Fast washout of thallium-201 from area of myocardial infarction: possible artifact of background subtraction

A recent report described a pattern of "reverse redistribution" on poststreptokinase 201Tl studies which was believed to be due to rapid washout of 201Tl from the infarct area related to reperfusion of the infarct vessel. We have also observed the phenomenon of rapid washout of 201Tl from the area of infarction in the absence of thrombolytic therapy. This study was undertaken to test the hypothesis that rapid washout of 201Tl from an area of infarction is an artifact of background subtraction usually employed in analysis of washout. A total of 61 patients with previous myocardial infarction who underwent cardiac catheterization and exercise 201Tl imaging were examined. Thallium-201 images were analyzed using a validated quantitative method employing interpolative background correction. Abnormally increased 201Tl washout was noted in 11 infarct segments in 10 (18%) patients. Infarct segments with rapid washout had significantly less initial uptake, and more severe associated wall motion abnormalities than infarct segments with normal washout. When quantitative analysis was repeated without background subtraction, no segments with rapid washout were observed. A phantom model was constructed to further test our hypothesis. The frequency of observed rapid washout was directly related to the severity of the initial defect and was entirely dependent upon utilizing background correction during the quantitative analysis. Our study suggests that rapid washout of 201Tl in an area of previous infarction reflects an artifact of background subtraction involved with standard quantitative analysis.

205Tl+ as a spectroscopic probe of the monovalent cation binding sites of bovine plasma activated protein C and des-1-41-light-chain-activated protein C

The kinetic properties of the stimulation by Tl+ of the amidase activity of bovine plasma activated protein C (APC) and a limited-proteolytic derivative of this enzyme, des-1-41-light chain APC (GDAPC), which has no remaining gamma-carboxyglutamic acid residues, have been compared, along with a 205Tl+ NMR analysis of the interaction of this cation with these enzymes, at 6 degrees C. In contrast to other monovalent cations, the productive kinetic complex of Tl+ and APC involves only a single Tl+ site, or class of sites, and is similar to GDAPC in this regard. In the case of each enzyme, the kinetic mechanism that best describes the participation of Tl+ is a rapid equilibrium type with random addition of the cation and substrate to the enzyme. The dissociation constants of the Tl+ X APC and Tl+ X GDAPC complexes have been determined by NMR analysis and have been found to be very similar to the same constants as calculated by kinetic means. These cation sites are also present intact on each zymogen, demonstrating that they are not generated as a result of activation. Our results also show that the Ca2+ binding sites of these proteins are exclusive of the T1+ site and that some interference with Tl+ binding is exercised by an active site-directed affinity label. We conclude that Tl+ can be effectively employed as a spectroscopic probe of the monovalent cation sites that serve an extensive stimulatory role in the amidolytic and esterolytic activities of APC.

Topographical relationships between the monovalent and divalent cation binding sites of des-1-41-light chain bovine plasma protein C and des-1-41-light chain-activated bovine plasma protein C

The paramagnetic effect of Mn2+ on the longitudinal relaxation rate (T1)-1 of 205Tl+, when both cations are bound to des-1-41-light chain bovine plasma protein C (GDPC) and its activation product, des-1-41-light chain-activated bovine plasma protein C (GDAPC), has been assessed by 205Tl+ NMR spectroscopy. A substantial shortening of the T1 for Tl+ bound to either protein was observed in the presence of Mn2+, an effect not noted upon substitution of Mn2+ with the diamagnetic cation Ca2+, which is known to bind to these proteins in a similar fashion to Mn2+. This paramagnetic effect was employed to estimate distances between the monovalent and divalent cation sites in these proteins, approximately 6.7 +/- 0.2 A with GDPC and 8.3 +/- 0.2 A in GDAPC. These data suggest that a conformational alteration occurs upon activation of GDPC which leads to an increase in the distance between the monovalent and divalent cation sites.

Myocardial uptake of thallium and rubidium during alterations in perfusion and oxygenation in isolated rabbit hearts

The comparative effects of altered cellular function and coronary perfusion on myocardial 201Tl and 83Rb uptake were evaluated in three groups of isolated rabbit hearts having isovolumic contractions. Paired-indication dilution experiments were performed with 201Tl, 83Rb, and 111In-labeled albumin as an intravascular reference marker. In Group A hearts (n = 12), isotope transport was determined during control, hypoxia, and ischemia. In Group B hearts (n = 8), isotope transport was measured at control flow and again at a 50% and 80% reduction. In Group C hearts (n = 8) only 201Tl uptake was determined at control and following coronary reperfusion. Myocardial 201Tl and 83Rb transport were not significantly different and were proportional to flow. Although all interventions caused significant hemodynamic alterations, neither tracer was affected by hypoxia at constant flow. Thallium-201 permeation, however, was transiently decreased immediately after coronary reperfusion. We conclude that myocardial uptake of 201Tl and 83Rb are similar and directly related to flow, but do not reflect hypoxia induced cellular dysfunction.

Quantitative assessment of thallium myocardial washout rate: importance of peak heart rate and lung thallium uptake in defining normal values

Traditionally, the results of exercise thallium scintigraphy were interpreted by transient defect analysis using initial and delayed images. Recently, washout rate analysis has been used for the relative quantification of exercise thallium scintigraphy. A diffuse slow washout from all myocardial regions has been defined as the indicator of extensive coronary artery disease. However, slow washout has occasionally been observed in normal cases and in healthy myocardial segments which are not supplied by a stenosed artery in patients with single or double vessel disease. We evaluate the factors influencing washout rate in 100 normal patients and 63 patients with angina pectoris (33 cases of single vessel disease and 30 cases of double vessel disease). The washout rates were calculated using circumferential profile analysis. In normal patients, washout rate was closely related to peak heart rate (r = 0.72) and inversely related to lung thallium uptake (r = -0.56). A diffuse slow washout was observed in seven (7%) of 100 normal patients, six (18%) of 33 cases of single vessel disease and eight (24%) of 30 cases of double vessel disease. The patients with diffuse slow washout showed significantly higher lung thallium uptake values and lower peak heart rates than those without diffuse slow washout (P less than 0.01). Thus, this false positive slow washout should be considered in the interpretation of quantitative exercise thallium scintigraphy.

Thallium(I) secretion across the isolated mucosa of rat descending colon

Unidirectional Tl+-fluxes across the isolated mucosa of rat descending colon were measured under short circuit (SCC) or voltage clamp conditions (VCC). Under SCC a serosal-to-mucosal net flux (Jnet = -0.22 nmol X cm-2 X h-1) was observed that agrees with the voltage-independent component measured under VCC. At 7 degrees C the secretory net flux was abolished. In controls both unidirectional fluxes were unsaturable between 0.1 and 500 mumol/l thallium (I). After furosemide or withdrawal of Cl- or Na+ Jnet was abolished. Ouabain decreased serosal-to-mucosal Tl+ flux and an energy-dependent absorptive net flux of Tl+ was observed, characterized by a rather low Km (10.2 mumol/l), Vmax (3.8 nmol X cm-2 X h-1) and apparent activation energies (delta E = 10.7 kcal X mol-1) typically for enzyme catalaysed reactions or narrow channel interactions. The data suggest that in the mucosa of rat descending colon Tl+ ions share, at least in part, the same transport systems at K+.

Quantitative aspects of myocardial perfusion imaging

Computer quantitation of myocardial perfusion images has enhanced the detection of thallium perfusion abnormalities compared to visual analysis. Computer analysis is more specific than visual analysis for detection of initial defects and more sensitive for detection of redistribution. Computer analysis is equally good for detecting thallium abnormalities in the distribution of the three major coronary arteries. Measurement of absolute clearance of thallium results in an unacceptable high false-positive rate. However, when clearance in a myocardial segment is compared to the fastest clearing segment in the heart, the specificity of clearance improves significantly. Quantitation of lung:heart ratio is very useful. Increased lung:heart ratio reflects exercise induced left ventricular dysfunction and is a strong marker of prognosis. Single photon emission computerized tomography (SPECT) offers the potential of more precisely sizing the risk area. The question of whether this technique offers a significant advantage over planar thallium imaging has to be answered.

Role of myocardial perfusion imaging in evaluating thrombolytic therapy for acute myocardial infarction

Myocardial thallium-201 scintigraphy is being increasingly employed as a method for assessing the efficacy of coronary reperfusion in acute myocardial infarction. New thallium uptake after intracoronary tracer administration after successful recanalization indicates that nutrient blood flow has been successfully restored. One may also presume that some myocardial salvage occurred if thallium administered in this manner is transported intracellularly by myocytes with intact sarcolemmal membranes. However, if one injects thallium by way of the intracoronary route immediately after reperfusion, the initial uptake of thallium in reperfused myocardium may predominantly represent hyperemic flow and regional thallium counts measured may not be proportional to the mass of viable myocytes. When thallium is injected intravenously during the occlusion phase the degree of redistribution after thrombolysis is proportional to the degree of flow restoration and myocardial viability. When thallium is injected for the first time intravenously immediately after reperfusion, an overestimation of myocardial salvage may occur because of "excess" thallium uptake in the infarct zone consequent to significant hyperemia. Another approach to myocardial thallium scintigraphy in patients undergoing thrombolytic therapy is to administer two separate intravenous injections before and 24 hours or later after treatment. Clinical studies have demonstrated that the improvement in defect size on serial images predicts improvement in regional function and patency of the infarct-related vessel. Finally, patients with acute myocardial infarction who receive intravenous thrombolytic therapy are candidates for predischarge exercise thallium-201 scintigraphy for risk stratification and detection of residual ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Statistical indices of 201Tl distribution in the myocardium]

A study was made of the diagnostic potentialities of a histogram analysis of scintigraphic count distribution on myocardium scans using 201Tl in 9 patients with dilated cardiomyopathy, 12 patients with coronary heart disease and 6 patients with primary pulmonary hypertension. Scans were recorded 10 min., 4 and 24 h after a single administration of 201Tl at rest in the front-forward, 45 degrees left forward oblique and left lateral projections. The heart area on a scan was marked by hand. Count distribution was represented by an intensity histogram. An array of 243 scans was processed independently by 2 operators of different professional skill. A man-machine classification procedure with algorithm teaching was implemented. The author showed a possibility of group distinction by scintillation count distribution in the heart area on myocardium scans using 201Tl, the distinguishing information being within the interval of 41-80% of maximum intensity in this area. Automatic marking of the heart area on a scan was found necessary to have an entirely automated system for distinguishing groups of examinees.

Biodistributions of 201Tl in tumor bearing animals and inflammatory lesion induced animals

The accumulation of 201Tl in tumor and inflammatory tissues were small. However, this nuclide showed a high concentration in viable tumor tissue, less in connective tissue (containing inflammatory tissue), and was not seen in necrotic tumor tissue regardless of the time after administration of 201Tl(I)-chloride. In inflammatory lesions, 201Tl accumulated in subcutaneous tissue infiltrated with neutrophils and macrophages, and quite large amounts of this nuclide were accumulated in subcutaneous tissue and sites where neutrophils were crowded. Most 201Tl existed in a free form in the fluid of tumor and inflammatory tissues regardless of the time after administration. A small amount of this nuclide was localized in the nuclear, mitochondrial and microsomal fractions in these tissues, and the nuclide was bound to protein in these fractions. The distribution of 201Tl(III)-chloride in tumor bearing animals was essentially the same as that of 201Tl(I)-chloride.

Organothallium(III) reagents for modification of biomacromolecules: interaction of thallium derivatives with transfer RNA

As an extension of work on the inhibition of enzymes by arylthallium(III) reagents, the thallium analogues of the organomercurials, we have studied the interactions of these molecules with transfer RNA. In contrast to thallous acetate, thallium(III) derivatives (thallic trifluoroacetate, p-methylphenylthallium(III) bis-trifluoroacetate (MPT) and o-carboxyphenylthallium(III) bis-trifluoroacetate) bound to Escherichia coli tRNA. The interaction was fully reversible upon Sephadex G-25 gel filtration, and binding constants and stoichiometries were evaluated by a number of procedures. The likely site of interaction was shown to be the thiouridine residue (s4U8) based on changes induced by MPT on the absorbance around 330 nm. No changes in stacking interactions could be detected from the absorption or circular dichroic spectra. The detailed structure of the groups on thallium(III) affected the interaction with tRNA. Thalliation at s4U8 affects the absorbance at 335 nm and the amino-acid uptake capacity of E. coli tRNAPhe in parallel, the latter being progressively inhibited by increasing amounts of MPT. In a model nucleoside system, uridine disulphide is probably formed from reduced thiouridine by the oxidative action of the Tl(III) reagents. No evidence of cross-linking of E. coli tRNA molecules under gel electrophoretic conditions was obtained in contrast to the model nucleoside. The easily reversible interaction of MPT with sulphur sites in E. coli tRNA contrasts with the stable (to gel filtration) bonds formed between MPT and (thiol) sites in enzymes.

Sex-specific criteria for interpretation of thallium-201 myocardial uptake and washout studies

A study was undertaken to determine the effect of gender on criteria for the quantitative analysis of exercise-redistribution 201Tl myocardial scintigraphy. The studies of 26 normal females and 23 normal males were subjected to bilinear interpolative background subtraction and horizontal profile analysis. Significant sexual differences were found in both regional uptake ratios and washout rates. These differences primarily reflected a proportionately decreased anterior and upper septal uptake in females, and faster washout in females. Faster myocardial 201Tl washout rates in females could not be clearly ascribed to either a physiological or artifactual explanation. It is concluded that since important differences exist between males and females in the detected pattern of 201Tl myocardial uptake and washout, sex-specific criteria may enhance the predictive accuracy of exercise-redistribution 201Tl myocardial scintigraphy.

Control of thallium and sodium fluxes in isolated adult rat heart cells by anthopleurin-A, verapamil and magnesium

Anthopleurin-A stimulated the initial rate of 201thallium uptake by isolated adult rat heart cells by a factor of 3.41 +/- 0.56, and induced a unique pattern of spontaneous beating activity. Ouabain inhibited the basal uptake rate by 58 +/- 11% and all the anthopleurin-A stimulated rate. The Km for thallium uptake was 0.95 +/- 0.26 mM, and was not changed by anthopleurin-A. Accumulated thallium was quickly released from cells by EDTA addition. Such release was inhibited 87 +/- 10% by verapamil. Thallium reuptake was initiated by restoration of magnesium to the medium. Reuptake was mostly inhibited by ouabain, but the residual ouabain-insensitive uptake remained. The ouabain-insensitive uptake was inhibited by ATP depletion. