Myocardial kinetics of thallium-201 after dipyridamole infusion in normal canine myocardium and in myocardium distal to a stenosis.

The purpose of the present study was to define myocardial and blood thallium-201 (Tl-201) kinetics after infusion of dipyridamole in normal canine myocardium and in myocardium distal to a coronary artery stenosis. Miniature radiation detector probes were implanted in the left ventricle in 39 open-chest dogs. A balloon constrictor was placed around the proximal left circumflex coronary artery. Electromagnetic flow probes were positioned proximally around both the left circumflex and left anterior descending coronary arteries. In five control dogs (group 1) the balloon occluder was not inflated; in 12 dogs (group 2) a mild stenosis was created such that resting flow was not reduced, yet the hyperemic response after 10 s of total occlusion was partially attenuated; in nine dogs (group 3) a moderate stenosis was created such that resting flow was not reduced, yet the hyperemic response was completely eliminated; and in 13 dogs (group 4) a severe stenosis was created such that resting flow was reduced. After intravenous dipyridamole (0.08 mg/kg . min-1 x 4 min), 1.5 mCi Tl-201 was injected intravenously and probe counts were collected continuously for 4 h. The mean 4-h fractional myocardial Tl-201 clearance for nonstenotic zones was 0.35, 0.27 for group 2 stenotic zones, 0.19 for group 3 stenotic zones, and 0.05 for group 4 stenotic zones (P less than 0.0001). After reaching peak activity, myocardial Tl-201 activity cleared biexponentially with a final decay constant lambda 2 = 0.0017 +/- 0.0001 min-1 (SE) for nonstenotic zones, 0.0011 +/- 0.0001 min-1 for group 2 stenotic zones, and 0.0006 +/- 0.0001 min-1 for group 3 stenotic zones (P less than 0.01). Group 4 stenotic zone Tl-201 clearances were negligible (decay constant essentially zero). Blood Tl-201 activity decayed triexponentially with a final blood lambda 3 = 0.0018 +/- 0.0001 min-1, which was almost identical to the final myocardial lambda 2 decay constant. Thus, the rate of myocardial Tl-201 clearance can distinguish between coronary stenoses of graded hemodynamic severity. These results may be applicable to quantitative techniques for determining myocardial Tl-201 clearance rates on serial clinical images after dipyridamole administration.

Kinetics of thallium-201 in reperfused canine myocardium after coronary artery occlusion.

To study the kinetics of thallium-201 in nonsalvaged acutely infarcted myocardium and salvaged myocardium, the tracer was administered after experimental left anterior descending coronary artery reperfusion 2 hours after occlusion. In 19 dogs, thallium activity was then monitored for 4 hours in the reperfused anterior wall and normal posterior wall using miniature cadmium telluride radiation detectors. After sacrifice, 13 of the dogs were found to have an infarcted anterior wall by triphenyltetrazolium-chloride staining. In these dogs, mean (+/- standard deviation) fractional 4 hour thallium clearance was 0.33 +/- 0.08 for the infarct zone and 0.15 +/- 0.06 for the normal control zone (p less than 0.001). When computer-modeled, the clearance curve from the infarct zone was biexponential. The second exponential clearance curve from the infarct zone began 19.1 +/- 3.2 minutes after tracer administration, and was indistinguishable from the monoexponential clearance curve from the normal control zone. Thallium clearance from the blood pool was triexponential, the final exponential clearance curve being indistinguishable from the normal control zone clearance curve. Six dogs were found to have a salvaged noninfarcted anterior wall by triphenyltetrazolium-chloride staining. In these dogs, mean fractional 4 hour thallium clearance was 0.20 +/- 0.07 for the reperfused zone, and 0.19 +/- 0.08 for the normal control zone (p = NS). When computer-modeled, clearance curves for the reperfused and control zones were monoexponential. The monoexponential clearance curve for the salvaged reperfused zone was indistinguishable from the monoexponential clearance curve for normal myocardium.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of decreased blood flow and ischemia on myocardial thallium clearance.

