to adenosine infusion compared to pts without the variable. ,1, = less change/ fewer symptoms; 1" = more change/more symptoms. Variable N AHR ASBP #Symptoms Aze->70yr 964 $ 1" - ,1, Diabetes 251 ,l, 1" $ Male 1058 $ 1" ,1, Atrial Fib. 127 ,1, 1" ,[, EF < 40% 167 $ 1" ,l, Possible mechanisms include autonomic dysfunction in diabetics and high circulating catecholamines in pts with low EF. Conclusion: There are several clinical variables which affect the hemodynamic and symptomatic responses to adenosine infusion.
To assess the diagnostic value of exercise Thallium 201 (TI) single photon emission computed tomography (SPECT) for the identification of patients (pts) with left main (LM) coronary artery stenosis (S), we studied 31 pts (mean age 60 _+ 10 years, 26 males, 5 females) with LM S > 50% who had exercise-redistribution SPECT. Twenty-seven pts had LM S associated with 1, 2 or 3 vessel disease respectively in 8, 9 and 10 pts; 21 of them had RCA S >_ 70% .Twenty-five out of 27 (93%) had a reversible TI defect (RD): 15 (52%) anterior, anteroseptal and/or apical, 3 (10%) anterolateral, 8 (26%) inferolateral, 11 (35%) inferior. The so called left main pattern was not observed. Four pts had isolated LM S: 3 had normal SPECT, 1 had a small anterior RD. Abnormal lung TI uptake was noted in 14 pts (45%) and ventricular cavity dilatation in 13 (42%). All the pts had a positive exercise test. Conclusion 9 despite its ability to detect CAD in 84% of these pts, SPECT could be normal and was not specific of left main disease. However when exercise testing data were added severe CAD could be identified.
$61-442
$61-444
REST-REDISTRIBUTION THALLIUM-201 AND R E S T M I B I S P E C T IN P A T I E N T S W I T H S T A B L E CAD: A Q U A N T I T A T I V E E V A L U A T I O N .
MYOVIEW FOR REST/STRESS MYOCARDIAL SPECT WITHIN 2 HOURS. A SPANISH-PORTUGUESE MULTICENTER TRIAL.
Claudio Marcassa, Alberto Cuocolo, Michele Galli, Simone Maurea, Marco Salvatore. Clinica del Lavoro Foundation IRCCS, Vemno (No) and Federico II Univ., Napoli, ITALY
RMontz,MJ.Perez-Castej6n,JA.Jurado,J.Martfn-Comfn,E.Esplugues, U Salgado,A.VentCysa,G.Cantinho,AT.Fonseca,MJ.Tabuenca,A.Garcfa, D.Ortega,C.Puente,Al Ferrer,JM Latre and JL Carreras. Complutense Univ.Madrid(Monitoring),7 centers in Spain and 4 centers in Portugal
Thallium-201 (T1) redistribution (RED) after resting injection reflects hypoperfused but viable myocardium. We compared resting MIBI with REST-4hr RED T1 uptake in 44 pts with documented CAD and regional asynergies (56-+10 yrs; LVEF 40-+15%). T1 and MIBI SPECT were performed on separate days; MIBI images were acquired 60 rain after injection. Tracer uptake was quantified in 22 seg/pt. In 456 seg with normal (>75% of peak activity) REST T1 uptake, MIBI uptake was preserved (86-+15%; >75% in 374/456, 82%). In 512 abnormal REST T1 seg, MIBI uptake was comparable to REST TI (50+18% vs 52+16%, p=ns) but was significantly lower than RED TI uptake (55-+18%, p< 0.01). Significant (>10% uptake increase) RED was documented in 147/512 (29%) abnormal REST T1 seg. Mean tracer uptake was: REST RED MIBI Seg. with RED (n=147) 51+17" 68-+17 54-+20":I: Seg. without RED (n=365) 52+15 49-+165 48+165 *p<.001 vs RED; $p<.05 vs REST In pts with chronic CAD and regional asynergies, MIBI activity 60 min after injection parallels RED TI activity in seg with fixed T1 defects only. Despite comparable resting T1 uptake, seg with RED had a greater 4hr T1 than MIBI uptake.
The diagnostic efficacy of 99mTc-tetrofosmin(Myoview)in patients with CAD was studied with a SPECT rest/stress protocol in 2 hours. Methods: The study included patients with diagnosis of uncomplicated CAD. With a radiochemical purity of >90%,each patient was injected with <__300MBq Myoview at rest and<9'O0MBq at peak of exercise. SPECT acquisitions were made l)at rest, and 2)with stress injection aprox. 1 hour after the rest injection. The images were read by 2 or 3 blinded experts in nuclear cardiology. The results were compared with those of coronary angiog:'aphy (CA). Results: From a total of 167 patients included, the data of 142 were completely evaluable (23 without CA, 2 with non evaluable images). Longer intervals between injection and SPECT acquisition at rest (32+ 14 min,n=82 vs. 7+4 min, n=85) did not influence significantly the diagnostic results. The quality of the rest images was excellent or good in 86%, Ix~orin 12% and non evaluable in 2~ The sensitivity(S) of SPECT to detect CAD with >75%/>50% steoosis was 96/93%, with an accuracy(A) of 82/85%. The localization of defects by SPECT in relation to perfusion territories of stenosed vessels (>75%~_50%) was achieved with S= 69/64% for LAD, 55/48% for LCX and 91/86% for RCA, with A-=-73/71%, 76/71'4~ and 64/73%. Concordances were 62% for single and 68% tk~r multiple vessel disease. Conclusions: This is the first large multicentcr clinical trial confirming the usefullness of Myoview in an ultrashort protocol (2 hours) myocardial rest/stress SPECT procedure.
$112
Abstracts Wednesday afternoon, April 26, 1995
$64-445
$64-447
Hyperacute Seintigraphic Visualization ofExperimental Reperfused Myocardial Infarction with Te-99m-Glucarate.
Locallz~tlon of Atherasclerotir Lesionl with In-Ill-Chimeric Z2D3 Antibody in Watanabe Rabbits and Rabbits with Experimentally-induced Lesions.
Jagat Nanda, Artiom Petrov, Chris PaL Ban An Khaw. Northeastern University and Massachusetts General Hospital, Boston, MA.
W E D N E S D A Y P M A P R I L
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
Narula J, Petrov A, Ditlow C, Chen F, Khaw BA. Northeastern University, Massachusetts General Hospital, Boston, MA; and Vasueor, Menlo Park, CA.
Te-99m-Glucarate (To-G) uptake is similar to dooxyglucose in severe myocardial ischemia, but was paradoxically maximal in necrotic myocardium. Therefore, the use of To.G for visnali7~tion of acute MI was evaluated in 4 mongrel dogs with acute experimental MI. Tc-G (10 mCi) uptake was compared to reperfuaed TI-201 (0.5 mCi) distribution and simultaneously administered In-Ill antimyusin FOb(AM) (0.25-0.6 mCi). After radiotracer administration, 1 rain serial images were obtained initially (0-60 rain) then hourly until 5 hours. Unequivocal visualization of MI with Tr was possible within 4 to 10 rain of tracer administration. At 5 H, the hearts were excised, and tracer distribution of approximately 1 g myocardial tissue samples were coanted in a gamma counter. Percent injected dose per g was calculated fo~"all 3 radiotracers in a total of 314 myocardial tissue samples. Infarct to normal activity ratios were determined. Tc-G uptake ratios were observed to bear a direct correlation to AM uptake ratios (r ffi 0.967). Tc-G uptake was inversely related to T1201 distribution (r = -0.79) which was similar to that Of AM to T1201 (r ~-0.77). Tc-G cleared from the blood with a T1~ of 4 rain and Ttr~ of 92 rain. Thus Tc-G can be used for hyperacute visuali7~'ation of experimental MI which is probably due to a combination of the avidity for the necrotic tissues and its rapid blood clearance.
A murine/human chimeric 73.30 IgG1 F(ab'h antibody specific proliferating smooth muscle ceils in b, man and rabbit atheroma was used for scintigraphic lecaiization of: (A) experimental athernsclerotic lesions in New Zealand White (NZW) rabbits induced by descending aorta deendothelialization followed by 6% peanut off, 2% cholesterol diet for 12 weeks and (B) in genetically hyperlipidemie Watanabe rabbits (~1 year old). In-lll-F(ab')2 (25-28.5 mBq) was administered intravenously and rabbits were imaged immediately, at 24 and 48 H. Uptake in the lesions (mean % injected dose/g + SEM) was compared to ln-lll-nouspecSfio human IgGl F(ab')2 (NS). Athemsclerotir lesions were vi~mliTed in 3 out of 4 rabbits in group (A). No lesions were vi~3aliT~l in group (A) rabbits injected with NS. Lesions were also not visttali7~d ill W a t g n ~ (group B) with either chimeric or NS. Rabbits (n) Antibody N~rmal (%ID) Lesion P NZW (4) 73,30 0,019_+0.003 0.112+0.0241 0.014 NZW (4) NS 0.007_+0.0010.027~-0.0041 Watarmhr (4) 73.30 0.013+0.002 0.032+0.004 0.81 Watanal~ (2) NS 0,016+0,003 0.036u A significant difference in the specific antibody loealiT~tion in the two models of atherosclemtic lesions in this study reflects different pathoganetic Charaeter~cs which suggests a~aingt interchangeable use of these two models.
$64-446
$64-448
MEASUREMENTS OF R E G I O N A L A N D GLOBAL LEFT VENTRICULAR FUNCTION H A V E INDEPENDENT PROGNOSTIC V A L U E IN PATIENTS WITH PRIOR M Y O C A R D I A L INFARCTION TD Miller. A M Weissler, TF Christian, K R Bailey, RJ Gibbons. Mayo Clinic, Rochester, MN, USA. To determine if regional asynergy (RA) contains prognostic information independent of global left venlricular ejection fraction (LVEF), 486 patients (421 M, 65 W, age 61• years) who underwent resting mdionuclide angiography >3 months after Q-wave myocardial infarction were followed for a median duration of 4.7 years. There were 95 deaths (61 cardiac, 34 noncardiac). Using regional LVEF from 3 regions, 5 mathematic indices of RA were te~ted for association with total mortality. The RA index (~2(global LVEF-regional LVEF)2/3 x 100/global LVEF) proved optimal. The univariate X z for RA index was 26.4 and for global LVEF 21.5. After adjustment for global LVEF, RA index added independent prognostic information (X2=7.8, p<0.01). Patients were subgrouped by high or low global LVEF and R A index. Four-year survival was RA index<25 RA index>25 p_ LVEF <40% 87% 65% <0.01 LVEF ~ 40% 92% 90% NS CONCLUSION: Quantitative radionuclide angiographic measures of global and regional ventricular function have independent prognostic value in patients with previous myocardial infarction. The R A index is most useful for refining mortality risk in patients with low global LVEF.
ACUTE EFFECTS ON PULMONARY AIRFLOW OF L V. DIPYRIDAMOLE CARDIAC STRESS TESTING M. Gwechenberger, S. Banyai, A. Staudenherz, M. Pruckmayer, T. Leitha; Univ. Clinic Nuclear Medicine, University Vienna, Austria Overt asthma is a eontraindication for dipyridamole (DPM) cardiac stress testing, yet the pulmonary effects of a diagnostic i.v. dose (7 gg/kg) of DPM in CHD patients with and without a clinical history suggestive of chronic obstructive pulmonary disease (COPD) have not been assessed. Pulmonary function parameters (FVC, FEV1, FEV3, FEV5, PEF, FEF 25%, FEF 50%, FIEF 75%, FEF 25-75%, FEF 7585%, FEF .2-1.2, FEF .5, FMFT, MVV) were monitored prior and immediately after DPM infusion in 170 consecutive patients and correlated to the changes of blood pressure and heart rate, the degree of CHD (reversible, irreversible segments in 2~ SPECT), the lung/heart uptake ratio and adverse effects during the DPM infusion (angina: 20%, severe dyspnea: 5~ headache: 11%, others: 5%). Moreover it was evaluated if the history of exertional dyspnea (48%), COPD (7%) and nicotin abuse (59%) correlated with the observed changes in pulmonary function parameters. All patients experienced statistically significant changes in the systolic (-10%) and diastolic (-12%) blood pressure and the heart rate (+20%). A statistically significant pulmonary airflow obstruction was only noted in small airways (FEF 75-85 %: -7%; p = 0,034). The changes in pulmonary function parameters were independent of the clinical history and the scintigraphicalty determined degree of CHD. Noteworthy, dyspnea during DPM was correlated with angina and a history of exertional dyspnea but not to a history of COPD. In conclusion these data do not advocate the use of DPM in asthmatics, yet show that the acute effects of DPM stress testing on pulmonary airflow are mild even in patients with a history suggestive of COPD.
