The Korean Journal of Nuclear Medicine (대한핵의학회지)

The Korean Society of Nuclear Medicine (대한핵의학회)
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Prediction of Salvaged Myocardium in Patients with Acute Myocardial Infarction after Primary Percutaneous Coronary Angioplasty using early Thallium-201 Redistribution Myocardial Perfusion Imaging

급성심근경색증의 일차적 관동맥성형술 후 조기 Tl-201 재분포영상을 이용한 구조심근 예측

  • Choi, Joon-Young (Departments of Nuclear Medicine Asan Medical Center, University of Ulsan College of Medicine) ;
  • Yang, You-Jung (Departments of Nuclear Medicine Asan Medical Center, University of Ulsan College of Medicine) ;
  • Choi, Seung-Jin (Departments of Nuclear Medicine Asan Medical Center, University of Ulsan College of Medicine) ;
  • Yeo, Jeong-Seok (Departments of Nuclear Medicine Asan Medical Center, University of Ulsan College of Medicine) ;
  • Park, Seong-Wook (Departments of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Song, Jae-Kwan (Departments of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Moon, Dae-Hyuk (Departments of Nuclear Medicine Asan Medical Center, University of Ulsan College of Medicine)
  • 최준영 (울산대학교 의과대학 서울아산병원 핵의학과) ;
  • 양유정 (울산대학교 의과대학 서울아산병원 핵의학과) ;
  • 최승진 (울산대학교 의과대학 서울아산병원 핵의학과) ;
  • 여정석 (울산대학교 의과대학 서울아산병원 핵의학과) ;
  • 박성욱 (울산대학교 의과대학 서울아산병원 내과) ;
  • 송재관 (울산대학교 의과대학 서울아산병원 내과) ;
  • 문대혁 (울산대학교 의과대학 서울아산병원 핵의학과)
  • Published : 2003.08.30
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Abstract

Purpose: The amount of salvaged myocardium is an important prognostic factor in patients with acute myocardial infarction (MI). We investigated if early Tl-201 SPECT imaging could be used to predict the salvaged myocardium and functional recovery in acute MI after primary PTCA. Materials and Methods: In 36 patients with first acute MI treated with primary PTCA, serial echocardiography and Tl-201 SPECT imaging ($5.8{\pm}2.1$ days after PTDA) were performed. Regional wall motion and perfusion were quantified with on 16-segment myocardial model with 5-point and 4-point scaling system, respectively. Results: Wall motion was improved in 78 of the 212 dyssynergic segments on 1 month follow-up echocardiography and 97 on 7 months follow-up echocardiography, which were proved to be salvaged myocardium. The areas under receiver operating characteristic curves of Tl-201 perfusion score for detecting salvaged myocardial segments were 0.79 for 1 month follow-up and 0.83 for 7 months follow-up. The sensitivity and specificity of Tl-201 redistribution images with optimum cutoff of 40% of peak thallium activity for detecting salvaged myocardium were 84.6% and 55.2% for 1 month follow-up, and 87.6% and 64.3% for 7 months follow-up, respectively. There was a linear relationship between the percentage of peak thallium activity on early redistribution imaging and the likelihood of segmental functional improvement 7 months after reperfusion. Conclusion: Tl-201 myocardial perfusion SPECT imaging performed early within 10 days after reperfusion can be used to predict the salvaged myocardium and functional recovery with high sensitivity during the 7 months following primary PTCA in patients with acute MI.