To determine the effect of reduced coronary blood flow on myocardial thallium-201 clearance over a range of flows, miniature radiation detectors were inserted into the left ventricular apex and positioned against the anterior and posterior endocardial walls in 21 dogs. Thallium was administered intravenously and myocardial tracer activity was monitored continuously for 1 hour in both walls. A balloon occluder was then partially inflated around the left anterior descending coronary artery in 19 dogs, producing a range of anterior wall blood flow reductions as assessed by the microsphere technique. Thallium activity was monitored continuously for 3 hours in both walls. Two dogs served as control animals and had no coronary artery occlusion at 1 hour. At the end of the 4 hour experiment, the dogs were sacrificed and the hearts counted in a well counter. The 19 dogs with coronary artery stenosis were divided into three groups (mild, moderate and severe flow reduction groups) on the basis of their poststenosis anterior/posterior wall regional myocardial blood flow ratios. The two control dogs had similar thallium clearances in the anterior and posterior left ventricular walls during the 3 hour period, as assessed by the radiation detectors, and by a final anterior/posterior wall thallium ratio near unity. All three groups of dogs with coronary stenosis had comparable fractional thallium clearances from the anterior and posterior walls before and after the balloon occluder inflation. The final anterior/posterior left ventricular wall thallium ratios were not significantly different than unity for all three groups of dogs.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative split dose thallium-201 imaging with exercise: a technique for obtaining rest and exercise perfusion images in one setting and markedly reducing the study time.

In the current study, a technique for performing serial thallium imaging after two separate tracer injections was applied to exercise thallium imaging, thus allowing the acquisition of rest and exercise images within 1 hour. Twenty-four patients with and 10 patients without significant coronary artery disease were studied. One mCi of thallium-201 was injected intravenously and imaging was performed at rest in three projections. The patient was then stressed and an additional 1 mCi of thallium injected during exercise. Images in the same three projections were collected. After computer realignment, the rest image was subtracted from the exercise image to produce an image representing perfusion during exercise. All 24 patients with coronary artery disease had a positive study, while 9 of 10 without disease had a negative study. The images were then interpreted using a computer method designed to quantitate regional myocardial thallium distribution and redistribution. With quantitative interpretation, 23 of 24 patients with coronary disease had a positive study, while only 1 without disease had a positive study. With qualitative interpretation, 39 (89%) of 44 stenosed coronary arteries demonstrated thallium defects in corresponding myocardial segments, while 54 (93%) of 58 nonstenosed coronary arteries did not. With quantitative interpretation, 38 (86%) of 44 stenosed coronary arteries demonstrated thallium defects in corresponding myocardial segments, while 53 (91%) of 58 nonstenosed coronary arteries did not. A split dose thallium imaging technique that allows imaging before and immediately after exercise, thus markedly reducing the study time, has been validated.

Superiority of quantitative exercise thallium-201 variables in determining long-term prognosis in ambulatory patients with chest pain: a comparison with cardiac catheterization.

