Area of ischemia assessed by physicians and software packages from myocardial perfusion scintigrams.

BACKGROUND: The European Society of Cardiology recommends that patients with >10% area of ischemia should receive revascularization. We investigated inter-observer variability for the extent of ischemic defects reported by different physicians and by different software tools, and if inter-observer variability was reduced when the physicians were provided with a computerized suggestion of the defects. METHODS: Twenty-five myocardial perfusion single photon emission computed tomography (SPECT) patients who were regarded as ischemic according to the final report were included. Eleven physicians in nuclear medicine delineated the extent of the ischemic defects. After at least two weeks, they delineated the defects again, and were this time provided a suggestion of the defect delineation by EXINI HeartTM (EXINI). Summed difference scores and ischemic extent values were obtained from four software programs. RESULTS: The median extent values obtained from the 11 physicians varied between 8% and 34%, and between 9% and 16% for the software programs. For all 25 patients, mean extent obtained from EXINI was 17.0% (± standard deviation (SD) 14.6%). Mean extent for physicians was 22.6% (± 15.6%) for the first delineation and 19.1% (± 14.9%) for the evaluation where they were provided computerized suggestion. Intra-class correlation (ICC) increased from 0.56 (95% confidence interval (CI) 0.41-0.72) to 0.81 (95% CI 0.71-0.90) between the first and the second delineation, and SD between physicians were 7.8 (first) and 5.9 (second delineation). CONCLUSIONS: There was large variability in the estimated ischemic defect size obtained both from different physicians and from different software packages. When the physicians were provided with a suggested delineation, the inter-observer variability decreased significantly.

Attenuation correction in CZT myocardial perfusion imaging comparison of supine-prone and low-dose CT-corrected supine acquisitions.

AIMS: The study aimed to investigate whether additional prone imaging delivers comparable results to supine imaging with low-dose computed tomography (CT) attenuation correction (CTAC) in cadmium, zinc and telluride (CZT) myocardial perfusion imaging. METHODS AND RESULTS: Thirty-four patients with an indication for myocardial perfusion imaging were studied with a CZT camera in the supine and then prone position. Furthermore, a low-dose CT was acquired. Three data sets were reconstructed and considered for analysis: (1) supine CZT, (2) supine CZT with CTAC and (3) supine CZT with additional prone CZT. Based on 17-segment polartomograms, we compared radiopharmaceutical uptake percentage, summed stress score (SSS), summed rest score (SRS), summed difference score (SDS), total ischemic and scarred segments, and finally scan classification and clinical decision-making. SSS of supine/supine-CTAC/supine-prone was 341/229/253 (P < 0.05), SRS was 246/156/164 (P < 0.05) and SDS was 104/88/96 (ns), respectively. Total ischemic segments were 65/67/65 (ns) and total scarred segments 96/62/69 (P < 0.05), respectively. The frequency of normal scans was highest for supine-prone, followed by supine-CTAC and supine (41/35/24%, respectively). Supine imaging indicated 23% of patients for invasive coronary angiography, both supine-CTAC and supine-prone 18%. These two showed a significant intercorrelation. CONCLUSION: Additional prone imaging and CTAC are mainly correct for the amount and extent of myocardial scars. Both methods increase the frequency of normal scans and show a significant agreement in clinical decision-making. Additional prone imaging appears as a useful alternative when a low-dose CT for attenuation correction is not available.

Respiratory resistance of patients during cardiac stress testing with adenosine: is dyspnea a sign of bronchospasm?

BACKGROUND: Adenosine is widely used for stress-testing in myocardial perfusion imaging. During adenosine infusion, dyspnea is one of the main complaints of patients. The aim of this study was to determine whether dyspnea during adenosine infusion is caused by bronchospasm. METHODS: Fifty-four patients were enrolled in the study. Seven of these 54 suffered from mild chronic obstructive pulmonary disease (COPD). We continuously measured respiratory resistance (Rrs), using impulse oscillometry. Respiratory resistance was measured before, during, and after a continuous infusion of 140 microg/kg/min adenosine. RESULTS: Sixty-seven percent of patients suffered from dyspnea during adenosine infusion. In patients with mild COPD, Rrs was higher compared with other patients (0.48 vs 0.27 kPa/L/s, P < .05). Neither patients with COPD nor those without COPD exhibited a significant increase in Rrs during adenosine infusion. The Rrs of patients with dyspnea was insignificantly lower compared with patients without dyspnea (P = .469). CONCLUSIONS: Dyspnea as a side effect of adenosine infusion is not correlated with impaired respiratory resistance in nonasthmatic patients and in patients with mild COPD. Thus bronchospasm is ruled out as cause of this clinical symptom. Despite the small number of COPD patients enrolled in the study, adenosine infusion might be possible in patients with mild COPD.