목적: 심근경색증 후 재관류술에 의해 구조된 심근의 범위는 중요한 예후 인자중의 하나이다. 급성심근경색증의 일차적 관동맥성형술 후 조기 Tl-201 재분포영상이 구조심근과 심근벽운동 호전을 예측할 수 있는지 알아보았다. 대상 및 방법: 흉통 발생 $5.2{\pm}2.8$시간에 급성심근경색증으로 일차적 관동맥성형술을 시행한 36명을 대상으로 관동맥성형술 후 $5.8{\pm}2.1$일에 디피리다몰 부하 -4 시간 재분포 Tl-201 SPECT 영상을 얻었다. Tl-201 재분포 영상은 좌심실을 16분절로 나누고, 각 분절의 섭취를 5등급으로 평가하였다. 심초음파는 내원 당시, 경색 후 7일, 30일, 7개월에 시행하였고, 구조심근 분절은 내원 당시 심초음파상 벽 운동 이상이 있으면서 30일 또는 7개월 심초음파에서 벽 운동이 호전된 분절로 정의하였다. 결과: 내원 당시 212분절에서 벽운동 이상을 보였다(저운동 41분절, 무운동 171분절). 이중 1개월에는 78분절(36.8%)에서, 7개월에는 97분절(45.8%)에서 벽 운동이 호전되어 구조심근으로 판정하였다. 구조심근을 찾는 Tl-201 재분포 영상의 수신자판 단특성곡선면적은 1개월에 대해서는 $0.79{\pm}0.03$, 7개월에 대해서는 $0.83{\pm}0.03$이었다. Tl-201 섭취 40%를 경계로 정할 때 재분포 영상의 구조심근을 찾는 예민도, 특이도는 1개월에서는 84.6%(66/68), 55.2%(74/134), 7개월에서는 87.6%(85/97), 64.3%(74/115)였다. 재분포영상에서 Tl-201의 섭취정도와 벽 운동의 호전될 확률은 서로 비례하는 경향을 나타내었다. 결론: 급성심근경색증의 일차적 관동맥성형술 후 10일 이내에 시행한 조기 Tl-201 재분포영상은 구조심근과 심근벽운동 호전 예측 판정에 높은 예민도로 유용하게 사용될 수 있는 검사이다.EX>$100{\mu}M$)는 각각 11.9배와 6.8배, K562(Adr) 세포에서($50{\mu}M$)는 각각 14.3배와 8배, K562(Vcr) 세포에서($10{\mu}M$)는 각각 7배와 5.7배 증가하였다. Cyclosporin A에 의한 MIBI와 tetrofosmin의 섭취율(30분)을 기저치(30분)와 비교해 본 결과 HCT15/CL02세포에서($50{\mu}M$)는 각각 10배와 2.4배, K562(Adr)세포에서($50{\mu}M$)는 각각 44배와 13배, K562(Vcr)세포에서($10{\mu}M$)는 각각 18.8배와 11.8배 증가하여, MIBI의 섭취율이 tetrofosmin보다 1.2배에서 4배정도 높게 나타났다. 결론: 이러한 결과로 보아 MIBI와 tetrofosmin은 다약제내성의 발현을 평가할 수 있는 방사성의약품으로 판단되며, 다약제내성 극복제의 효능평가에는 MIBI가 tetrofosmin보다 더 우수할 것으로 사료되나, 세포추에 따른 차이가 있을 수 있으므로 보다 많은 세포주에서의 추가적인 연구가 필요할 것이다.여 후 구한 MPD는 평균 $13.3{\pm}1.9GBq\;(9.7{\sim}16GBq)$ 이였고, 치료용량 방사성옥소 투여 후 구한 MPD는 평균 $13.8{\pm}2.1GBq(10.4{\sim}16.3GBq)$로 유의한 차이가 얻었으며 (p=0.20), 두 수치간에는 유의한 상관 관계가 있었다(r=0.8, p<0.0001). 7명의 환자에서 말초혈액림프구 중기염색체 분석법으로 MPD를 측정하였는데 혈액의 피폭선량은 $1.78{\pm}0.03Gy$였으며, 같은 환자에서 혈중 방사능소실곡선으로부터 구한 피폭선량은 $1.54{\pm}0.03Gy$로 유의하게 낮았으나 (p=0.01), 두