The purpose of this study was to determine the prognostic utility of quantitative exercise thallium-201 imaging and compare it with that of cardiac catheterization in ambulatory patients. Accordingly, long-term (4 to 9 years) follow-up was obtained in 293 patients who underwent both tests for the evaluation of chest pain: 89 had undergone coronary artery bypass graft surgery within 3 months of testing and were excluded from analysis, 119 experienced no cardiac events and 91 had an event (death in 20, nonfatal myocardial infarction in 21 and coronary artery bypass operations performed greater than 3 months after cardiac catheterization in 50). When all variables were analyzed using Cox regression analysis, the quantitatively assessed lung/heart ratio of thallium-201 activity was the most important predictor of a future cardiac event (chi 2 = 40.21). Other significant predictors were the number of diseased vessels (chi 2 = 17.11), patient gender (chi 2 = 9.43) and change in heart rate from rest to exercise (chi 2 = 4.19). Whereas the number of diseased vessels was an important independent predictor of cardiac events, it did not add significantly to the overall ability of the exercise thallium-201 test to predict events. Furthermore, information obtained from thallium-201 imaging alone was marginally superior to that obtained from cardiac catheterization alone (p = 0.04) and significantly superior to that obtained from exercise testing alone (p = 0.02) in determining the occurrence of events. In addition, unlike the exercise thallium-201 test, which could predict the occurrence of all categories of events, catheterization data were not able to predict the occurrence of nonfatal myocardial infarction. The exclusion of bypass surgery and previous myocardial infarction did not alter the results. In conclusion, data from this study demonstrate that exercise thallium-201 imaging may be superior to data from both exercise testing alone and cardiac catheterization data alone for predicting future events in ambulatory patients who have undergone both exercise thallium-201 imaging and catheterization for the evaluation of chest pain.

Comparison of ejection fraction and pulmonary blood volume ratio as markers of left ventricular function change after coronary angioplasty.

Exercise-induced increases in pulmonary blood volume ratio have been shown to be a sensitive marker of coronary artery disease, and correlate well with exercise-induced increases in left ventricular filling pressure. To compare the impact of single vessel coronary disease on left ventricular systolic function (ejection fraction) versus diastolic filling pressure (pulmonary blood volume) before and after intervention, serial supine exercise gated blood pool scans were performed before and after coronary angioplasty in 32 patients with isolated left anterior descending coronary artery disease. By applying previously established criteria of abnormal ejection fraction (rest less than 50% or failure to rise by 5% with exercise) and pulmonary blood volume ratio (greater than 1.06), 66% of the patients were found to have abnormal responses before angioplasty by ejection fraction compared with 81% abnormal responses by pulmonary blood volume ratio (p = 0.15). After angioplasty, the proportion of patients with abnormal ejection fraction (59%) was essentially unchanged, whereas only 38% continued to have an abnormal pulmonary blood volume ratio (p less than 0.01 compared with before angioplasty). The mean pulmonary blood volume ratio also decreased significantly from 1.15 +/- 0.10 before angioplasty to 1.02 +/- 0.15 after angioplasty (p less than 0.001). It is concluded that in single vessel coronary artery disease: 1) pulmonary blood volume ratio is abnormal at least as frequently as is ejection fraction; 2) in contrast to ejection fraction, pulmonary blood volume ratio improves significantly after successful angioplasty; and 3) pulmonary blood volume ratio may be a more sensitive indicator of changes in ventricular function after an intervention in single vessel coronary disease.

Regional variability in the myocardial clearance of thallium-201 and its importance in determining the presence or absence of coronary artery disease.

There are several limitations in using absolute myocardial clearance of thallium-201 for the detection of coronary artery disease. Noncardiac factors such as peak exercise heart rate and blood level of thallium can affect its absolute myocardial clearance. However, because all myocardial segments in a given heart are exposed to the same noncardiac factors, a relative difference in myocardial clearance of thallium between segments could reflect the presence of coronary artery disease. Accordingly, myocardial clearance of thallium was analyzed in 370 patients. Patients in Group I (n = 45) had less than 1% probability of having coronary artery disease, patients in Group II (n = 44) had normal coronary arteries and patients in Group III (n = 281) had coronary artery disease. Although mean myocardial clearance of thallium in 15 myocardial segments in three views in Group I subjects was 3.4 +/- 0.7 hours, the variability between the slowest and fastest clearing segments in the same subject was as much as 98%. This variability was systematic, suggesting technical reasons associated with imaging as the cause of the variability: 78% of the slowest clearing segments were basal whereas 53% of the fastest clearing segments were apical (p less than 0.01). When Group II and III patients were compared based on Group I values, the absolute myocardial clearance of thallium had a sensitivity and specificity of 92 and 16%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic value of computer-quantitated exercise thallium imaging early after percutaneous transluminal coronary angioplasty.

