Korean Journal of Radiology

The Korean Society of Radiology (대한영상의학회)
권호 표지
DOI QR코드

DOI QR Code

Impaired Coronary Flow Reserve Is the Most Important Marker of Viable Myocardium in the Myocardial Segment-Based Analysis of Dual-Isotope Gated Myocardial Perfusion Single-Photon Emission Computed Tomography

  • Lee, Won Woo (Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine) ;
  • So, Young (Department of Nuclear Medicine, Konkuk University School of Medicine) ;
  • Kim, Ki-Bong (Department of Thoracic & Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine) ;
  • Lee, Dong Soo (Institute of Radiation Medicine, Medical Research Center, Seoul National University)
  • Received : 2013.09.18
  • Accepted : 2014.01.14
  • Published : 2014.04.01
⟨ Previous Next ⟩

Abstract

Objective: The aim of this study was to investigate the most robust predictor of myocardial viability among stress/rest reversibility (coronary flow reserve [CFR] impairment), $^{201}Tl$ perfusion status at rest, $^{201}Tl$ 24 hours redistribution and systolic wall thickening of $^{99m}Tc$-methoxyisobutylisonitrile using a dual isotope gated myocardial perfusion single-photon emission computed tomography (SPECT) in patients with coronary artery disease (CAD) who were re-vascularized with a coronary artery bypass graft (CABG) surgery. Materials and Methods: A total of 39 patients with CAD was enrolled (34 men and 5 women), aged between 36 and 72 years (mean $58{\pm}8$ standard in years) who underwent both pre- and 3 months post-CABG myocardial SPECT. We analyzed 17 myocardial segments per patient. Perfusion status and wall motion were semi-quantitatively evaluated using a 4-point grading system. Viable myocardium was defined as dysfunctional myocardium which showed wall motion improvement after CABG. Results: The left ventricular ejection fraction (LVEF) significantly increased from $37.8{\pm}9.0%$ to $45.5{\pm}12.3%$ (p < 0.001) in 22 patients who had a pre-CABG LVEF lower than 50%. Among 590 myocardial segments in the re-vascularized area, 115 showed abnormal wall motion before CABG and 73.9% (85 of 115) had wall motion improvement after CABG. In the univariate analysis (n = 115 segments), stress/rest reversibility (p < 0.001) and $^{201}Tl$ rest perfusion status (p = 0.024) were significant predictors of wall motion improvement. However, in multiple logistic regression analysis, stress/rest reversibility alone was a significant predictor for post-CABG wall motion improvement (p < 0.001). Conclusion: Stress/rest reversibility (impaired CFR) during dual-isotope gated myocardial perfusion SPECT was the single most important predictor of wall motion improvement after CABG.