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References

  1. The GUSTO Angiographic Investigators. The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. N Engl J Med 1993;329：1615-22
  2. Zijlstra F, de Boer MJ, Hoorntje JC, Reiffers S, Reiber JH, Suryapranata H. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993;328：680-4
  3. Zijlstra F, Beukema WP, van't Hof AW, Liem A, Reiffers S, Hoorntje JC, et al. Randomized comparison of primary coronary angioplasty with thrombolytic therapy in low risk patients with acute myocardial infarction. J Am Coll Cardiol 1997;29：908-12
  4. Ito H, Okamura A, Iwakura K, Masuyama T, Hori M, Takiuchi S, et al. Myocardial perfusion patterns related to thrombolysis in myocardial infarction perfusion grades after coronary angioplasty in patients with acute anterior wall myocardial infarction. Circulation 1996;93：1993-9
  5. Kaul S, Villanueva FS. Is the determination of myocardial perfusion necessary to evaluate the success of reperfusion when the infarct-related artery is open? Circulation 1992;85：1942-4
  6. Dilsizian V, Bonow RO. Current diagnostic techniques of assessing myocardial viability in patients with hibernating and stunned myocardium. Circulation 1993;87：1-20
  7. Pierard LA, De Landsheere CM, Berthe C, Rigo P, Kulbertus HE. Identification of viable myocardium by echocardiography during dobutamine infusion in Xpatients with myocardial infarction after thrombolytic therapy： comparison with positron emission tomography. J Am Coll Cardiol 1990;15：1021-31
  8. Schwaiger M, Brunken R, Grover-McKay M, Krivokapich J, Child J, Tillisch JH, et al. Regional myocardial metabolism in patients with acute myocardial infarction assessed by positron emission tomography. J Am Coll Cardiol 1986;8：800-8
  9. Maddahi J, Ganz W, Ninomiya K, Hashida J, Fishbein MC, Mondkar A, et al. Myocardial salvage by intracoronary thrombolysis in evolving acute myocardial infarction： evaluation using intracoronary injection of thallium-201. Am Heart J 1981;102：664-74
  10. Smart SC, Sawada S, Ryan T, Segar D, Atherton L, Berkovitz K, et al. Low-dose dobutamine echocardiography detects reversible dysfunction after thrombolytic therapy of acute myocardial infarction. Circulation 1993;88：405-15
  11. Ito H, Tomooka T, Sakai N, Higashino Y, Fujii K, Katoh O, et al. Time course of functional improvement in stunned myocardium in risk area in patients with reperfused anterior infarction.Circulation 1993;87：355-62
  12. Ragosta M, Camarano G, Kaul S, Powers ER, Sarembock IJ, Gimple LW. Microvascular integrity indicates myocellular viability in patients with recent myocardial infarction. New insights using myocardial contrast echocardiography. Circulation 1994;89：2562-9
  13. Sciagra R, Bolognese L, Rovai D, Sestini S, Santoro GM, Cerisano G, et al. Detecting myocardial salvage after primary PTCA： early myocardial contrast echocardiography versus delayed sestamibi perfusion imaging. J Nucl Med 1999;40：363-70
  14. Santoro GM, Bisi G, Sciagra R, Leoncini M, Fazzini PF, Meldolesi U. Single photon emission computed tomography with technetium-99m hexakis 2-methoxyisobutyl isonitrile in acute myocardial infarction before and after thrombolytic treatment： assessment of salvaged myocardium and prediction of late functional recovery. J Am Coll Cardiol 1990;15：301-14
  15. Lomboy CT, Schulman DS, Grill HP, Flores AR, Orie JE. Granato JE. Rest-redistribution thallium-201 scintigraphy to determine myocardial viability early after myocardial infarction. J Am Coll Cardiol 1995;25：210-7
  16. Kim S, Yamabe H, Yokoyama M. Impaired coronary circulation in acute myocardial infarctio n： a dipyridamole-thallium-201 study. Eur J Nucl Med 1997;24：210-4
  17. The TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) trial： phase 1 findings. N Eng J Med 1985;312：932-6
  18. Rentrop PK, Thronton JC, Feit F, Buskirk M. Determinants and protective potential of coronary collaterals as assessed by angioplasty model. Am J Cardiol 1988;61：677-84
  19. Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. J Am Soc Echocardiogr 1989;2：358-67
  20. Metz CE. Basic principles of ROC analysis. Semin Nucl Med 1978;8：283-98
  21. Melin JA, Becker LC, Bulkley BH. Differences in Thallium-201 uptake in reperfused and nonreperfused myocardial infarction. Circ Res 1983;53：414-9
  22. Villanueva FS, Glasheen WP, Sklenar J, Kaul S. Assessment of risk area during coronary occlusion and infarct size after reperfusion with myocardial contrast echocardiography using left and right atrial injections of contrast. Circulation 1993;88：596-604
  23. Okada RD, Pohost GM. The use of preintervention and postintervention thallium imaging for assessing the early and late effects of experimental coronary arterial reperfusion in dogs. Circulation 1984;69：1153-60
  24. Perrone-Filardi P, Pace L, Prastaro M, Piscione F, Betocchi S, Squame F, et al. Dobutamine echocardiography predicts improvement of hypoperfused dysfunctional myocardium after revascularization in patients with coronary artery disease. Circulation 1995;91：2556-65
  25. Perrone-Filardi P, Pace L, Prastaro M, Squame F, Betocchi S, Soricelli A, et al. Assessment of myocardial viability in patients with chronic coronary artery disease. Rest-4-hour-24-hour 201Tl tomography versus dobutamine echocardiography. Circulation 1996;94：2712-9
  26. Narahara KA, Thompson CJ, Maublant JC, Criley JM, Mena I. Estimation of left ventricular mass in normal and infarcted canine hearts using thallium-201 SPECT. J Nucl Med 1987;28：1315-21
  27. Narahara KA, Villanueva-Meyer J, Thompson CJ, Brizendine M, Mena I. Comparison of thallium-201 and technetium-99m hexakis 2-methoxyisobutyl isonitrile single-photon emission computed tomography for estimating the extent of myocardial ischemia and infarction in coronary artery disease. Am J Cardiol 1990;66：1438-44
  28. Christian TF, O'Connor MK, Hopfenspirger MR, Gibbons RJ. Comparison of reinjection thallium 201 and resting technetium 99m sestamibi tomographic images for the quantification of infarct size after acute myocardial infarction. J Nucl Cardiol 1994;1：17-28
  29. O'Connor MK, Caiati C, Christian TF, Gibbons RJ. Effects of scatter correction on the measurement of infarct size from SPECT cardiac phantom studies. J Nucl Med 1995;36：2080-6
  30. Medrano R, Lowry RW, Young JB, Weilbaecher DG, Michael LH, Afridi I, et al. Assessment of myocardial viability with 99mTc sestamibi in patients undergoing cardiac transplantation. A scintigraphic/pathological study. Circulation 1996;94：1010-7
  31. Miller DD, Verani MS. Current status of myocardial perfusion imaging after percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 1994;24：260-6
  32. Otsuka M, Itagane H, Haze K. Clinical significance of improved persistent defect by thallium-201 reinjection imaging in the subacute phase of myocardial infarction. J Cardiol 1999;33S：67-74
  33. Mochizuki T, Murase K, Sugawara Y, Higashino H, Kikuchi T, Miyagawa M, et al. Twenty-four-hour Tl-201 delayed scan underestimates myocardial viability in patients with acute myocardial infarction after percutaneous transluminal coronary angioplasty. Ann Nucl Med 2001;15：93-6