To develop an approach to predicting adverse events after percutaneous transluminal coronary angioplasty (PTCA), 50 patients had thallium-201 exercise testing within 1 month after successful single vessel coronary angioplasty and were followed up for a mean of 18 months. Adverse events were: 1) clinical events consisting of recurrent angina (17 patients) and myocardial infarction (1 patient); 2) treatment events consisting of repeat coronary angioplasty (10 patients) and coronary bypass surgery (1 patient); and 3) restenosis, defined as a greater than 30% increase in luminal stenosis (15 of 38 recatheterized patients). There were no deaths. Of the clinical, exercise, angiographic and thallium scan variables analyzed by stepwise logistic regression, postangioplasty gradient greater than 20 mm Hg predicted clinical events and treatment events, and the number of segments with slower thallium clearance predicted clinical events, treatment events and restenosis. Using Cox Hazards model regression of survival without events, the number of transient qualitative thallium defects also predicted clinical events and restenosis. At 1 year after angioplasty, 24% of patients with these variables had restenosis compared with only 6% of those without these variables and 36% of patients with these variables had a clinical or treatment event compared with 8% of patients without these variables. Three measures of the adequacy of myocardial perfusion (post-angioplasty gradient, reduced thallium clearance and transient thallium defects) were additive predictors of adverse events after coronary angioplasty with the relative risk being approximately four times greater in patients with these variables than in those without. Such adverse events, therefore, are usually a consequence of inadequate revascularization.

Contrast echocardiography in acute myocardial ischemia. III. An in vivo comparison of the extent of abnormal wall motion with the area at risk for necrosis.

To define the in vivo relation between abnormal wall motion and the area at risk for necrosis after acute coronary occlusion, 11 open chest dogs were studied. Five dogs underwent left anterior descending coronary artery occlusion and six underwent left circumflex artery occlusion. Area at risk was defined at five short-axis levels (mitral valve, chordal, high and low papillary muscle and apex) using myocardial contrast echocardiography. Wall motion was measured in the cycles preceding injection of contrast medium. Two observers used two different methods to measure wall motion. In method A, end-diastolic to end-systolic fractional radial change for each of 32 endocardial targets was determined. The extent of abnormal wall motion was then calculated using three definitions of wall motion abnormality: akinesia/dyskinesia, fractional inward endocardial excursion of less than 10%, and fractional inward endocardial excursion of less than 20%. In method B, the information from the entire systolic contraction sequence was analyzed and correlated with a normal contraction pattern. The best linear correlation between area at risk (AR) and abnormal wall motion (AWM) was achieved using method B and expressed by the following linear regression: AWM = 0.92 AR + 3.0 (r = 0.92, p less than 0.0001, SEE = 1.7%). Of the three definitions of abnormality used in method A, the best correlation was achieved between area at risk and less than 10% inward endocardial excursion and was expressed by the following polynomial regression: AWM = -0.01 AR2 + 1.5 AR -0.14 (r = 0.92, p less than 0.001, SEE = 1.7%). These data demonstrate that there is a definite relation between area at risk and abnormal wall motion but that this relation varies depending on the method used to analyze wall motion. However, wall motion during acute ischemia is also influenced by the loading conditions of the heart. Because these may vary in a manner that is independent of the ischemic process, measurement of both risk area and abnormal motion may provide a more comprehensive assessment of cardiac function in myocardial ischemia than is provided by the measurement of either alone.

A noninvasive radiographic technique for evaluation of exercise-induced changes in cardiac function.

An electrocardiographic-triggered radiographic technique for obtaining a single image of the heart at both end-systole and end-diastole was used in conjunction with upright bicycle exercise to detect stress-induced changes in 1) systolic and diastolic cardiac transverse diameter, and 2) regional motion of the free left ventricular wall. Twenty-one patients were studied; 10 had normal coronary arteries and 11 had significant coronary artery disease. Twenty patients (10 with normal coronary arteries and 10 with coronary artery disease) also had multigated radionuclide blood pool scans at rest and with exercise. All patients without coronary disease showed a decrease in systolic cardiac transverse diameter with exercise and a slight increase in amplitude of motion of the left ventricular free wall. Eight (73%) of the 11 patients with coronary artery disease showed an increase in systolic transverse cardiac diameter with exercise (p less than 0.001), and 5 developed either new regional left ventricular asynergy or deterioration of segments with rest asynergy. Eight of the 10 patients with coronary artery disease who had rest and exercise radionuclide scans had an abnormal ejection fraction response to exercise. However, only 4 of the 10 control patients who had multigated scans had a normal ejection fraction response, although all showed normal regional wall motion with exercise. This new approach is inexpensive and easily performed. These preliminary data suggest that it may be a useful adjunct to cardiac stress testing and is worthy of further study.

Contrast echocardiography in acute myocardial ischemia: I. In vivo determination of total left ventricular "area at risk".

Myocardial contrast echocardiography has been shown recently to accurately assess the "area at risk" for necrosis after acute coronary occlusion in the experimental model. Risk area quantitation, however, has been studied primarily from single tomographic planes. Because the three-dimensional extent of myocardial necrosis depends on the total volume of myocardium at risk, the total left ventricular "area at risk" was determined in 11 dogs (Group A) with either left anterior descending or left circumflex artery occlusion using contrast echocardiography and compared with risk area determined by technetium autoradiography. An excellent correlation was found between the two methods (r = 0.96%, y = 0.91x + 1.5, p less than 0.001, SEE = 3.17). A comparison of risk area for individual levels of the left ventricle using both methods, however, showed some variation in the degree of correlation, with the poorest fit being apparent at the apex. To identify the source of the variation, errors caused by data registration were minimized in six additional dogs (Group B) by implanting epicardial markers at a single level and measuring "area at risk" at this level using both methods. When no registration error was present, the correlation between the two methods was excellent (r = 0.99, y = 0.92x + 2.6, p less than 0.001, SEE = 0.55). In conclusion, the "area at risk" for infarction after acute coronary occlusion can be determined accurately for the entire left ventricle as well as for a single tomographic slice using myocardial contrast echocardiography. This was validated using technetium autoradiography, which is an established method of determining "area at risk" in the experimental setting.

Right ventricular ejection fraction response to exercise in patients with coronary artery disease: influence of both right coronary artery disease and exercise-induced changes in right ventricular afterload.

To determine the influence of proximal right coronary artery disease and right ventricular afterload on right ventricular ejection fraction response to exercise, 64 patients were studied at rest and after supine exercise with gated equilibrium radionuclide angiography and coronary angiography. Right ventricular afterload response to exercise was estimated from determinations of exercise-induced changes in pulmonary blood volume, previously shown to correlate with exercise-induced changes in pulmonary capillary wedge pressure. Values for right ventricular ejection fraction decreased from rest to exercise (48 +/- 5% to 42 +/- 9%, p less than 0.001) in patients with an elevated pulmonary blood volume ratio. Values were unchanged in patients with isolated proximal right coronary artery disease (rest 49 +/- 3%, exercise 47 +/- 7%), decreased in patients with combined right and left coronary disease (rest 48 +/- 6%, exercise 39 +/- 10%, p less than 0.001) and increased (rest 47 +/- 5%, exercise 52 +/- 6%, p less than 0.001) in patients with isolated left coronary artery disease. To determine the coinfluence of coronary anatomy and changes in pulmonary blood volume, patients were classified by pulmonary blood volume ratio. Among patients with a normal pulmonary blood volume ratio, right ventricular ejection fraction did not change significantly in those with proximal right coronary artery disease during exercise, but increased significantly in patients with isolated left coronary disease. Among patients with an elevated pulmonary blood volume ratio, right ventricular ejection fraction during exercise increased significantly in those with proximal right coronary artery disease but was unchanged in patients with isolated left coronary disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of exercise perfusion and ventricular function imaging: an analysis of factors affecting the diagnostic accuracy of each technique.