Keywords

Acknowledgement

Supported by : National Research Foundation (NRF), SNUBH

References

  1. Rahimtoola SH. Coronary bypass surgery for chronic angina--1981. A perspective. Circulation 1982;65:225-241 https://doi.org/10.1161/01.CIR.65.2.225
  2. Iskandrian AS. Myocardial viability: unresolved issues. J Nucl Med 1996;37:794-797
  3. Ragosta M, Beller GA, Watson DD, Kaul S, Gimple LW. Quantitative planar rest-redistribution 201Tl imaging in detection of myocardial viability and prediction of improvement in left ventricular function after coronary bypass surgery in patients with severely depressed left ventricular function. Circulation 1993;87:1630-1641 https://doi.org/10.1161/01.CIR.87.5.1630
  4. Taki J, Nakajima K, Bunko H, Kawasuji M, Tonami N, Hisada K. Twenty-four-hour quantitative thallium imaging for predicting beneficial revascularization. Eur J Nucl Med 1994;21:1212-1217
  5. Zimmermann R, Mall G, Rauch B, Zimmer G, Gabel M, Zehelein J, et al. Residual 201Tl activity in irreversible defects as a marker of myocardial viability. Clinicopathological study. Circulation 1995;91:1016-1021 https://doi.org/10.1161/01.CIR.91.4.1016
  6. Dilsizian V, Rocco TP, Freedman NM, Leon MB, Bonow RO. Enhanced detection of ischemic but viable myocardium by the reinjection of thallium after stress-redistribution imaging. N Engl J Med 1990;323:141-146 https://doi.org/10.1056/NEJM199007193230301
  7. Ohtani H, Tamaki N, Yonekura Y, Mohiuddin IH, Hirata K, Ban T, et al. Value of thallium-201 reinjection after delayed SPECT imaging for predicting reversible ischemia after coronary artery bypass grafting. Am J Cardiol 1990;66:394-399 https://doi.org/10.1016/0002-9149(90)90692-T
  8. Snapper HJ, Shea NL, Konstam MA, Oates E, Udelson JE. Combined analysis of resting regional wall thickening and stress perfusion with electrocardiographic-gated technetium 99m-labeled sestamibi single-photon emission computed tomography: prediction of stress defect reversibility. J Nucl Cardiol 1997;4(1 Pt 1):3-10 https://doi.org/10.1016/S1071-3581(97)90043-X
  9. Berman DS, Kiat H, Friedman JD, Wang FP, van Train K, Matzer L, et al. Separate acquisition rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion single-photon emission computed tomography: a clinical validation study. J Am Coll Cardiol 1993;22:1455-1464 https://doi.org/10.1016/0735-1097(93)90557-H
  10. Chua T, Kiat H, Germano G, Maurer G, van Train K, Friedman J, et al. Gated technetium-99m sestamibi for simultaneous assessment of stress myocardial perfusion, postexercise regional ventricular function and myocardial viability. Correlation with echocardiography and rest thallium-201 scintigraphy. J Am Coll Cardiol 1994;23:1107-1114 https://doi.org/10.1016/0735-1097(94)90598-3
  11. Cho SG, Kim JH, Cho JY, Kim HS, Bom HS. Myocardial blood flow and flow reserve in proximal and mid-to-distal lesions of left anterior descending artery measured by N-13 ammonia PET/CT. Nucl Med Mol Imaging 2013;47:158-165 https://doi.org/10.1007/s13139-013-0208-6
  12. Matzer L, Kiat H, Wang FP, Van Train K, Germano G, Friedman J, et al. Pharmacologic stress dual-isotope myocardial perfusion single-photon emission computed tomography. Am Heart J 1994;128(6 Pt 1):1067-1076 https://doi.org/10.1016/0002-8703(94)90735-8
  13. Mazzanti M, Germano G, Kiat H, Kavanagh PB, Alexanderson E, Friedman JD, et al. Identification of severe and extensive coronary artery disease by automatic measurement of transient ischemic dilation of the left ventricle in dual-isotope myocardial perfusion SPECT. J Am Coll Cardiol 1996;27:1612-1620 https://doi.org/10.1016/0735-1097(96)00052-6
  14. Hachamovitch R, Kang X, Amanullah AM, Abidov A, Hayes SW, Friedman JD, et al. Prognostic implications of myocardial perfusion single-photon emission computed tomography in the elderly. Circulation 2009;120:2197-2206 https://doi.org/10.1161/CIRCULATIONAHA.108.817387
  15. Rozanski A, Berman DS, Gray R, Levy R, Raymond M, Maddahi J, et al. Use of thallium-201 redistribution scintigraphy in the preoperative differentiation of reversible and nonreversible myocardial asynergy. Circulation 1981;64:936-944 https://doi.org/10.1161/01.CIR.64.5.936
  16. Alfieri O, La Canna G, Giubbini R, Pardini A, Zogno M, Fucci C. Recovery of myocardial function. The ultimate target of coronary revascularization. Eur J Cardiothorac Surg 1993;7:325-330; discussion 330 https://doi.org/10.1016/1010-7940(93)90175-B
  17. Bonow RO, Maurer G, Lee KL, Holly TA, Binkley PF, Desvigne- Nickens P, et al. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med 2011;364:1617-1625 https://doi.org/10.1056/NEJMoa1100358
  18. Fallavollita JA, Canty JM Jr. Differential 18F-2-deoxyglucose uptake in viable dysfunctional myocardium with normal resting perfusion: evidence for chronic stunning in pigs. Circulation 1999;99:2798-2805 https://doi.org/10.1161/01.CIR.99.21.2798
  19. Shah BN, Khattar RS, Senior R. The hibernating myocardium: current concepts, diagnostic dilemmas, and clinical challenges in the post-STICH era. Eur Heart J 2013;34:1323-1336 https://doi.org/10.1093/eurheartj/eht018
  20. Lim H, Fallavollita JA, Hard R, Kerr CW, Canty JM Jr. Profound apoptosis-mediated regional myocyte loss and compensatory hypertrophy in pigs with hibernating myocardium. Circulation 1999;100:2380-2386 https://doi.org/10.1161/01.CIR.100.23.2380
  21. Margonato A, Mailhac A, Bonetti F, Vicedomini G, Fragasso G, Landoni C, et al. Exercise-induced ischemic arrhythmias in patients with previous myocardial infarction: role of perfusion and tissue viability. J Am Coll Cardiol 1996;27:593-598 https://doi.org/10.1016/0735-1097(95)00491-2
  22. Afridi I, Kleiman NS, Raizner AE, Zoghbi WA. Dobutamine echocardiography in myocardial hibernation. Optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty. Circulation 1995;91:663-670 https://doi.org/10.1161/01.CIR.91.3.663
  23. Paeng JC, Lee DS, Kang WJ, Lee BI, Kim KB, Chung JK, et al. Time course of functional recovery after coronary artery bypass grafting surgery according to the preoperative reversibility of perfusion impairment on myocardial SPECT. Eur J Nucl Med Mol Imaging 2005;32:70-74 https://doi.org/10.1007/s00259-004-1623-9
  24. Smart SC. The clinical utility of echocardiography in the assessment of myocardial viability. J Nucl Med 1994;35(4 Suppl):49S-58S
  25. Lee WW, Park EK, Eo JS, Lee SW, Kim CH, So Y, et al. Evaluation of immediate post-stress wall motion on adenosine stress/rest thallium-201 gated myocardial SPECT. Int J Cardiovasc Imaging 2006;22:213-222 https://doi.org/10.1007/s10554-005-9001-7
  26. Beanlands RS, Nichol G, Huszti E, Humen D, Racine N, Freeman M, et al. F-18-fluorodeoxyglucose positron emission tomography imaging-assisted management of patients with severe left ventricular dysfunction and suspected coronary disease: a randomized, controlled trial (PARR-2). J Am Coll Cardiol 2007;50:2002-2012 https://doi.org/10.1016/j.jacc.2007.09.006
  27. Velazquez EJ, Lee KL, Deja MA, Jain A, Sopko G, Marchenko A, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med 2011;364:1607-1616 https://doi.org/10.1056/NEJMoa1100356
  28. Schinkel AF, Poldermans D, Elhendy A, Bax JJ. Assessment of myocardial viability in patients with heart failure. J Nucl Med 2007;48:1135-1146 https://doi.org/10.2967/jnumed.106.038851