Attenuation correction of myocardial SPECT perfusion images with low-dose CT: evaluation of the method by comparison with perfusion PET.

UNLABELLED: In cardiac SPECT, specificity is significantly affected by artifacts due to photon absorption. As the success of attenuation correction depends mainly on high-quality attenuation maps, SPECT low-dose CT devices are promising. We wanted to evaluate the usefulness of a SPECT low-dose CT device in myocardial perfusion scintigraphy. For the evaluation of attenuation correction systems, primarily comparisons with coronary angiography are used. Because the comparison of a method showing myocardial perfusion with an investigation displaying the morphology of vessels yields some difficulties, we chose perfusion PET with (13)N-ammonia as the reference method. METHODS: We prospectively analyzed 23 patients (6 women, 17 men) with known or suspected coronary artery disease. Rest studies and studies under pharmacologic stress with adenosine were performed. After simultaneous injection of (13)N-ammonia and (99m)Tc-sestamibi, a dynamic PET acquisition was started. The SPECT study was performed about 2 h later. Based on 20-segment polar maps, SPECT with and without attenuation correction was compared with PET-derived perfusion values and ammonia uptake values. The PET uptake images were also smoothed to adjust their resolution to the resolution of the SPECT images. RESULTS: The concordance of SPECT and PET studies was improved after attenuation correction. The main effect was seen in the inferior wall. Especially in the apex and anterolateral wall, there were differences between SPECT and PET studies not attributable to attenuation artifacts. Because these differences diminished after smoothing of the PET studies, they might be due to partial-volume effects caused by the inferior resolution of the SPECT images. CONCLUSION: The x-ray-derived attenuation correction leads to SPECT images that represent myocardial perfusion more accurately than nonattenuation-corrected SPECT images. The benefit of the method is seen primarily in the inferior wall. The low resolution of the SPECT system may lead to artifacts due to partial-volume effects. This phenomenon must be considered when perfusion PET is used as a reference method to investigate the effect of attenuation correction.

Global and regional myocardial oxygen consumption and blood flow in severe cardiomyopathy with left bundle branch block.

OBJECTIVE: In patients with dilated cardiomyopathy (DCM), left bundle branch block (LBBB) is a common finding. The characteristic feature is an asynchronous septal wall motion and most frequently a delay of the lateral and/or posterior wall segments. With the onset of cardiac resynchronization therapy, there is a focus on the specific pathophysiology of a LBBB. However, quantitative data on regional myocardial oxygen consumption (MVO(2)) and blood flow (MBF) are missing. METHODS: We studied 31 patients with severe DCM and LBBB (ejection fraction 22.1+/-7.1%) and 14 patients with mild to moderate DCM without LBBB (ejection fraction 46.7+/-7.9%). Global and regional MVO(2) as well as MBF were determined from a dynamic (11)C-acetate positron emission tomography (PET) study. RESULTS: Global MVO(2) and MBF were lower in the DCM group with LBBB than in the control group (P<0.05). Regionally, the LBBB group revealed a higher (P<0.05) MVO(2) and MBF in the lateral wall than in the other walls. The control group did not show significant differences between the myocardial walls and demonstrated a smaller variability of the parameters. CONCLUSION: DCM patients with LBBB exhibit a more heterogeneous distribution of MVO(2) and MBF among the myocardial walls than DCM patients without LBBB. Due to the LBBB associated electromechanical alterations, the highest regional values of MVO(2) and MBF are found in the lateral wall.

[A dynamic heart phantom for quality control in functional nuclear cardiac imaging]. / Ein dynamisches Herzphantom für die Qualitäitskontrolle in der nuklearkardiologischen Funktionsdiagnostik.

A dynamic heart phantom for the quality control of tomographic systems used in nuclear cardiology imaging was developed, built, and tested. The heart phantom anatomically simulates the left ventricle of the heart. The variable parameters are represented by the volume of the left ventricle, the temporal course of the filling event, and the frequency of the filling of the left ventricle. These parameters can reliably simulate the wall motion, wall thickening, ejection fraction, and stroke volume of the left ventricle.

Scintigraphy for risk stratification of iodine-induced thyrotoxicosis in patients receiving contrast agent for coronary angiography: a prospective study of patients with low thyrotropin.

The risk of iodine-induced thyrotoxicosis in euthyroid patients receiving iodine-containing contrast agents is known to be low, but data on this risk in patients with latent hyperthyroidism are scarce. We investigated the role of thyroid scintigraphy using Tc-99m preceding the application of iodine-containing contrast material to estimate the risk of iodine-induced thyrotoxicosis in patients with low levels of TSH. In a prospective study on 91 patients, thyroid scintigraphy was performed before coronary angiography (CA). In patients with technetium thyroid uptake (TCTU) less than 1%, CA was done without prophylactic drugs (n = 56). Patients with TCTU greater than 1% were treated either with 900 mg of perchlorate or, depending on the autonomous volume, combined with 20 to 60 mg thiamazole. In the 56 patients with TCTU less than 1%, no case of iodine-induced hyperthyroidism occurred within 4 wk after CA. In the patients who received prophylactic drugs, two cases of mild thyrotoxicosis were observed. Our data suggest that in patients with low levels of TSH, the risk of hyperthyroidism after application of iodine-containing contrast media is negligible if TCTU is less than 1%. In these patients, CA can be performed without administration of prophylactic drugs.

A method to remove artifacts in attenuation-corrected myocardial perfusion SPECT Introduced by misalignment between emission scan and CT-derived attenuation maps.

UNLABELLED: Nonuniform soft-tissue attenuation affects the diagnostic accuracy of SPECT in myocardial perfusion imaging. The attenuation map required for attenuation correction can be acquired using x-ray tomography (CT). Frequent findings in attenuation-corrected images are defects in the apical and anterior myocardial wall. We assume that these are artifacts produced by misalignment of SPECT images and the attenuation map. METHODS: One hundred forty patients underwent myocardial perfusion imaging with 99mTc-methoxyisobutylisonitrile. Twenty-seven of 140 showed pronounced defects in the apical or anterior wall only after CT-based attenuation correction. SPECT and corresponding CT slices were examined for misalignment in the ventrodorsal direction (y-direction) visually and by threshold-based delineation of the body surface. Mismatched studies were realigned and image reconstruction and analysis were redone. The effect of the correction was assessed visually and by semiquantitative analysis based on a 20-segment model using 4D-MSPECT. RESULTS: In 15 of 27 patients, the improved coregistration led to smaller and less-pronounced defects in the regions mentioned. In 6 of 27 patients, former defects were judged as normal. No improvement was seen in only 4 patients. In these 4 subjects, the mismatch in the y-direction was <1 pixel (7 mm), and visual inspection suggested a coincident mismatch in the craniocaudal direction. In 2 cases, coregistration was not possible because the body outline extended beyond the CT field of view. Semiquantitative analysis revealed a significant increase of the relative uptake in the apex; in the apical segments of the anterior, septal, and inferior wall; and in the mid-anterior and mid-anteroseptal segment. Basal segments of the anterolateral, lateral, and inferolateral wall and the middle inferolateral segment showed a significant decrease of relative uptake. CONCLUSION: Misalignment in the y-direction between SPECT and the attenuation map can lead to artifacts in the apical, septal, and anterior wall, which will appear as defects. It also can cause overcorrection in the basal inferior and lateral segments. There is evidence that mismatches along the other directions may have a similar effect. The coregistration of SPECT and the attenuation map needs to be verified for every patient, even when using integrated dual-modality imaging devices.

Effect of cardiac resynchronization therapy on global and regional oxygen consumption and myocardial blood flow in patients with non-ischaemic and ischaemic cardiomyopathy.

AIMS: We studied the effects of cardiac resynchronization therapy (CRT) on global and regional myocardial oxygen consumption (MVO2) and myocardial blood flow (MBF) in non-ischaemic (NICM) and ischaemic dilated cardiomyopathy (ICM). METHODS AND RESULTS: Thirty-one NICM and 11 ICM patients, all of them acute responders, were investigated. MVO2 and MBF were obtained by 11C-acetate PET before and after 4 months of CRT. In NICM global MVO2 and MBF did not change during CRT, while the rate pressure product (RPP) normalized MVO2 increased (P=0.03). Before CRT regional MVO2 and MBF were highest in the lateral wall and lowest in the septum. Under therapy, MVO2 and MBF decreased in the lateral wall (P=0.045) and increased in the septum (P=0.045) resulting in a more uniform distribution. In ICM, global MVO2, MBF, and RPP did not change under CRT. Regional MVO2 and MBF showed no significant changes but a similar tendency in the lateral and septal wall to that in NICM. CONCLUSION: CRT induces changes of MVO2 and MBF on a regional level with a more uniform distribution between the myocardial walls and improved ventricular efficiency in NICM. Based on the investigated parameters, CRT appears to be more effective in NICM than in ICM.