Exercise thallium-201 perfusion scans and gated equilibrium blood pool scans were performed in 120 catheterized patients with a chest pain syndrome. Eighty-six patients had coronary artery disease and 34 patients did not. The effects of gender, propranolol, exercise level, exercise ischemia, history of typical angina, history of previous myocardial infarction, electrocardiographic Q waves, number of diseases vessels and extent of coronary artery obstruction on diagnostic accuracy were evaluated. The overall sensitivity and specificity of thallium scans were 76 and 68%, respectively, and those of gated blood pool scans 80 and 62% (p = not significant). Propranolol decreased the specificity of thallium scans (propranolol = 42%; no propranolol = 87%, p less than 0.05). Thallium scans and anginal history were less sensitive for detecting coronary disease in women (men: thallium = 79%; angina = 77%; women: 54 and 46%, respectively; p less than 0.05). Exercise level did not significantly affect the diagnostic accuracy of either scan. Thallium and gated scans were both highly sensitive (95%) in detecting disease in 20 patients with a prior myocardial infarction, angina and a positive electrocardiogram. The sensitivity of the thallium scan significantly decreased as the number of diseased vessels decreased. Both thallium and gated scans were less frequently positive in patients with atypical angina or no Q waves, but were not significantly influenced by electrocardiographic ischemia. The sensitivity and specificity of both scans were low in 57 patients with the combination of atypical angina, no history of infarction and equivocal stress electrocardiogram thallium = 61 and 63%, respectively; gated = 61 and 67%). When stress thallium scan evaluation included the electrocardiogram and thallium scan interpretation, the diagnostic accuracy was 81%. When all the information from gated scans (wall motion, ejection fraction, pulmonary blood volume) was combined for final gated scan evaluation, the diagnostic accuracy was 83%. When electrocardiographic data were added to all three gated scan variables, diagnostic accuracy was 77%. In conclusion, thallium perfusion and gated blood pool scans have reasonable diagnostic accuracy for coronary artery disease in a group of patients with a moderately high prevalence of disease. However, combined variables from each test are needed to provide reliable diagnostic accuracy.

Quantitation of myocardial infarct size from thallium-201 images: validation of a new approach in an experimental model.

A new computer-based method has been developed to quantitate myocardial infarct size from the size of the regional thallium-201 deficit. The operator outlines the left ventricular myocardial activity with an ellipse. The program then plots the background-corrected activities of the highest mean value in a 3 pixel myocardial band perpendicular to and within the ellipse. The approach uses a new interpolative background correction. To determine the accuracy of this approach in assessing regional thallium deficit size, acute myocardial infarction was produced in six dogs by 24 hour occlusion of the proximal left anterior descending coronary artery. Infarct size was assessed from planar thallium images of the dog heart in three views, each with the chest opened and closed and with the heart excised and placed in a cradle. Before removal of the heart, triphenyltetrazolium chloride was infused to delineate normal from infarct tissue. Transverse slices of left ventricle were made and thallium images of the slices acquired. Infarct size delineated by triphenyltetrazolium chloride staining was expressed as a percent of the total left ventricular slice surface area (planimetric infarct size). Infarct size from whole heart and left ventricular slice thallium images was expressed as a percent of the total length of the left ventricular perimeter (perimetric infarct size). This was determined from points below a certain percent of normalized peak thallium activity in the computer-generated thallium activity curve.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative analysis of dipyridamole-thallium images for the detection of coronary artery disease.