JOURNAL OF NUCLEAR CARDIOLOGY Volume 2, N u m b e r 2, Part 2
Abstracts Wednesday afternoon, April 26, 1995
$65-449
$65-451
BIVENTRICULAR CONTRACTILE RESERVE IN PATIENTS WITH END-STAGE LUNG DISEASE.
EARLY DECLINES IN CARDIAC ALLOGRAFT RADIONUCLIDE EJECTION FRACTION ARE ASSOCIATED WITH INCREASED LATE MORTALITY.
M. Henzlova, J. Machac, J. Diamond, A. Gass, G. Schilero, M.Padilla. Mount Sinai Medical Center, New York, New York The severity of cardiac dysfunction influences therapeutic decisions in pts with end stage lung disease. Thirty nine lung transplant candidates [22MA7F} free of CAD, underwent gated blood pool imaging with biventricular election fraction [RVEF, LVEF) determination at rest, and 19 pts also after up to 40 mcg.&.g..fnin of dobutamine. At rest, RVEF was norm al (> 40~ } in 7 pts, mildly to moderately decreased {2039~] in 26 pts and severe/y decreased {<20~. ] in 6 pts. The corresponding LVEF differed significantly among these groups: 58 + 13%, 53+ 12~ and 40_+ 10~., respectively, [p=0.02}. After dobutamine, RVEF increased from 28 + 13 to 40-+20~. [p<0.O01} and LVEF from 54+14 to 69+13~0 (p<0.001) in pts with normal or mildly to moderately decreased rest RV E F [ N = 15}. RV augm entation was m inim al (12 + 55 to 14+ 5%,p=NS} in pts with severe RV dysfunction at rest (N=4}. However, their LVEF increased significantly [from 41 + 8 to 67_+19X, p=0.03}. Thus: 1. There is an association between the severity of RV and LV dysfunction. 2. Dobutamine unmasks RV contractile reserve only in pts with mild-to moderate RV impairment. 3. LV contractile reserve is demonstrable independent of the degree of RV dysfunction. 4. D obutam ine challenge may help to identify pts with reversible LV dysfunction who would otherwise be excluded from tung transplantation.
Kirk W. Walker, Jonathan W. Carmichael, Richard A. Wilson, Ranae M. Ratkovec, Ray E. Hershberger. The Oregon Cardiac Transplant Program, Oregon Health Sciences University, Portland, Oregon, 97201. Radionuclide left ventricular ejection fractions (LVEFs) are used extensively to assess cardiac allografl systolic function after transplant. However, the normal allografl LVEF and changes in allograft LVEF over time are not well defined - nor have changes in LVEF been associated with adverse outcome. All adult heart transplants recipients between 12/86 and 7/92 who survived at least one year (n=159) were followed (range=l.1 to 7.3 years; median=3.3). None was lost to follow-up. LVEFs were obtained at both 1 and 12 months after transplant in 137 patients, Endomyoeardial biopsies, mean arterial blood pressures and pulmonary capillary wedge pressures were obtained within several days of the LVEF tests. Results showed that the mean LVEF declined 9% during the first year from 64% to 55% (P<0.01). This decline did not correlate with changes in loading conditions, or with episodes of acute rejection (n = 73). Declines in the LVEF > 9% were associated with increased all cause late mortality (n=l 1/15; P < 0.05), and late cardiac mortality (n=6/6; P = 0.013). Therefore, the majority of heart transplant recipients who survive at least one year exhibit a decline in LVEF (mean = 9%). Declines >9% are associated with increased late mortality.
$65-450
$65-452
SYMPATHETIC REINNERVATION AFTER HEART TRANSPLANTATION: DUAL ISOTOPE NEUROTRANSMITTER-SCINTIGRAPHY, NOREPINEPHRINE CONTENT AND IMMUNOHISTOCHEMISTRY
EVALUATION OF LEFT VENTRICULAR EJECTION FRACTION IN CARDIOMYOPLASTY TREATED PATIENTS. Elisa Milan, Pierluigi Rossini, Aurora Vaccari, Aduro Terzi Roberto Lo Russo, Raffae e Gi-ubbini.Nuclear Medicine and Cardiac Surgery Dpts Civic Hospital, Brescia- Italy. The measurement of left ventricularejection fraction (LV EF) by gated radionuclide angiography (GILA) after cardiomyoplas~j (CMP) represents a methodological issue because the cardiomyost=mulatoris normally set at a 2:1 heart to muscle contraction ratio but the R-R nterval is the same for both assisted and non assisted beats, thus precluding the reconstruction of different volume curves for the two contraction modalities. We overcame this limitation by filtering the spontaneous ECG-R wave of the non assisted beat and registering only the spike corresponding to the simultaneous heart andmuscle depolarisation during the assisted beat. Using a mini-list acquisition procedure we included in a single reconstructed cardiac cycle a sequence of two cardiac beats allowing to share by computer processing the assisted from the non assisted LV volume curve. We studied 9 lots treated by cardiornyoplasty for NYHA class III heart failure. GRA was performed at rest before surgery and one year after the operation. The LV EF was 20/2+ 5.6% for the preoperative evaluation(a), 16.3~2.8% and 12.1_+6.1% for postoperative assisted (b) and non assisted (c) beats respectively; p<.03 between b and c, p=n.s between a and b, p=n.s between a and c. No significant differences were observed within the three groups regarding peak ejection rate and peak filling rate. In conclusion, our method offers the possibility to measure the hemodynamic parameters derived from (3RA separately for assisted and non assisted beats. LV EF improves during skeletal muscle assistance in comparison to non assisted beats; however, no significant differences were observed in comparison to preoperative data.
Christina GiJrtner, Bernd J. Krause, Harald Klepzig Jr., Giinter Herrmann, Szaboles Lelbach, Lisa Vockert, Andreas Hartmann, Frank D. Maul, W.Tilmann Kranert, Ernst Mutschler, Klaus Hfibner, Gustav HGr. University Hospital Frankfurt am Main, Germany Cardiac transplantation goes along with surgical disruption of the nerve fibres from their somatas resulting in sympathetic denervation. In order to investigate the occurrence of sy.mpathetic reinnervation neurotransmitter scintigraphy using the norepinephrine analogue 1-123-MIBG (Metaiodobenzylguanidine) was performed in 15 patients 2-69 months after transplantation, norepinephrine content and immunohistochemical reactions of antibodies to Schwann cell-associated SI00 protein, to neuron specific enolase (NSE) and to norepinephrine were examined in 34 endomyocardial biopsies of 29 patients 1-88 months after transplantation. Antero-basal 1-123-MIBG uptake indicating partial sympathetic reinnervation could be shown in 40 % of the patients 37-69 months after transplantation. By immunohistochemistry 83 % of the investigated patients 1-72 months after transplantation showed nerve fibres in their biopsies but no positive reaction to norepinephrine. Significant norepinephrine content indicating reinnervation could not be detected in any biopsy. Conclusion: In spite of lacking norepinepbrine content there seems to be immunohistochemical and scintigraphic evidence of sympathetic reinnervation. An explanation to this contradictory finding may be the reduced or missing norepinephrine storage ability compared to the restored uptake ability of the regenerated sympathetic nerve fibres.
Sl13
W E D N E S D A Y P M A P R I L 2 6
Sl14
Abstracts Wednesday afternoon, April 26, 1995
P20-453
P20-455
R E L I A B I L I T Y ()F E J E C T I O N F R A C T I ( ) N F R O M S P E C T G A T E D BLOOD P O O L SCANS
LV V O L U M E S AND W A L L M O T I O N A S S E S S E D WITH GATED PET : COMPARISON W I T H MUGA
ML Bartlett, SL Bacharach, G Srinivasan, V Dilsizian, C. Barker, G Lan. Nat'l Inst. of Health, Bethesda, USA
H Boyd, R Gunn, N Marinho, D Costa, S Karwatowski, PG Camici. MRC Clinical Sciences Centre, RPMS, Hammersmith Hospital, London, UK.
Recently, there has been interest in using SPECT to produce Gated Blood Pool (GBP) scans. Drawing ROls on each SPECT slice is laborious and subject to large variability. However, SPECT images can be reprojected to give planar images from any desired angle and, with an easily-automated rectangular mask, background can be largely excluded. This makes the calculation of ejection fraction (EF)much less dependent on the positioning of a background ROI. We have collected both conventional planar and SPECT GBPs from 5 CAD patients. Inter- and intra-observer variability was assessed on both planar and reprojected SPECT images. The background fraction (% ED counts) dropped from 48% for planar to 14% for SPECT. Even if no correction was made for background, EF dropped only .03 for SPECT (vs .08 for planar, p<.001). Further we found that the variation (standard deviation) in EF was the same for both planar and SPECT including background (.I)24 and .025 respectively) but that the variation rose to .033 for planar without background whereas for SPECT it rose to only .029. We conclude that EF can be measured with low variability from reprojetted SPECT GBP images and that background correction may not be necessary.
To date cardiac PET studies have focused on the measurementof myocardialblood flow, metabolismand receptors while LV function and volumes have been derived by other modalities. The main drawback of this approach is the difficulty of data co-registration which limits clinical interpretation. The aim of this study was to evaluate whetherit is possible to measure cardiac volumes and wall motion with PET. Nineteen patients with and without coronary artery disease underwent a PET scan and MUGA on 2 consecutive days. A 9 min PET scan (16 gates/cardiac cycle) was acquired after inhalation of 3 MBq/ml of C150 at the rate of 500ml/min over 4 min using a multislice camera (CTI-Siemens 931). After short axis reslicing, principle components analysis (PCA) was performed on the gated image to facilitate recognition of the ventricles. A blood volume (BV) image was created from the PCA image and a threshold was applied to the BV to generate a LV mask. The mask was then applied to the image to obtain LV end diastolic (ED) and end systolic (ES) volumes. LV ejection fraction measured with MUGA was 38_+16% (range 15-71%) and that measured with PET was 44+18% (range 11-75%) (p=ns). There was a linear correlation between the ejection fraction measured with MUGA and that measured with PET (y = 4.03 + 1.04x, r = 0.90, p < 0.01). PET measurements of LV volumes were as follows: LV-ED volume ranged from 82 to 248 ml and LV-ES volume ranged from 22 to 200 ml. In conclusion: 1) LV ejection fraction can be accurately measured by gated PET and 2) absolute ED and ES LV volumes can be quantitated simultaneously with the other physiologicalPET parameters,
P20-454
P20-456
3-D WALL PARAMETERIZATION METHOD FOR QUANTITATIVE LVEF OF GATED SPECT SESTAMIBI WITH LV DYSFUNCTION AND SEVERE PERFUSION DEFECTS
Assessment of myocardial systolic and diastolic function with multi-gated myocardial SPECT.
Ronald G. Schwartz, Jeanne M. Eckdahl, Craig Thompson, University of Rochester Medical Center, Rochester, NY, USA
W E D N E S D A Y P M A P R I L 2 6
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
Myocardial perfusion Tc-99m-sestamibi imaging with gated SPECT (GS) permits accurate assessment of LVEF, but automated LVEF in patients (pts) with LV dysfunction (LVD) and severe perfusion defects (SPD) requires further evaluation. To assess reproducibility of automated LVEF with LVD and SPD, we developed a 3-D myocardial wall parameterization method (MDIM) and compared blinded visual estimations of EF by GS and echocardiography (Echo) to it in 49 pts with EF< 55%. Linear regression and correlation of duplicate EF by MDIM (A); and in 26 pts (53%) with SPD (B) were studied. Visually estimated EF by GS (C) and echo (D) were compared to LVEF by MDIM. Results: LVEF (38.7 + 2.1) by MDIM was similar to C (39 _+ 1.9), and D (42.2 + 1.8, P<0.02). LVD pts with SPD had lower LVEF than pts with LVD and no SPD (31.8 + 3.0 vs. 46.5 + 2.1, P<0.001). Correlations: MDIM vs: R SEE N P MDIM (A) 0.971 3.55 49 <0.001 SPD (B) 0.955 4.42 26 <0.001 GS Visual (C) 0.804 7.87 49 <0.001 Echo Visual (D) 0.73 8.60 49 <0.001 Conclusions: 1.3-D quantitative LVEF is highly reproducible in pts with LVD and SPD. 2. Accuracy of visually estimated LVEF by GS is good and by echo is fair compared to MDIM.
I Adachi, Y Sugioka, Y Ohtake, A Moriguchi, S Tamoto, K Sueyoshi, I Narabayashi Osaka Medical College, Japan. To evaluate myocardial systolic and diastolic function, we performed ~gmTc-tetrofosminmulti-gated myocardial SPECT in 4 normal volanteers, 10 hypertrophic cardiomyopathy(HCM), 1 dilated cardiomyopathy(DCM), 26 coronary artery disease(CAD), 2 hypertensive heart disease (HHD) and 3 others (total 46 patients, mean age 58yo, 36 males, 10 females). All cases were injected 555 MBq of 99~q'c-tetrofosmin intravenously at rest. A triple detector gamma-camera (GCA-9300A) and a data processing computer (GMS-5500A) were used in this study. A cardiac cycle (R-R interval) was divided into 16 frames (50-80 msec per I frame). Six myocardial volume curves(MVC) of each segment (ANT, APEX and INF in VLA, SEP, APEX and LAT in HLA) were made out of a series of ROIs' counts applied by cardiac pool method. The patterns of MVC were classified into 5 patterns ( Normal (N), Delayed Contruction(DC), Delayed Relaxation(DR), Mixed(M) and Normal with Decreased amplitude(ND)). Myocardial uptake was evaluated visually of grading into hypertrophy(5,4), normal(3), hypoperfusion(2,1,0). We compared patterns of the myocardial volume curves to myocardial uptake in the same segments (total 276 segments). MVC shows DR (39.5%) in 38 hypertrophic segments(4or5), DC (16.9%), ND(15.5%) and M(12.8%) in hypoperfusion segments (0,1or2) and N(55.1%) in normal segments(3). We conclude that MVC with multi-gated SPECT can evaluate myocardial systolic and diastolic function directly.
JOURNAL O1~NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday afternoon, April 26, 1995
Sl15
P20-457
P20-459
CLINICAL VALIDATION OF A NEW QUANTITATIVE APPROACH TO ANALYSE 99mTc-MIBI Gated-SPET: A MULTICENTER STUDY. Giuseppe Rubini, Gianluca Valentini, Valerio Todino, Giovanni Moscatelli, Giuseppe Fiorentini, Paolo Miletto, Roberto Dentici, Marcello Capo, Mario Lepera, Alberto Cuocolo, Gianni Bisi. Nucler Mededicine Dept. Bad University, ITALY. The aim of this study was to evaluate the clinical application of two semiquantitative analysis to 99mTc MIBI G-SPET first one based on bull's eye images and second one on circumferential profiles. We considered bull's eye plot obtained from subtraction diastolic from systolic bull's eye images. The circular profile method was based on segmental (6 segments) difference in counts between systolic and diastolic frames. Preliminary analysis was performed on two slices. In 40 Pts we performed echocardiography, blood pool scintigraphy, and coronamgraphy. All underwent a two day Stress/Rest G-SPET protocol. Acquisition started after 90 min ergonomic test and 99mTc-MIBI injection (64x64 matrix, 180 orbit, 32 steps, 50 sec/step, 8 frames/cycle. LEHR collimator). Segments with no or slight count increase at rest G-SPET were considered infarcted. These semiquantative data were compared also with clinical and angiographic data. In ischaemic Pts we found, in stress data analysis, an exact correspondence between bull's eye analysis and counts increase greater than 10%. In necrotic areas no counts change or negative value was found. This semiquantative analysis seems to be able to clarify clinical problems. Perhaps automatic analysis would be better.
IMAGE INVERSION TECHNIQUE TO OBTAIN LEFT VENTRICLE FUNCTIONAL PARAMETERS BY 99mTc-MIBI LAO 45~Gated PLANR STUDY. A MULT/CENTER STUDY. Valerio Todino, Gianluca Valentini, Giuseppe Rubini, Antonio Favella, Giovanni Moscatelli, Giuseppe Fiorentini, Roberto Dentici, Paolo Miletto, Alberto Cuocolo, Gianni Bisi. Reg. Apost. ALBANO L. (Rome) Hospital, ITALY. Image inversion technique applied to 99mTc-MIBI LAO 45 ~ gated-Planar study allows the use of the software for automatic edge detection as well as for gated blood pool study analysis. The activity/time curve obtained is strictly related to the real LV functional parameters: EF, regional EF, wall motion, phase and amplitude parametrics image and volume estimation. A manual correction for LV perimeter ROIs was necessary only in a few patients with large perfusion defects. In order to have a usefull count rate we computed at least 600 cardiac cycles. To firstly evaluate the method we compared data from 30 Pts who underwent 99mTc-MIBI planar gated study (ANT LAO45 ~ LAO70 ~ after G-SPECT to those with radionuclide equilibrium angiography. Results showed a very good linear correlation between EF and EDV calculated from blood pool and from gated-planar MIBI study (LAO 45~ (r=0.969, p<0.001; r=0.871, p<0.01). Wall motion analysis showed an interesting superimposition between the two methods. In conclusion we suggest that performing a LAO45~ gated-Planar 99mTc-MIBI study associated with 99mTc-MIBI G-SPECT it is possible obtain LV perfusion pattern and functional parameters with one tracer injection.
P20-458
P20-460
~ ~ 99mTc,MIBI ~ SPET TO EVALUATE VIAItE MYOCARI~JM:~ Y DATAOFA M I . L ~ S'IUDY. Gianluca Valentini, Valerio Todino, Giuseppe Rubini, Stefano Gobbi, Luigi Paccaloni, Caudio Palpacelli, Alfonso Berbellini, Sergio Ancidei, Emesto Brianzoni. Nucl. Med. Dept9 Hospital of Macerata, ITALY.
LEFT VENTRICULAR DYSFUNCTION CAN BE PREDICTED BY THE THALLIUM CAVITY-TO-MYOCARDIUM RATIO BUT NOT BY THE HEART-LUNG RATIO.
The aim of the study was to evaluate the use of low dose Dobutamine ODD) c,.sr~ in detecting viable myocardium. We visualized viable tissue and evaluated functional reserve. 10 Pts with previous AMI and reduced ejection fraction, awaiting revascularization were studied. All Pts recieved 1100 MBq of 99mTc-MIBI and base line G-SPET (64x64 matrix, 180~ orbit, 32 steps, 50 sec/step, 8 frames/ cycle, LEHR collimator) was acquired after 90 min. Then, during dobutamine infusion (5 pgr/Kg/rrin.), a second GSPET was acquired. Sectors with low counts and no motion in base line G-SPET were selected. We evaluated the counts increase from diastolic to systolic frames during base line and LDD G-SPET. This analysis was performed by the circular profiles method and systolic minus diastolic bull's eye map. A 16 Myocardial Segment (MS) model was used. In 28 MS there were no counts change between basal and I.DD GSPEr. 19 MS showed a segmental sytolic counts increase during LDD infusion only. W e c o n s i d e r e d t h e s e s e g m e n t s as v i a b l e myocardium. This preliminary study shows that Base line/tDDG-SPETcan be considered a promising test to detect viable myocadium and to quantitate its functional reserve.
Jeroen J. Bax, Frans C. Visser, Pieter G. Raijmakers, Gerrit J.J. Teule, Cees A. Visser. Free University Hospital Amsterdam, The Netherlands. Recent data suggest that the ratio of counts in the left ventricular (LV) cavity to that in normal myocardium (C/M ratio) of thallium (T1-201) SPECT can be used to assess LV dysfunction. We studied the relation between the LV ejection fraction (EF) and the C/M ratio. Also, the relation between the heart-lung ratio (as another parameter of LV dysfunction) and the LVEF was studied. Methods: in 75 subjects in whom a catheterization was performe--~, a resting T1-201 SPECT was obtained. C/M ratios were computed from a midventricular short-axis slice. H/L ratios were determined from an axial slice. Correlations were determined using linear regression. The lower limit of a normal C/M ratio (mean-2SD) was determined from data from subjects with normal coronary arteries and normal LV function (LVEF>50%). Results: the C/M ratio showed a good correlation with the LVEF (r=-0.74, p<0.001). The H/L ratio did not correlate with the LVEF (r=0.19, p=0.09). The lower limit of a normal C/M ratio was 0.55. At a cut-off point for C/M ratio=0.55 the positive predictive accuracy for a LVEF>50% was 74%, and the negative predictive accuracy was 87%. Conclusion: a relation etween the C/M ratio and the LVEF ~ a high C/M ratio > 9 (_0.55) p re dlCts normal LV function. H/L ratios do not provide this information. Thus, additional information regarding LV dysfunction can be obtained from SPECT rest studies.
W E D N E S D A Y P M A P R I L 2 6
S116
Abstracts Wednesday afternoon, April 26, 1995
P20-463
DOBUTAMINEFIRST PASS EJECTIONFRACTION IS NOT HELPFUL IN IDENTIFYING POST-INFARCTION PATIENTS WITH MULTIVESSEL CORONARY ARTERY DISEASE UNDERGOING TC99m-TETROFOSMINPERFUSIONIMAGING.
Piyamitr Sritara* ME)., Chanika Sritara** MD.
First pass ejection fraction (FP) could be an advantage of Tc-99m tracers for myocardial perfusion. To examine the potential utility of dobutamine FP in identifying patients (pts) with multivessel disease (MVD) post infarction, we examined 14 patients with recent Q wave myocardial infarction (MI) with dobulamine Tc-99m-tetrofosmin perfusion imaging. 6 pts had MVD on coronary angiography. Maximal dobutamine dose was 26:1:10pg/kg/min. 4 pts experienced angina pectors. Dobutamine stress/rest Tc-ggm-tetrofosmin identified all 6 pts with MVD (12/14diseased vessels). FP at rest was 45_+14%and at peak dobutamine 56_+16%.A failure to increase FP during stress >5% or decrease of FP was characterized as evidence of MVD. Only 216 pts with MVD presented abnormal FP response. 1 pt with 1 VD had a false positive FP response and decreased FP (63% ,-.--42%). In conclusion : Dobutamine Tc-99m tetrofosmin is a reliable perfusion imaging test to identify pts with MVD post infarction. The addition of FP at stress/rest does not appear to be helpful in identifying those pts. The prognostic significance of FP remains to be examined.
A P R I L
Tc-99m Tetrofosmin GSPECT for L V E F Estimation "Department of Medicine and **Department of Radiology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
Left ventficularejectionfraction (LVEF), routinelyobtained by MUGA (mdiouuelidemultiplegatedacquisition),is a strongprognosticfactorin postMI patients can be performedwith Tc-99m tetrofosmin,a myocardialpeffusionagent whose propertiesyieldhighcountingstatisticsmadpermitgatedSPECTacquisitionand hence LVEE To assessits accuracyand reproducibilityin estimatingLVEP.we compared LVEFobtainingfromTe-99mtetrofosminwiththat fromMUGA,performedwithin2 daysof theformer,in 30 consecutivepatientswithknownor suspectedCADwhowere sentfora myocardialperfusionstudy. Eachpatientrecieved24 mCiofeitherTc-99mtetrofosminat peakstress. Eight framepercardiaccycle180degreegatedSPEC~wasperformed60 rainthereafter.Using slicesfrommidventricularverticaland horizontallongaxesand basalshortaxisfromR wavetriggeredend-diastolicand end-systolicframes,semiautomaticROlsweredrawn at the endecardialborderusingsecondderivativemethod. The LVEFwas calculated separatelyforHLAandVLAfromthe formulaEF= ( l - A L e s / A L e d ) x l 0 0 ; whereALes was the productof theareaof thelong axisand the length of the perpendiculardiameter of thebasalshortaxisof the end-systolicframeand ALedwas thatof theend-diastolic frame.TheglobalEFwasthemeanof theI~ fromVLAand HLAviews Thereisa g~xl correlationbetweenLVEF from the two methods(R =0.86) The interobserver variabilitywas0.77 and the intraobserverreproducibilitywas 0.86. We concludedthatby usingECG gatedteclmiqueLVEF.a strongprogaostic factor,couldbe obtainedfroma singlemyocardialperfnsionstudy.
P20-462
P20-464
REPRODUCIBILITY OF ]SCHAEMIA USING TI-201.
Variability o f Normal Wall Thickening by Quantitative Gated SPECT in a Normal Population
E A Jones, A C Tweddel, W D Evans and A H Henderson. University Hospital of Wales mad University of Wales College of Medicine, Cardiff, Wales, UK.
P M
March/April 1995, Part 2
P20-461
J. Lekakis, V. Prassopoulos, T. Athanassoulis, R. Vezyrgianni, M Emmanuel, N. Agrios, E. Papadakis, P. Kostamis, S.Moulopoulos. "Alexandra" University Hospital, Athens, Greece.
W E D N E S D A Y
JOURNAL OF NUCLEAR CARDIOLOGY
Myocardial imaging is still predominantly performed using T1201 but there is very little data on reproducibility. We studied 14 male patients with angiographically determined multivessel coronary disease. Gated planar TI-201 images were acquired in three views using an Elscint mobile gamma camera following maxinial bike exercise, the procedure being repeated two days later. All inmges were reported blind by 2 independent observers. The 3 views were divided into 5 segments with ~erfusion (P) and wall uiotion (WM) in each segment being re ~orted as normal or abnormal. P(%) WM(%) No. of abnormal segments Day 1 Observer 1 88/210(42%) 38/210(18%) Observer 2 90/210(43%) 87/201(4!~ No. of segments showin~ chan~e in classification CHANGE Observer 1 34/210(16%) 34/210(16%) Observer 2 40/210(19%) 52/210(25%) Segments showing a change in wall motion were significantly different between observers, mainly due to disagreement in the septum and apex. We conclude tlaat in repeated TI-201 imaging changes in perfitsion and/or wall motion may be expected in about 20% of niyocardial segments,
Coronado, [C, Tilkemeier, PL, Miriam Hospital, B r o w n University, Providence, RI, U S A Although gated S P E C T ( G S ) h a s been in clinical use there has been no evaluation o f normal wall thickening patterns using quantitative wall thickening(QWT). To evaluate this we studied 17 males and 18 females with a < 5 % pretest likelihood o f C A D with normal perfusion images using QWT. Q W T was assessed in 8 slices from apex to base and 8 segments per slice using a count ratio m e t h o d (end systole/end diastole) b y two observers. Inter-observer correlation was high (r=0.76). Males had significantly lower Q W T ratios c o m p a r e d to females, 1.43 + 0.19 vs. 1.48 + 0.21 (p< 0.001). Furthermore, the Q W T ratios significantly decreased sequentially from apex to base independent o f sex. Females: 1.63 + 0.22, 1.34 + 0.21; Males: 1.54 _+ 0.22, 1.34 + 0.19, apex and base respectively, p < 0.001 for trend. There were no segmental differences in any o f the 8 slices. Therefore, a non-uniform contraction pattern is present in normal pts., decreasing from apex to base. Thus, sex based normal data for Q W T are necessary to assess normal wall thickening. The use o f GS Q W T should have great impact on the interpretation o f GS images.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
P20-465 ISCHEMIC HEMODYNAMIC CHANGES INDUCED BY DIPYRIDAMOLE (DIP) OR BY EXERCISE (EX), EVALUATION BY 99MTC MIBI FIRST PASS ANGIOGRAPHY (FPA). Medici A, "Vignati A, Tredici S, ^Mazzucchelli L, De Petra V. ~Colombo L. Cardiology and ^Nucl .Med,Depts, Busto Arsizio Hospital, Italy
Abstracts Wednesday afternoon, April 26, 1995
S117
P20-467 Simultaneous detarmination of myocardial wall thickening and regional EF by PET - preliminary results. G. HOr, F.D. Maul, W. T. Kranert, A. Kadmian-Tabdz, N. Bauersachs, H. Klepzig, R.P. Baum, A. Hertel, M Oiehl, U. W. Scherer, J. W. Goethe-University, Frankfurt, Germany
33 CAD pt s were submitted to rest and stress simultaneous FPA and myocardial SPECr with 99mTc-MIBI (perfusion defects only on stress images were found). Hemodynamic parameters were obtained from FPA at rest (R) and at the peak (P) of maximal EX test (16 pts] or of DIP (0,7 mg/Kg/4min; 17 pts not able to perform maximal EX): systolic and mean blood pressure (SBP, MBP). HR, double product [DP], LV EF, systolic time (ST), peak e_~ection rate and time (PER,PET), peak filling rate and time (PFR,PFT), ED and ES volumes (EDV,ESV], stroke volume (SV) and cardiac output (CO). Statistic analysis showed difference between DIP and EX only for EDV at R and for HR,SBP,MBP,DP,ST, PFT,CO at P. Between R and P, difference was found for HR,DP,ST,CO,PET,PFR in DIP group and for HR,SBP,MBP,DP.ST. PFR,PFT,CO in EX group. These data suggest: 1.DIP and EX are performed in pts wlth different EDV; 2.DIP and EX cause different changes not only of HR,SBP,MBP,DP but also of systolic and diastolic parameters.
The aim of the study was to correlate F-18-FDG uptake and simultaneous wall thickening. Patients: 10 patients suffering from CAD subsequent to myocardial infarctions with multivessel disease (MVD) (EF<40%), Cineventdculography (CVG) preceded gated PET (GAPET). Methods: Each patient was injected 370 MBq F-18-FDG. Myocardial activity distribution was registered by an ECAT EXAT 47. Global- (GEF) and regional EF (REF) were derived by a geometrical model as adapted to GAPET. Eight gates were choosen with a tail-drop correction: Results:GEF's (PET-derived!) correlate significanty with CVGderived GEF (R=0,64). 24 of 71 evaluated segments were abnormal, 10 of which (40%) were defined as "hibernating" (normal or slightly reduced FDG-uptake along with reduced metabolic wall-thickening). The EF of the corresponding segments was negative (-10% in average). Two segments indicated a mild, two a moderate and 14 exhibited a scar, the latter group with a EF of -2.7% (average). Conclusions: Our preliminary results indicate clinically reliable GEFs and REFs derived by GAPET. Regions with hibernating myocardium present with a negative EF, confirming ischemic bulging. Areas with a scar show an akinesia. It can be expected, that the REF and GEF (simultaneously determined with metabolic wall thickening and FDG-uptake) may improve the differential diagnosis between scar and hibernating myocardium.
P20-466
P20-468
SIMULTANEOUS EVALUATION OF LEFT VENTRICULAR (LV) WALL THICKENING (TH) AND PERFUSION (PE) WITH 201-TL GATED PLANAR MYOCARDIAL IMAGING, Vignati A, Mazzucchelli L, Medici A, Tredici S. Lomuscio G, Dottorini ME and Colombo L. Nucl .Med.Dept.Busto Arsizio Hospital, Italy
LIMITATION OF QUANTITATIVE ANALYSIS OF REGIONAL LV WALL THICKENING WITH Tc-99m MIBI GATED SPECT
As previously described, ECG-gated planar imaging with 201-TI provides images of both PE and TH. 48 pts were submitted to thallium scan (to evaluate PE and TH) and to ERNA (to obtain LV ejection fraction (EF) and images of function (FU)). PE, TH and FU images were divided into 5 segments; a 0-3 score was given to each segment and the average scores were calculated (MPE, MTH, MFU) and compared with EF, with an absolute TH index (ATH=average count change on gated PE images) and with a relative TH index (RTH= THI / end-diastolic average counts). Segment by segment analysis showed good agreement between TH and FU but poor agreement of PE with TH or FU, EF showed close correlation with ATH, RTH, MTH and MEU (r>.82). MPE showed poor correlation with ATH, MTH, MFU and EF (r .72] but bad correlation (r=,59) with RTH. These results suggest that: I.LV FU and TH are correlated but maybe do not show the same phenomenon; 2.to some extent, LV FU and TH are independent from PE.
Shigeo Kawano, Yoshio Ishida, Kohei Hayashida, Yoshiaki Hirose, Nobukazu Takahashi, Shuji Fukuoka, Makoto Takamiya. National Cardiovascular Center, Osaka, Japan. Previous studies have suggested that the systolic increase in myocardial radioactivity represented by Tc-99m MIBI gated SPECT (GS) reflects regional LV wall thickening. To evaluate the influence of systolic LV chamber twisting on the regional analysis, we studied 17 patients (pts) with myocardial infarction by performing GS and by estimating the circumferential profiles of tracer distributions in end-diastolic (ED) and end-systolic (ES) short-axis (S-A) images (3 planes), and regional %wall thickening (%WT). Three S-A images were analyzed by dividing into 16 segments in each. In 23 (45%) of 51 S-A images from 17 pts, the profile curve indicating reduced tracer uptake in the infarcted area was shifted from ED to ES images: 16 in clock-wise and 7 in counter-clockwise rotation. Also, the magnitude and/or the direction of the rotational shift among the three S-A images were different in 9 pts (18%). These results suggest that the effect of the chamber twisting on the analysis of regional wall thickening is not negligible and must be carefully interpreted in Tc-99m gated MIBI SPECT.
W E D N E S D A Y P M A P R I L 2 6
Sl18
Abstracts Wednesday afternoon, April 26, 1995
P20-469
P21-471
EVALUATION OF CORONARY REVASCULARIZATION WITH GATED SESTAMIBI SPECT: QUANTITATIVE ANALYSIS OF SEGMENTAL MYOCARDIAL PERFUSION
COMPARISON OF MULTIGATED RADIONUCLIDE VENTRICULOGRAPHY AND 2 D ECHOCARDIOGRAPHY IN THE DETECTION OF SYSTOLIC ABNORMALITIES IN CHILDREN WITH DUCHENNE'S MUSCULAR DYSTROPHY.
T Massardo. P Gonzalez, P Humeres, A Mufioz, J Jofre, P Hidalgo. University of Chile Hospital, Santiago, Chile We assessed the changes in myocardial perfusion at 64 415 days (M4-SD) after coronary revascularization (REV) using Tc-99m sestamibi gated SPECT in 37 pts (31 with prior myocardial infarction) during dipyridamole administration. REV consisted of coronary angioplasty (A) in 18 pts and coronary bypass grail surgery (CABG) in 19 pts. An average of 18 and 2.5 vessels per pt received A and CABG, respectively. Diastolic SPECT images were computer-quantified and statistically compared with a corresponding diastolic gated SPECT normal data bank comprising 40 normal volunteers. After REV a similar reduction in total perfusion defect size (28% and 4i%, p=ns) and iscbemic defect size (75% vs 81%, p=ns) resulted with A and CABG, respectively. The reduction in defect severity however, was greater after CABG than after A (51% vs 29%, p<0.05) Thus. A and CABG provide similar reduction in overall defect size and ischemic defect size, but CABG affords greater improvement in defect severity
P20-470
Wall Motion Abnormality Detected by ECG-gated Myocardial Perfusion Study and by Echocardiography Pakorn Chandanamattha*ME).. P Sritara', C Sritara**, S Boonbaichaiyapruck*.K Likittanasombat'LS Tanomsup'~ "Department of Medicine and "Department of Radiology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
W E D N E S D A Y
P M A P R I L
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
By incopomtinggated-ECGto myocardialperfusionimagingstudy, regional wallmotionabnomalityand left ventricularejectiontraction(LVEF) strongprognosticfactor,can be assessed. We comparedregionalwallmotion and LVEF detectedby EOGgatedmyocardialperfusionimagingstudy,using ~'rc Tetrofosmin,and 2D echocardiography to assess the accuracyof the former. Method: Twenty-fourpatientsunderwent myocardialperfusionstudy andechocardiography,blindlyperformedby singlecardiologist. Eachpatient received24 mCiofTc-99mtetrofosminat peakstress. Eightframesper cardiac cycle 180degreegatedsPECTwas performed60 minthereafter. Usingslices frommidventricularverticaland horizontallongaxes andbasalshortaxisfrom R wavetriggeredend-diastolicand end systolicframes,semi-automaticROIs weredrawnat the endocardialborderand LVEFwas calculated. Results: There was no significantdifferencein LVEF detected by myocardialperfusionimagingstudyand by 213 echazardiography(oorrelalion coefficient=0.75). A goodcorrelationof wallmotionabnormality,detecetedby myocardialperfusion imagingstudyand by 2D echocardiography,was also observed. SensilivityofECGgatedSPECr indetectingwallmotionabnormality is 87.5%and specificityof 87.5%. Therefore,we concludedthat in additionto LV peffusion,ECG gated myocardialperfusionimagingstudycan givean accurateinformationconcerning wall motionabnormalityandLVEF.
Gtinsel VuraL Mustafa [lnlti, Deniz O~uz, Btilent Turgut, Sabahat inamr, Rana Olgunttirk. Gazi University Medical Faculty, Departments of Nuclear Medicine and Pediatric Cardiology. Ankara / TURKEY. Cardiac involvement is a common feature of Duchenne's type muscular distrophy (DMD) especially in the late stages of the disease. The purpose was to evaluate cardiac functional abnormalities in DMD using, Equilibrium multigated radionuclide ventriculography ( M U G A ) and 2D Echocardiography ( Echo ). 21 DMD patients ( mean age: 8.26 _+4.30, range 3 -17 ) and 12 age-matched controls ( mean age: 8.53 + 4.18, range: 3 -16 ) were included in the study. The two techniques were performed by different laboratories withouth any prior knowledge of the clinical status of the patients. MUGA studies were performed in two projections RAO / LAO, ant. / left lat. - simultaneously using a dual head GCamera ( GE-Optima ) and ejection fraction of the left ventricle (EF) was calculated by an automated edge detection program. Echo was performed by two investigators and EF was calculated by Teicholz method. Mean EF value obtained in DMD and controls were ; 45.5+6.1%, 56.4+3,8 %, (p<.005) in MUGA studies and, 60.8 + 5.9 %, 67.5 + 7.3 % ( p< .01) in Echo. In -1 SD lirnites sensitivity of MUGA and Echo in the detection of decreased EF in DMD, were 8 1 % and 52 % , respectively. In MUGA studies, peak emptying rate ( DMD: 3.06 +.4, controls: 3.55 +.4, p<.001 ) and, end systolic time ( DMD: 270.05 + 20.5, controls: 302.90 • 22.4, p<.001 ) were also found significantly abnormal in DMD when compared to control group. However, no significant difference was noted in dystolic parameters. In conclusion MUGA was more sensitive and not-operator dependant test in the detection of systolic abnormalities, especially in calculation of EF in children with DMD when compared to Echo. P21-472
RADIOISOTOPIC EVALUATION AFTER FONTAN TYPE OF REPAIR FOR TRICUSID ATRESIA OR ~INGLE VENTRICLE F. Tartagni, S. Biancoli, S. Specchia, M. Levorato, M. Bonvicini, M.F, Picchio, F. Fallani, C. Corbelli, S. Fanti, N. Monetti. S. Orsola-malpighi Hospital, Bologna, Italy. 10 young patients (pts) (mean age 12 +_3; range 8 - 17 years) underwent clinical and functional evaluation following (1 - 12 years; average 7.4 • 4) Fontan repair for tricuspid atresia or single ventricle. All pts were sympthoms free and without clinical signs &heart failure. Effort tolerance was clinically normal, but determination of maximal oxigen consumption (Max VO2) resulted reduced in all eases, A MUGA study with determination of ejection fraction (EF) and volumes (V) was performed at rest in all pts and during stress in 5 cases. A lefi~ ventricular pattern was imaged in all cases. In 7/10 pts EF was low (< 45%) when compared to values of normal systemic ventricles. No correlations were found between Max VO2, ventricular function and clinical patterns. Conclusions: these preliminary results seem to indicate that evaluation &cardiac V and EF is feaseble and extremely useful also in pts with a main pumping ventricle. Attention should be reserved to Fontan pts in whom left ventricle dysfunction may preced signs of heart failure.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday afternoon, April 26, 1995
P21-473
P21-475
MYOCARDIAL PERFUSION (PH) W I T H SPECT AND S E S T ~ I B I IN CHILDREN W I T H CORONARY PATHOLOGY. 0tero, F; Sa!vati, A; ~arde!!a, A; Campanelli, H: Pasqua!ini, T; Artagaveytia, D; Degrossi, O; Garcia del Rio, H y Lic. Ortlz, M. Hospital de Nifios Dr. R. Gut!errez e Institute Argentine de Diagn6stico y Tratamiento. The purpose was study myocardial perfusi6n a b n o r ~ l i t y in children with anomalous implantation of left coronary artery (ACA) (Gr.I) and with Kawa~aki disease (KD) (Gr. II). METHODS: MP was study in 18 ncrmal patients (Gr. III), in 8 patients of (Gr.I) 3 of them surgically corrected {Gr la) and 12 patients of Gr.!l[. They sere study with g P E C T and Sestamibi in basal and exercise conditions (12 patients with d i p i r i d ~ o l ) . P ~ i T ~ S : Gr.iil had a normal MP (2 false positive in basal state}. ~n Gr. I 80 % had severe alteration in MP in different sesmentary in rest: 20 % had normal MP in rest and exercise Gz'. la: 2 patients normalized P~ at rest and exer,cide, i patient r~mained abnormal. Gr.ll: 9 patient~ had normal MP and 3 had different degree of abnormalities at rezt and with dipirldamol. c " c ~ i O ~ q ~ . ~ [- This method showed to be useful to detect isdeiimia in ACA and ~D. 2- In comparison with normal the sensibility for ACA was 87,5 % and specificity i00 ~, for the patients with ~D the sensibility wa~ 7(9 % with specificity i00 ~ atrest. 3- The :~erated patients with good evolution improved its MP during exercise; this inverted redistribution probably • due to persistent collateral circulation.
EXERCISE ABILITY AFTER ATRIAL CORRECTION FOR TRANSPOSITION OF THE GREAT A R T E R I E S (TGA): ROLE OF THE RIGHT VENTRICULAR DYSFUNCTION.
Sl19
L.Labb6, L. Bordenave, A. Choussat, J.P Broustet, D. Ducassou, J.L Barat, H6pital cardiologique du Haut-L6vSque, Pessac, FRANCE. We studied 50 patients after atrial correction for TGA, mean age 12 years (37 boys, 13 girls) and 50 normal children of comparable sex, age and body surface area. All children realized an exercise test with gas exchange measurement. Only in the patient group, the right ventricular ejection fraction (RVEF) was calculated by radionuclide ventriculography (Te 99m) at rest (50 patients) and during exercise (32 patients). Cardiorespiratory response to exercise was lower in patient group.RVEF was abnormal (<40%) at rest in 14%. During exercise, right ventricle response was abnormal (RVEF increased less than 5%) in 45% and the end-exercise value of RVEF was abnormal (<50%) in 34%. There was a relative correlation between end-exercise RVEF and VO2max (r=-0,61) or aerobic treshold (AT) (r=0,6). In patient with abnormal exercise RVEF, exercise duration, VO2max , and AT were lower (p<0,005). Conclusion : classic abnormal cardiorespiratory response to exercise after atrial correction for TGA seems to be related to right ventricular dysfunction.
P22-476
P21-474 NYOCAP3)IAL HYPOXAEMIA DETECTIOM BY PET IN CHILDREN WITH VALVULAR AORTIC STEMOSIS. Strengers Jan LM, Pruim J, Btanksma PK, deJong R, Kuipers JRG, Vaatburg W. Beatrix Children's and University Hospital, Groningen, The Netherlands Myocardial hypoxaemia in children with valvular aortic stenosis is the indication for intervention. Assessment of myocardial perfusion (MP) and perfusiom reserve (MPR) by PET might be a better indicator for myocardial hypoxaemia than currently applied diagnostic modalities. 15 children (14 boys,1 g i r l , 8-14 yrs.) were investigated by ECG, Hotter, bicycle-ergometry and echocardiography. HPrest, MP after Dipyridamole stress test (dst) and HPR were assessed by (N-13)ammonia PET. in each session the child received the bedy-weight adjusted equivalent of 370 MBq (N-13)-ammonia as a bolus. HP was calculated using Kety's model with bloodpool a c t i v i t y in the l e f t ventricle as input curve. MPR was calculated from the formula MPdst-MPre t/HPdst*lO0. These values were compared with those of normal adults. According to standard echo- and electrocardiographic criteria patients were divided into three groups: mild stenosis (echo pressure drop <50 mmHg), moderate stenosis (50-75 mmHg pressure drop, without ischaemia on ECG), severe stenosis (>75 mmHg or ischaemia). PET data were normal in case of mild or moderate stenosis. In all patients with a severe stenosis at least MPrest, MPdst or MPR was abnormal, in two patients an increased MPrest and MPdst with a indicated an adequate compensation of myocardial normal MPR perfusion to the increased pressure load. In two patients an increased MPrest with a decreased MPR might indicate a failing compensation during dst and myocardial hypoxaemia, as maximum oxygen delivery to the heart is mainly flow related. From this group we conclude that assessment of MP and MPR in children with valvular aortic stenosis might be a more sensitive tool in diagnosing myocardial hypoxaemia than currently applied non-invasive diagnostic modalities.
EVALUATION OF RADIONUCLIDE ANGIOGRAPHY IN THE DIAGNOSIS OF ARRHYTHMOGENIC RIGHT VENTRIGULAR CARDIOMYOPATHY (ARVC). D. Le Guludac, M. Slama, R. Franck, G. Grimon, Y. Petagnief, M. Faraggi. HGpital Blchat, Beckire and J. Rostand, France. In pts with recurrent right ventricular tachycardia, the diagnosis of ARVC is based upon the presence of RV wall motion abnormalitieson X-ray angiography,withoutevidence of other heart disease. X-ray and radionuclideangiography were prospectivelycompared'in 73 pts with ventricular tachycardia. Were analysed: the presence of right ventricular enlargement and global hypokinesia, and segmental wall motion abnormalities, using visual analysis for both techniques and Fourier analysisfor radionuclideangiography. The disease was noted as absent or present, and diffuse or Iocalised ; the interobserver reproducibility of both tehniques for the diagnosis was tested in 27 randomly selected patients. Results:According to X-ray angiography, 53 patients were considered as having ARVC (31 diffuse and 22 Iocalised forms), and 20 patients as having a normal RV. The sensitivity of radionuclide angiography was 94.3%, specificity 90%, positive and negative predictive values 96% and 85.7%. The agreement for the location of the wall motion abnormalitieswas 60% for the apex, 76% for the outflow tract, 82% for the inferior wall and 74% for the free wall. The diagnosticinterobserverreproducibilityof Xray and radionuclide angiography was 74% and 96.2% respectively. Conclusion: In a selected population, radionuclide agniography is an accurate and reproducibletool for the diagnosisof ARVC.
W E D N E S D A Y P M A P R I L 2 6
S120
Abstracts Wednesday afternoon, April 26, 1995
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
P22-477
P22-479
Withdrawn
is FOCAL MYOCARDIAL ISCHEMIA THE CAUSE OF ANGINA PECTORIS IN SYNDROME X? Joan G. Meeder, Rutger L. Anthonio, Eng S. Tan, Paul K. Blanksma, Jan Pruim, Willem Vaalburg, Kong I Lie. University Hospital Groningen, The Netherlands. The aim of this study was to confirm the hypothesis that a patchily distributed increased tone of the prearteriolar coronary vessels might cause focal ischemia and subsequently angina pectoris in syndrome X (i.e. angina pectoris, ischemic-like stress ECG despite angiographically normal coronary arteries). Using N-13 ammonia parametric PET and parameters of heart rate variability (HRV), segmental myocardial perfusion and its relation to autonomic function were examined. Compared to 16 age- and sex-matched healthy volunteers, the coefficient of variation of segmental perfusion, as a measure of perfusion heterogeneity, was higher in syndrome X patients (17.0 + 3,2 versus 13.6 + 2.2 %; p<0.01). In contrast with votunteers, patients showed negative correlations (p < 0.05) between this coefficient of variation and HRV-parameters, The study supports the notion that angina peetoris in syndrome X might be caused by focal ischemia, since a marked perfusion heterogeneity was found. Since heterogeneity is inversely related with HRV-parameters, it is tempting to speculate that abnormal response of coronary vessels to autonomic tone plays a pathogenetic role.
P22-478
Septal glucose utilization in patients with left bundle-branch block depends on severity of left anterior descending artery disease G. Schulz, J. vora Dahl, U. Buell. University of Aachen, Germany
W E D N E S D A Y P M A P R I L
Commonly left bundle-branch block (LBBB) is caused by isehemic heart disease in the supplying area of left anterior descending artery (LAD). To determine its influence on the evaluation of septal myocardial viability, we studied 8 patients with constant complete LBBB following chronic myocardial infarction. PET-studies with 150 MBq 2-1SF-fluoro-2-deoxyglucose (FDG) and SPECT with 400 MBq 99mTc-2-Methoxy-Isobutyl-Isonitril (MIBI) were quantitatively evaluated in 25 polar left ventricular regions of interest (ROI) per patient. Regional uptake of MIBI and FDG was normalized to the ROI with highest MIBI uptake (100%). Anglography revealed in 5 patients proximal occlusion or stenosis > 75% of LAD. In 3 patients a peripheral stenosis was shown, or the ramus diagonalis was affected or a sufficient bypass graft supplied this vessel area. advanced LAD disease mild/revasc. LAD disease total septal total I septat ROIs n = 124 n = 30 n = 75 n = 18 MIBI% 73 +18 64 +11 67 +19 75 +20 I FDG% 64 • 39 • 60 • + 68 • + mean • standard deviation, *1" significant for p<0,001, +/+ not sign. In the group with mild / revascniarised LAD disease the LBBB itself did not reveal an indicatible effect on septal glucose utilization. However, in the group with advanced LAD disease decreased septal glucose metabolism (values as in complete scar) may be additional attributed to the LBBB because perfusion was partieulary preserved, resulting in a limitated validity of FDG-PET in septal viability evaluating in such cases.
P22-480
1231-MIBG TO EVALUATE LATE CARDIAC EFFECTS OF CANCER THERAPY. Renato A. Vald6s Olmos, Willem W. ten Bokkel Huinink, Luc G.H. Dewit, Cornelis A. Hoefnagel, Harm van Tinteren. The Netherlands Cancer Institute, Amsterdam. Recognition of adverse late cardiac effects from cancer therapy may enable identification of patients with risk of cardiotoxicity at cancer retreatment. We evaluated both myocardial adrenergic neuron function, with 123I-MIBG, and systolic function, by measurement o f ejection fraction (EF), in 17 cancer patients (16 F, 1 M, mean age 50+/-8 years): 10 with anthracycline therapy and/or thoraxic irradiation 8-156 months (median 33) before radionuclide tests; 7 without previous anthracycline-or radiotherapy (controls). 123I-MIBG uptake was quantified by a heart-tomediastinum ratio (HMR) on planar images after 4 hours. In patients who had received cancer therapy, HMR (range: 1.21-1.72, median 1.55) was significantly decreased (p<0.001) in comparison to controls (range 1.81-2.06, median 1.9). EF (range 45%-57%, median 47% vs. 50%70%, median 59%) was also significantly lower (p<0.003), but with some overlap in individual values. Assessment of late cardiac effects from cancer therapy with 123I-MIBG appears to be feasible. In these patients, detection o f cardiac adrenergic neuron derangement may help to confirm increased risk for cancer retreatment.
JOURNAL OF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday afternoon, April 26, 1995
S121
P22-481
P22-483
MAPPING OF ANTHRACYCLINE MYOCARDIAL DAMAGE WITH lllln-ANTIMYOS!N SPECT.
QUANTITATIVE EVALUATION OF BLOOD-FLOW AND ARTERIOVENOUS SHUNTING IN DIABETIC LIMB.
Renato A. Vald~ Olmos, Willem W. ten Bokkel Huinink, Peter F. Bruning, Cornelis A. Hoef~agel. The Netherlands Cancer Institute, Amsterdam, NL.
Sabahat namr, Mustafa 0niL), Berna Okudan, Canan Alataw H0seyin Alklm. Gazi University Medical Faculty, Departments of Nuclear Medicine and Internal Medicine. Ankara / TURKEY.
In order to determine the distribution of cardiac uptake and its complementary value in confirming myocardial damage, SPECT was performed in 18 patients investigated with lllln-antimyosin for anthracyeline cardiotoxicity. Studies,
obtained after 48 hours, were evaluated together with planar anterior and LAO images, Quality of SPECT images was analysed in relation to the degree of cardiac uptake quantified by heart-to-lung ratios (HLR) on planar anterior images. SPECT demonstrated unequivocal myocardial uptake in 14 patients with a better delineation of the left ventricle than planar views. However, right ventricle uptake was better seen on anterior planar images. Myocardial visualization by SPECT was satisfactory in cases with HLR of over 1.7. Myocardial damage was diffuse in all but two cases: in one patient diffuse uptake was accompanied by very intense accumulation in the posterior wall and another patient showed uptake only in anterior wall; further analysis ruled out myocardial infarction in these patients. Complementary SPECT, verifying myocardial uptake of lllln-antimyosin, may lead to a better interpretation of quantitative parameters. Anthracycline damage appears to concern the myocytes of all ventricle segments.
P22-482 Cardiotoxlcity of combined chemotherapy in patients with hematopoletic malignancies - - Use of '"1-MIBG myocardial SPECT - Nozomi Niitsu, J u n - i c h i Yamazaki, Masaki Igarashi, Masanori Umeda, and Takeshi Morishita. First Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan To assess cardiac sympathetic nervous dysfunction, '23I-metaiodobenzylguanidine (MIBG) myocardial SPECT was p e r f o r m e d in p a t i e n t s w i t h h e m a t o p o i e t i c malignancies who received chemotherapy including adriamycin (ADM). The mean total dose of ADM was 2A7.6mg/m~ (50~560mg/m2). '2~I-MIBG myocardial SPECT images were acquired at 20 min and 4 hours after intravenous injection of MIBG, and the washout rate (WR) of the total left ventricular area was calculated. 1) A significant positive correlation was noted between the WR and the total dose of ADM (p<0.001). 2) Ventricular arrhythmias occurred more frequency in patients with an enhanced WR. 3) Sympathetic nervous d y s f u n c t i o n was s u g g e s t e d to be involved in the development of myocardial abnormalities associated with chemotherapy. 4)Although the WR returned to normal in many patients at 3 ~ 6 months after the discontinuation of chemotherapy, long-term follow-up was needed for patients in whom the WR increased by 40~50% or more. The WR calculated from MIBG, myocardial SPECT appears to be a useful index of cardiotoxicity for deciding on the discontinuation of chemotherapy of dose reduction.
The aim of the study .was to evaluate peripherial vascular disease and the effect of autosympathectomy in microcirculation in diabetic limb using intraarterial administration of Tc-99m MAA. 13 NIDDM patients( mean age : 58.6 + 7.6, range: 4272 years) who had foot ulceration and neuropathy were included in the study. 37 MBq of Tc-99m MAA (10-60 ~t in diameter, approx. 5x104 particles) was injected into femoral artery at the lesion site. Dynamic (1 sec / 150 frames and 60 sec / 10 frames) and wholebody images were obtained. Perfusion ratios were quantified as lesion to intact tissue (PR) using appropriate ROl's. A-V shunting ratio (AVR) was also quantified from the dynamic data set. Mean PR was significantly higher at lesion site; 5.17 _+ 2.27. As it can be expected from this finding all of the patients in this study group recovered with conservative management. In whole body images lung uptake was observed in all cases. AVR was significantly higher in ulcer area ( 22.8 + 14.1 ) when compared to normal tissue ( 10.3 + 5.7 ), p< .025. Increased non-nutrient blood flow through A-V short circuits especially in ulcer zone indicates the role of neuropathy in the development of ulcer. PR might be an objective criterion in the determination of healing potential of diabetic ulcers. P22-484 SYMPATHETIC NERVE ACTIVITY BY IODINE-123 METAIODOBENZYLGUANIDINE IN SYNDROME X Takeshi Tanaka, Tadanori Aizawa, KazuzoKato. The CardiovascularInstitute,Tokyo, Japan To assess sympatheticnerve activity of patients(pts) with syndrome X(SX, chest pain and normal coronary artery) 30 pts with both normal coronary artery and normal stress thailium-201 myocardial images underwent stress Iodine-123 metaiodobenzylguanidine myocardial images(MIBG images). Although pts complained of chest pain, pts continued exercise in case of no aggravation of chest pain. At end point MIBG was injectedand a further minute exercise was performed. Delayed MIBG imageswere performed4 hours later. Nine pts(3 male and 6 female, age 60-+9years) complainedof chest pain during exercise. Average time of beginning of chest pain was 4.7_+2.0 minutes. Average exercise time was 8.7_+1.4 minutes. Average ST-depressionwas 0.7_+0.5ram. In 7 pts stress MIBG images revealed defects. In all 9 pts delayed MIBG images revealed new defects, indicatingincreased washout rate of MIBG and averageextent; score was 44_+13%. The defects did not correspond to coronary anatomy. Remaining21 pts did not complainedof chest pain. Average exercise time was 9.6_+l.4minutes(np). Average ST depression was 1.5_+0.9mm(np). In 5 pts stress MIBG images revealed small defects corresponding to coronary anatomy. No new defects were noted in delayedimages. In pts with SX coronary perfusion was normal during chest pain, however MIBG uptake was depressed.DepressedMIBG uptake during chest pain and increased washout of MIBG might be characteristicso1 SX. In pts with SX norepinephrineupt~e at sympatheticnerve ending might be depressed during chest pain. In rest state norepinephrine release at sympatheticnerve ending might be acceralated.
S122
Abstracts W e d n e s d a y a f t e r n o o n , A p r i l 26, 1995
P22-485
P22-487
DIAGNOSIS OF CARDIAC SARCOIDOS1S BY I-123 MIBG AND TL-201 SPECT IMAGING. Haruto Fujioka, Satoshi O h a s h i , Keiko Kobayashi, Chic Hatsumi, Naoaki T a m u r a , Hiroyuki Sato, Hiroshi Yzmlaguclti. Cardiology, Internal Medicine, J u n t e n d o University School of Medicine, Tokyo, JAPAN. Tile major(77%) c a u s e of d e a t h in s a r c o i d o s i s pattents(pts) is c a r d i a c event in J a p m l . On the o l h e r h a n d , primaaN c a r d i a c involvement is not oRen recognized clinically, a l t h o u g h it may b e d e m o n s t r a t e d a t a u t o p s y in 2 0 - 3 0 % of c a s e s of s a r c o i d o s i s , m a s t of w h t e h d e m o n s t r a t e generalized s a r c o i d o s i s . It is useful to k n o w the p r e s e n c e of c a r d i a c s a r c o i d o s i s ( C S ) in the em'ly p h a s e , b e c a u s e t h i s d i s e a s e is c a p a b l e of In'eating. In fltis s t u d y , we investigate file u s e f u l n e s s of I-123 MIBG(MIBG) mid TI-201{TI) SPECT in d e t e c t i n g CS. All pts(n=30, male; 11 } were d i a g n o s e d .as s a r c o i d o s i s by hilar l y m p h o a d e n o p a t h y or b y uveitis. 111MBq of MIBG a n d TI were injected at r e s t a n d d u a l SPECT i m a g i n g w a s done. Exteni score(ES) a n d severity score(SS) were c a l c u l a t e d u s i n g norn~l bull's eye lnap, all(:[ c o m p a r e d to r e s u l t s of echocardiogrtui~ (UCG) electrocardtogram(ECG) a n d Holter ECG (Holter). 3 0 pts were divided into 2 g r o u p s . Pts in g r o u p A (n=l l) h a d abnornhalittes in E C G o r Holter, pts in g r o u p B /n=19) did not h a v e either. All pts in g r o u p A revealed a h n o r m a l a c c u m u l a t i o n of both MIBG a n d TI, a n d only 3 of t h e m h a d UCG abnornh31ities. In g r o u p B, 2 pts h a d a b n o r m a l a c c u m u l a t i o n ol TI, 10 pLs h a d that of MIBG. The former 2 pts were i n c l u d e d m the latter 10 pts. N o b o d y in this grotq~ h a d rely UCG a b n o r m a l i t y . "From c a l c u l a t e d ES a n d SS (both MIBG a n d TI), nificanfly high s c o r e s were recognized in g r o u p A, in both a n d SS, w h e r e a s r e m a i n e d low in g r o u p B on lhe average. T h o u g h , i n g r o u p B, a few pts h a d significa3~tly high s c o r e s , almost e q u a l to those in g r o u p A. In g r o u p A, ES a n d SS of MIBG t e n d e d to h e high, c o m p a r e d to those of Ti. We recognized s c i n t i g r a p h i c a b n o r m a l i t i e s in all pts who h a d ECG a b n o r m a l i t i e s , a n d also recognized h i g h ES a n d SS in a few pts who did not d e m o n s t r a t e a b n o r m a l ECG. S c i n t i g r a p h i c a b n o r m a l i t i e s , TI is of c o u r s e b u t e s p e c i a l l y M[BG, have possibilities to indicate m y o c a r d i a l i n v o l v m e n t b y s a r c o i d o s i s w h i c h is not able to b e d e t e c t e d b y UCG, ECG or Holter.
Assessment of Diastolic Filling Reveals Early Cardiotoxicity Following Bone Marrow Transplantation. SS. Lele, I'lL Thomson, J$. Atherton, FA. Khafagi, ST Durrant, MP. Frenneaux. Royal Brisbane Hospital, Brisbane, Australia
P22 -486
P22-488
Venoennstriction during Lower Body Negative Pressure in Patients with Neurocardiogenic Syncope H L Thomson, S S Lele, J Atherton, K N Wright, G W Muehle, W J McKenna, M P Frenneaux, Departments of Cardiology Royal Brisbane Hospital Brisbane Australia, and St George's Hospital London U.K.
IS OVERACTIVITY OF SYSTEM DEMONSTRABLE
~
W E D N E S D A Y P M A P R I L
JOURNAL OF NUCLEAR CARDIOLOGY M a r c h / A p r i l 1995, P a r t 2
Background: We tested the hypothesis that in patients with neurocardiogenic syncope(NCS) there may be a failure of venocoastriction in response to central volume unloading and that this may be a primary abnormality leading to an empty hypercontractile ventricle proposed as the substrate for NCS.. Patients and Method: 16 patients with NCS and abnormal tilt table tests ( 12 male and 13 female age 23-70 mean 45.5 years) and 20 healthy controls with normal tilt table tests (15 male 5 female age 25-70 mean 42.2years ) were studied. We evaluated the forearm venous pressure-volume relationship as a measure of forearm venous tone using a nuclear technique before and during the application of subhypotensive lower body negative pressure(LBNP)(20 mm Hg) Results(expressed as mean + SD): LBNP caused a reduction in venous volume at all venous occluding pressures of 11 +5% compared with baseline in controls vs a mean reduction of 10+7% in patients (p =NS), In one patient LBNP caused an increase in venous volume of 9%. Conclusions: For the group as a whole, forearm venous tone increased normally during subhypotensive LBNP in patients with NCS. The observation of a paradoxical venodilator response in one patient during LBNP(present at 10 and 20 mm Hg LBNP ( sub hypotensive) suggests a primary abnormality of venous control may be present in a subset, deserving study in a larger series.
We hypothesized that abnormalities of diastolic filling during exercise may be an early feature of late anthracycline cardiotoxicity. We assessed 25 consecutive patients surviving one year following bone marrow transplantation (BMT) and 10 age matched controls using radionuclide ventricalography during semi erect cycle exercise. 6 patients had received anthracyclines and melphalan(Group I), 9 cyclophosphamide alone (Group /I) and 11 anthracycline and cyclophosphamide(Group~ prior to BMT. Results Ejection fraction was similar at rest and at peak exercise in the controls and patients (564-5.9 vs 55.54-10.9% p NS at rest and 69.2.-+6.9 vs 62.44-12.3% p NS at peak exercise respectively ). Peak filling rate was similar at rest and at peak exercise in the two groups (3.04.0.7 vs 3.3=1:1.4 EDV/s p NS at rest and 7.8a:1.9 vs 6.34-2.7EDV/s p NS at peak exercise ). TTPF was slightly prolonged at rest in patients compared to controls (133~:28 vs 1844-72 ms p=0.04) and at peak exercise was markedly longer in patients (140.44-39.2 in patients vs 634.38.2 c:ontrols p<0.0001 ). There was a loss of the normal inverse relationship between "[q"PF and HR ( r=0.78 p<0.05 in controls vs r ~ . l l p NS in patients) implying the development of diastolic dysfunction during exercise in some patients. In group I patients TTPF was prolonged at rest and during exercise but fell in all patients during exercise, ha group II patients resting TrPF was normal but increased paradoxically during exercise in one patient and the decrease in TTPF in the remaining patients was markedly attenuated. In group III patients resting TrPF was prolonged and rose on exercise in 3 patients. Conc/us/oNs. The combination of cyclophosphamide and anthracycline produces specific abnormalities of exercise diastolic filling which is known to carry a greater risk for late cardiotoxicity.
THE SYMPATHETIC IN S Y N D R O M E X ?
SD Rosen, S Guzzetti, A Dritsas and PG Camici, M R C Clinical Sciences Centre, RPMS, Hammersmith Hospital, London, UK. Excessive activation of the sympathetic nervous system (SNS) has been suggested as an aetiological factor in syndrome X (SX, anginal pain, ischaemic-like stress ECG and normal coronary arleriogram). To test this hypothesis, we measured and assessed the correlations amongst: plasma catecholamines, corrected maximum resting QT interval (QTc-max), myocardial B-adrenoceptor (gAR) density (using PET with 11C-CGP-12177) and frequency domain parameters of heart rate variability (HRV). Pooled data from 18 SX patients [age, mean (SD), 58 (9) years, range 33-69] was compared to that from 20 controls [(2, age 44 (13) years, range 21-77]. Plasma noradrenaline (NA) was higher in SX than C [2.90 (1.03) vs 1.86 (0.85) riM; p<0.01]. QTc-max was prolonged in SX compared to C [439 (33) ms vs 417 (21) ms, p<0.01]. BAR was non-significantly lower in SX [7.88 (1.92) vs 8.76 (2.06) pmol/g]. Amongst the HRV data, the night-time (midnight to 6 am) decline in the low frequency (LF, ~0.10 Hz) c o m p o n e n t found in C was absent in SX [42(2) normalized units (nu) vs 50(3) nu; p<0.05]. In conclusion: These data confirm that there is altered cardiovascular autonomic regulation in syndrome X, with enhanced sympathetic activation, detectable by the non-invasive methods described.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday afternoon, April 26, 1995
P22-489
P22-491
,~v'+~..~**,_,~,~r T~~T~C~',~,~,~, ~.~,FI' \~NTPdCULAR FUNCTION AT REST ,&ND Dt~J-N-G EXERCISE IN MYASTHENIA GRAVIS
Myocardial perfusion and ventricular function in asymptomatic type I Diabetes Mellitus patients. FJ. Setoain, A. Garcia, J, MagriS,~, E, Esmatjes, M. Huguet, J. Vidal, C. Par~, S. Vidal, A. Betriu. Hospital Clfnic. Barcelona. Spain.
Kozarevic N . Pavlovic S,, Rakocevic V., Sobic D., Bosniakovic V. Institute of Nuclear Medicine, CCS, Belgrade, Yugoslavia Patients with myasthenia gravis can develop heart disease. Twenty two patients (t5 male, 7 female, mean age 33x5 years) with ocular and bulbar form of myasthenia graVis were studied in order to evaluate left ventricular tkmction. Global EF and diastolic parameters (peak filling rate-PFR and time tc peak filling rate-TPFR) were detemuned at rest and during exercise usi_n6 equilibrium radionuclide ventriculography In addition, QT interval in ECG at rest and during exercise after R-R interval normalisation was measured. ~ l patients had normal global EF at rest, During exercise global EF in i5 patients was increased by more then 5% while in 7 patients at remained unchanged or slightly decreased. In 4 of them PFR at rest was reduced, TPFR and QT interval in ECG were prolonged. In one patient only diastolic parametrs were abnormal. One patient had aprolonged QT interval with normal systolic and diastolic left ventricular function. No other ECG abnormalities were found Our results showed a slightly reduced left ventricular function using radionuclide ventriculography and ECG changes in 4 (l 8%) patients with the ocular form of myasthenia gavis. In 4 (14%) patients either systolic, diastolic or QT interval changes were found.
To evaluate if diabetes mellitus may develop silent myocardial ischemia or some abnormalities in left ventricular (LV) function, a total of 33 young Type I diabetes mellitus patients without evidence of cardiovascular disease were studied. Rest and stress Radionuclide angiocardiography, 99mTc-Sestamibi SPECT and 2D-Echo were performed in all patients and coronary angiography (CA) in 1 1 patients. Basal LV ejection fraction was 56.5 + 6.6% and increased to 63 + 7.4 on exercise. Rozanski's criteria were normal in 17 patients and abnormal in 1 6. 2D-Echo was normal in all patients but one. Abnormal stress Sestarnibi was detected in 18 patients and only 3 had reversible rest defects. CA was normal in all patients. Thus, there is a number of asymptomathic young diabetes patients who can have abnormal ventricular function and inespecific perfusion abnormalities not related to coronary lesions.
P22-490
P22-492
DIAGNOSIS OF CORONARY ARTERY DISEASE (CAD) IN ASYMPTOMATIC PATIENTS WITH CHRONIC DIALYSIS THERAPY: ACCURACY OF STRESS TL-SPECT. M.Faraggi, M.Dahan, L.Sarda, R.Lebtahi, B.Legallicier, D.Himbert, D.Le Guludec. Bichat,Beaujon,Tenon Hosp, Paris, France.
SCINTIGRAPHIC ESTIMATION OF MYOCARDIAL PERFUSION REGIONSSUPPLIEDBY HYPOPLASTICCORONARYARTERIES.
CAD is the main cause of death in patients (pts) with end stage renal disease. Non invasive diagnosis of CAD in chronic dialysis pts without chest pain may be difficult since EKG and wall motion studies are altered by myocardial hypertrophy and exercise capability is limited. We prospectively evaluated the accuracy of a combined dipyridamole (0.7 mg/kg/4mn) and exercise stress TI-SPECT in 40 consecutive pts (32 male, 54+11 years), receiving chronic dialysis therapy since 3.7+3.5 years. All were asymptomatic, without previous myocardial infarction and both investigated by TI-SPECT and then coronary angiography. Positive criterias (double blinded interpretation) were: coronary artery stenosis >50%, and reversiNe defects on stress/4hrsreinjection SPECT studies. Significant CAD was found in 10 pts (25%) with 1,2,3 vessel disease in respectively 4, 5 and 1 pts. TI-SPECT was positive in 12 pts, with 3 false positive results (all concerning the inferior wall) and 1 false negative. Sensitivity, specificity, positive and negative predictive values were respectively 90, 90, 75, and 96%. Conclusion: this study confirms the high prevalence of CAD in asymptomatic chronic dialysis therapy pts and a good stress TI-SPECT accuracy.
S123
PanagiotisParaskevas,JohnSkoumas,Michail Souvatzoglou,Irene Souvatzoglou, Diagnostic Center of Nuclear Medicine, Athens, Greece The purpose of this study is to estimate the regional porfusion of myocardium by usingThalium-2gl scintigraphy in stress and at rest in patients with one or more hypoplastic coronary arteries, diagnosedby coronaryangiogram.One or two hypoplasticcoronary arterieswerefound, by coronaryangiogram, in twenty ninepatientstwenty five men and four women-aged 42 to 70 years. They underwentmyocardialscintigraphywith TL-201in stress and at rest by using gamma camera and computerizedanalysis (Elscint Co). Seventeenpatients had hypoplastic the right coronary artery, ten hypoplastic the circumflex, one hypoplastic the left anterior descendingartery and one hypoplasticthe obtuse marginal artery. Results of the myocardial scintigraphyof the left ventricle were as following: 7 patients (24.13%) normal perfusion, 2 patients (29%) previous infarct and 20 patients (68.6%) reversibleischemia.Thus, ischemia of the area perfused by a hypoplastic coronary artery seemsto be due to low bloodflow throughthis artery. In conclusion, hypoplastic coronary arteries or major branches could produce ischemia in the myocardiumwhichis suppliedby them evenwithout any critical stenoticlesions.
S124
Abstracts Wednesday afternoon, April 26, 1995
P22-493
P22-495
RIGHT VENTRICULAR ISCHEMIA 1N PAT1ENIES w r r H PRIMARY PIJLMONARY HYPERTENSION.SCINTIGRAPHIC HNDINGS IN 18 CASES
MYOCARDIAL PERFUSION DURING ADENOSINE AND REINJECTION TL-201 SCINTIGRAPHY IN PATIENTS WITH SYNDROME X
Biahistozky D., Gomez A~ Martinez ML, Santos E, F. Sandoval J. Alexanderson E. In. 8 mm Hg, The thalium redis'tribulion test was negative in the remaining 8 patients.
We concluded that R V "ischemia" as assesed by the thalnim test may play a role in the genesis of RVI)
P22-494
P22-496
MENTAL STRESS INDUCED LEFT VENTRICULAR DYSFUNCTION: ROLE OF CHANGES IN ARTERIAL AND VENTRICULAR ELASTANCE AND VENTRICULO-ARTERIAL COUPLING Diwakar Jain, Sherif Shaker, Matthew Burg, Frans J Th Wackers, Barry L Zaret. Yale University, New Haven CT.
EVALUATION OF LEFT VENTRICULAR FUNCTION AND A U T O N O M I C P A T T E R N IN THE POST I N F A C T I O N PERIOD. A S C I N T I G R A P H I C AND HOLTER STUDY.
Redistribution
with
RVEDP > 8
9 1
without 3 5
Fischer's exact test p < 0 05, Odds ratio 15.95% CI 0.90 to 784.8.
P M A P R I L
Francesco Nudi, Achille Gaspardone, Fabrizio Tomai, Lucid Mango, Anna De Fazio, LuigJ Chiariel]o, Pier A. Gioffr~. Division of Heart Surgery, Tor Vergata University, Rome, I The ischemic or non ischemic nature of ECG changes in Syndrome X patients is still controversial. Exercise-induced perfusion defects on Thallium-201 images are observed inconsistently. In this study 10 patients (1 man, 9 women, mean age 57 ys) with anginal pain, exercise-induced ST segment depression, normal coronary arteries and negative ergonovine test underwent semiquantitative adenosine planar thallium scintigraphy (TI). Each of 12 segments was scored from 0 (> 2.5 SD of the mean activity of a control group) to 3 (< 50% of the peak activity). All patients showed perfusion atmormalities on the early post-adenosin e images and had their usual anginal pain. Five patients showed ECG ctanges during adenosine infusion. Five patients had uptake defects also on the reinjection images but there was no significant correlation between the presence of ischemic ECG changes and the severity or the extent of uptake abnormalities cn the early post-adenosine and reinjection images. Thus, during adenosine-induced vasodilation, all patients with syndrome X presented abnormalities on TI. This finding confirms the presence of Thallium uptake abnormalities in patients with syndrome X although they do not account entirely htr the ECG alterations observed in these patients.
RVEDP < 8
W E D N E S D A Y
JOURNALOF NUCLEARCARDIOLOGY March/April 1995, Part 2
Stress, either physical (Ex) or mental (MS), alters cardiac performance by affecting cardiac contractility, loading conditions or both. MS decreases left ventricular (LV) ejection fraction (El=) in a significant proportion of coronary artery disease (CAD) patients (Pts). The exact mechanism for this is unclear. Arterial elastance (Ea),Ventricular elastance (Ees) & ventriculo-arterial coupling (VIA C) are indices of changes in afterload, cardiac contractility, and relationship between contractility and afterload. Conventionally, these indices are obtained invasively, limiting their routine clinical use. We noninvasively studied changes in EF, Stroke Work (SW), Ea, Ees, and V/A C with MS and Ex in 21 CAD Pts (17 men, 4 women, age 56+11 yrs) using radionuclide angiocardiography and Doppler derived central aortic pressures. 9 Pts showed >_5%decrease in EF on MS (Gp I) and 12 did not (Gp II). Decrease in EF was accompanied by a drop in SW in Gp I and a rise in Gpll (-381_+697 vs 488+1012, p=0.02). Changes (A) in Ees, Ea and V/A C with MS are: AEes , AEa AV/A C Gpl 0.18_+0.35 0,37_+0,22 0.15+_0,24 Gpll 0.12_+0.36 0.14_+0.3" 0.03_+0.07 *p<0.05 Ex responses of Ea. Ees and V/A C were not different in the two Gps. Thus, MS induced decrease in EF and SW in CAD Pts is associated with an increase in Ea without a change in Ees. These data indicate the mechanistic primacy of peripheral vascular responses in determining MS induced LV dysfunction in CAD.
Ruffini L, Granata D, Testa R, Sara R, Spinelli F, Parodi O. Nuclear Medicine Dpt., CNR Clinical Physiology Institute, Niguarda Hospital, Milan, Itaiy. Beta-adrenergic stimulation can improve contractility in dyssynergic but viable myocardial also in relation with receptorial density and function. Aim of this study was to evaluate LV ejection fraction (EF) at baseline and during dobutamine infusion (DOB, 10 mcg/Kg/min in 5 rain.), in 12 patients with first acute myocardial infarction (AMI), 1 and 4 weeks after AMI. Standard deviation (SD) of R-R intervals by Holter monitoring and blood-urinary cathecolamine dosage (BC and UC) provided assessment of autonomic balance and sympathetic neuroormonal activity, respectively. Results: BC and UC did not cliange at 1 and 4 week evaluation. Despite similar baseline EF (46_+10% vs 48_+9% respectively, NS), EF during DOB showed higher increase at 4 weeks than l week (AEF 11+_5 vs 7+6 respectively, p<.05). This pattern parallels with a significant improvement of Holter SD, suggesting a variation of sympatho-vagal balance with an increased sensitivity of adrenergic receptors. Temporal changes of autonomic pattern may explain variable functional response to DOB infusion.
JOURNALOF NUCLEARCARDIOLOGY Volume 2, Number 2, Part 2
Abstracts Wednesday afternoon, April 26, 1995
$125
P22-497
P22-499
CARDIAC ACCUMULATION OF I~F-FLUOROTAMOXIFEN IN PATIENTS WITH BREAST CANCER
EFFECTIVE CARDIOPROTECTION AGAINST E P I ~ I N CARDIOTOKICITY BY ICRF-187:A SCINTIGRAPHIC STUDY R. Sciuto, A. Ferraironi, A. Tofani, P. Vici, I.A. ~ s i t o , M. Lopez and C.L. Maini "Regina Elena" Natl. Cancer Inst., Rome, Italy
T. Inoue, S. Wallace, E.E. Kim, D.J. Yang, P. Bassa, D.A. Podoloff. Gunma University, JAPAN and M.D. Anderson Cancer Center, Houston, USA. Tamoxifen (TX) is a nonsteroidal antiestrogen for treatment and prevention of breast cancer. It has many acceptors besides the estrogen receptor. Recent reports suggests that TX has a cardioprotective estrogen-like effect in postmenopausal women. 18F-Fluorotamoxifen (FTX) was developed, and a pilot study was performed to evaluate the clinical usefulness of FTX in breast cancer patients. The cardiac area was included in the field of view in 5 patients of this pilot study. None of them had a history of ischemic heart disease. High cardiac uptake of FTX was found on transaxial images obtained consecutively up to 90 min. after injection of FTX. There were various patterns of FTX distribution in the heart; 1 patient with homogenous distribution, 2 with defect of the lateral wall, I with patchy distribution, and 1 with questionable uptake. One patient with the defect of the lateral wall showed homogenous cardiac uptake of FDG. This patient d i e d 5 months later, presumably of myocardial tumor infiltration. Cardiac uptake of FTX suggests that i) its cardioprotective benefits may be related not only to the serum cholesterol reduction, but also to a direct cardioprotective action and, 2) non-uniform cardiac uptake may be related to myocardial damage. Further studies are required to confirm these hypotheses.
P22-498 MYOCARDIAL DAMAGE OF THE PATIENTS WITH VASOSPASTIC ANGINA PECTORIS: FOLLOW UP STUDY WITH 1-123 BMIPP SPECT Yoshiyuki Arai, Sumio Mizuno, Yoshifumi Takahashi, Kazutaka Yamamoto* Fukui Cardiovascular Center and Fukui Medical School *, Fukui, Japan lschemia alters the myocardial metabolism of free fatty oxidation. BMIPP( ~-methyl iodophenyl pentadecanoic acid) has been proposed as a new tracer of cardiac free fatty acid metabolism. This study was performed to elucidate the ability of BMIPP SPECT(BMIPP) to detect myocardial damage of the patients(pts) with vasospastic angina pectoris (VSA). We examined 24 VSA pts without organic coronary stenosis. 6 pts had follow up studies for more than 3 months. Serial 180~ SPECT images were obtained starting at 20 minetes after injection of 3 mCi of BMIPP at rest. BMIPP showed regional low radioactivity in 19 out of 24 pts (79.2%). Each segments with decreased activity closely corresponded to the areas perfused by the vasospastic areteries in 16 out of 19 pts (84.2%). 3 pts without VSA attacks for more than 2 years had no abnormal findings on BMIPP. In 4 follow up pts, latter BMIPP showed improvement compared with former images with disappearance of VSA attacks. The other 2 pts with increase of VSA attacks showed deteriorated tracer uptake on the latter BMIPP. These results suggest that BMIPP detects myocardial damage of the pts with VSA and the damage with VSA is reversible. BMIPP is a useful marker for the disease activity of VSA.
ICRF-187 cardioprotection (1000 mg/sqm) against high dose (140-160 mg/sqm) epirubicin (EPI) cardiotoxicity was evaluated in 54 cancer pts. (A) by angiocardioscintigraphy and antimyosin immuno scintigraphy (IS)using the heart lung rate (HLR). 48 cancer pts. given no ICRF-187 were used as control group (B). Normal threshold values w e r e ~ 50%for LVEF and
Group A B
for HLR (specificity=f00%). LVEF 63+7 644-7
HLR LVEF ~ HLR ~ 1.59+_.25 0 43% i. 98• 30 0 90%
9 760
A 64+8 1.79_+.23 7% 90% B 58+8 2.30_+.40 15% 100% mean + sd; o = prevalence of abnormal value ICRF-187 offers an effective cardioprotection. While a pump disfunction is evident only at high EPI dose, myocite membrane damage is shown already at intermediate doses by IS.
P22-500 M E N T A L STRESS AS A T R I G G E R O F MYOCARDIAL ISCHEMIA. A NEW MODALITY O F STUDY.
N~stor A. Vita, Jos~ M. Lotti, Maris Gassman, Jorge A. Cachero. Hospital Italiano de Rosario. Argentina. In order to evaluate 2 different mechanims o f ischemia, Mental Stress (MS) and Exercise Stress (Ex) were performed in 17 pts with proved CAD. Sixteen men and 1 woman, mean age 58+9 were submitted to three separate 99mTc-MIBI SPECT: one at MS, one at Ex and one at rest. LV was divided into 20 segments and a semiquantitative score was assigned (3 normal, 2 mild, 1 moderate and 0 severe)MS was done by a trainee psychologist. HR and BP were monitored. Thirteen pts.(76%) had ischemic response to MS, and 16 pts (94%)to Ex. In 10 pts the extension (EI) and severity of ischemia (SI) was greater in Ex than MS, in 4 pts was reater in MS. equal in both and in 3 Exercise vs. MentalStress Basal 117:1:20 p<0.0001 68• H.R. 67 4- 17 150 • 20 B.P.s 137 4- 22 169 + 27 p<0.015 96• p<0.7 94 4- 19 B.P.n 90 4- 1l 5.2 4- 305 p<0.05 3.8 4- 3.4 E.I. 6.4 4-4.6 p<0.0l 4.3 4-4.2 S.I. Thus, MS triggers myocardial ischemia. Lower double product during MS suggests a reduced oxygen supply
S126
Abstracts Wednesday afternoon, April 26, 1995
P22-501 EFFECT OF r~ - ADRENERGIC RECEPTOR BLOCKATORS ON METABOLISM OF THYROID HORMONES IN HYPERTHYROIDISM Jovan V. Gjorgievski, Jelka Gjorgievska, Petar D. Stefanovski, Snezana Mihajlovska, Zlatko I. Petrovski, Vida Naumovska, Department of Nuclear Medicine and Clinical Physiology,Medical Centre, Bitola, Republic of Macedonia It has been proved that blockators of f~-adrenergic receptors inhibit the conversion of thyroxin (T-4) to triiodothyronine (T-3) in normal subjects and in the patients with hyperthyroidism. In the present study thyroid hormones were measured in the patients with hyperthyroidism before and after the application of blockators of e~-adrenergic receptors. In a group of 12 patients with hyperthyroidism and 12 control patients the administration of 40mg propranolol affected the decrease of T-3 level after 2 - 3 hours, while the concentration of rT-3 showed the successive increase. The concentrations of T-4 in serum were not significantly changed. The data suggest that in hyperthyroidism the conversion of T-4 might shift rather in inactive (T4->rT3) than in active metabolic direction (T4->T3}. The blockators of r~-adrenergic receptors increase these changes.
W E D N E S D A Y P M A P R I L
JOURNAL OF NUCLEARCARDIOLOGY March/April 1995, Part 2