To determine if the detection of coronary artery disease by dipyridamole-thallium imaging is improved by quantitative versus qualitative analysis, and combining quantitative variables, 80 patients with chest pain (53 with and 27 without coronary artery disease) who underwent cardiac catheterization were studied. Segmental thallium initial uptake, linear clearance, monoexponential clearance and redistribution were measured from early, intermediate and delayed images acquired in three projections. Normal values were determined from 13 other clinically normal subjects. When five segments per view were used for quantitative analysis, sensitivity and specificity were 87 and 63%, respectively, for uptake, 77 and 67% for linear clearance, 60 and 60% for monoexponential clearance and 62 and 56% for redistribution. Of the four variables, uptake and linear clearance were the most sensitive (p less than 0.01) and specificity did not differ significantly. Using three segments per view, the specificity of uptake increased (p less than 0.05) to 78% without a significant change in sensitivity (85%). With this approach, sensitivity and specificity did not differ from those of qualitative analysis (85 and 78%, respectively). Stepwise logistic regression analysis demonstrated that the best quantitative thallium correlate of the presence of coronary artery disease was a combination variable of "either abnormal uptake or abnormal linear clearance, or both." Using five segments per view, the model's specificity (85%) was greater than that of uptake alone (p less than 0.02), with similar sensitivity (92%). Using three segments per view, the model's specificity (93%) was greater than that of uptake alone (p less than 0.05) and of qualitative analysis (p less than 0.05), with similar sensitivity (85%).(ABSTRACT TRUNCATED AT 250 WORDS)

In vivo detection of reperfused myocardium by nuclear magnetic resonance imaging.

To assess the potential of in vivo nuclear magnetic resonance imaging for the detection of reperfused myocardium, in vivo T2-weighted spin echo images were obtained of dogs at 0.15 tesla. Imaging was done during 3 hours of coronary occlusion (group I), and during 3 hours of coronary occlusion followed by 1 hour of reperfusion (group II). On sacrifice, the hearts were drained of blood and imaged in situ to determine the effect of in vivo imaging on myocardial signal intensity. The hearts were then excised and imaged at 1.4 tesla to compare the effect of high resolution imaging on image quality. Of the six hearts in group I and the eight hearts in group II with a myocardial infarction and suitable image quality, four of the former hearts and six of the latter demonstrated a small but visible increase in infarct signal intensity at 3 hours of occlusion on the time to echo [TE] = 60 ms, single echo images. The T2 (transverse) relaxation time of the infarct (measured in vitro by spectrometer) increased by 13% when compared with normal tissue. In contrast, the reperfused infarct was more easily visualized, with signal intensity increasing by 31 +/- 17% and infarct T2 increasing by 20%. Imaged at 1.4 tesla, the excised hearts showed the infarct to be subendocardial during occlusion and extending transmurally with reperfusion. It is concluded that, although visualized, the increase in infarct signal intensity at 3 hours of coronary occlusion is small and this is consistent with the small increase in infarct signal intensity and T2 relaxation.(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial uptake and clearance of thallium-201 in normal subjects: comparison of dipyridamole-induced hyperemia with exercise stress.

Thallium-201 uptake and clearance after dipyridamole infusion may differ from that after exercise stress because the hemodynamic effects of these two interventions are different. In this study of normal volunteers, thallium kinetics after dipyridamole (n = 13) were determined from three serial image sets (early, intermediate and delayed) and from serial blood samples and compared with thallium kinetics after exercise (n = 15). Absolute myocardial thallium uptake was greater after dipyridamole compared with exercise (p less than 0.0001), although the relative myocardial distribution was similar. The myocardial clearance (%/h) of thallium was slower after dipyridamole than it was after exercise. Comparing dipyridamole and exercise, the differences in clearance were large from the early to the intermediate image (anterior, -11 +/- 17 versus 24 +/- 5, p = 0.0005; 50 degrees left anterior oblique, -7 +/- 11 versus 15 +/- 8, p = 0.004; 70 degrees left anterior oblique, 3 +/- 9 versus 21 +/- 6, p = 0.001). In contrast, the differences in clearance were small from the intermediate to the delayed image (anterior, 15 +/- 4 versus 20 +/- 2, p = 0.025; 50 degrees left anterior oblique, 15 +/- 4 versus 19 +/- 3, p = 0.13; 70 degrees left anterior oblique, 15 +/- 3 versus 18 +/- 2, p = 0.047). Thallium uptake and clearance in the liver, splanchnic region and spleen were greater after dipyridamole (p less than 0.001). Blood thallium levels were greater after dipyridamole (p less than 0.05) and cleared more slowly (p = 0.07). Thus, myocardial thallium-201 uptake and clearance after dipyridamole infusion differ from thallium kinetics after exercise. This difference is, in part, related to associated differences in extracardiac and blood kinetics. Diagnostic criteria for the detection of abnormal thallium-201 clearance must be specific for the type of intervention.

Determination of the quantitative thallium imaging variables that optimize detection of coronary artery disease.

Although quantification of exercise thallium images has been previously reported, the relative value of different imaging variables for detection of coronary artery disease has not been analyzed in a large group of patients with cardiac catheterization data. Regional initial thallium uptake, redistribution and clearance on thallium study were measured in 325 patients also undergoing cardiac catheterization (281 patients with and 44 patients without coronary artery disease). Normal values were defined in 55 other clinically normal subjects. When five myocardial segments were analyzed in each view, the respective values for sensitivity and specificity were 95 and 50% for initial thallium uptake, 60 and 87% for redistribution and 74 and 66% for clearance. Initial thallium uptake was the most sensitive but least specific (p less than 0.001), whereas redistribution was the least sensitive and most specific (p less than 0.001). Using stepwise logistic regression analysis, the best correlate of coronary artery disease was initial thallium uptake. Addition of redistribution to a mathematical model of the probability of coronary artery disease did not alter sensitivity, but increased specificity from 50 to 70% (p less than 0.001). Once initial uptake and redistribution were considered, myocardial thallium clearance provided no additional improvement in the correlation. Excluding the two basal segments in each view from the analysis increased the specificity from 70 to 80% (p less than 0.001) without affecting sensitivity. Of the 15 patients (5%) with coronary disease not detected using this approach, none had left main disease and 10 (67%) had one vessel disease. A combination of variables derived from quantification of exercise thallium images provides a superior sensitivity and specificity for the detection of coronary artery disease compared with the use of a single variable.

Noninvasive tissue characterization: diagnosis of lipomatous hypertrophy of the atrial septum by nuclear magnetic resonance imaging.

An atrial septal mass was identified by echocardiogram in a patient with multiple subcutaneous lipomas. In order to differentiate the benign condition of lipomatous hypertrophy from myxoma, thrombus and other tumors, nuclear magnetic resonance and computed tomographic imaging were performed. Both techniques identified the adipose nature of the tissue noninvasively, consistent with the diagnosis of lipomatous hypertrophy. Pathologically demonstrated lipomatous hypertrophy in a postmortem heart was similarly characterized by nuclear magnetic resonance imaging.

Prognostic value of exercise thallium-201 imaging in patients presenting for evaluation of chest pain.

Accurate prognostic information is important in determining optimal management of patients presenting for evaluation of chest pain. In this study, the ability of exercise thallium-201 myocardial imaging to predict future cardiac events (cardiovascular death or nonfatal myocardial infarction) was correlated with clinical, coronary and left ventricular angiographic and exercise electrocardiographic data in 139 consecutive, nonsurgically managed patients followed-up over a 3 to 5 year period (mean follow-up, 3.7 +/- 0.9), using a logistic regression analysis. Among patients without prior myocardial infarction (100 of 139), the number of myocardial segments with transient thallium-201 defects was the only statistically significant predictor of future cardiac events when all patient variables were evaluated. Among patients with myocardial infarction before evaluation (39 of 139), angiographic ejection fraction was the only significant predictor of future cardiac events when all variables were considered. This study suggests an approach to evaluate the risk of future cardiac events in patients with possible ischemic heart disease.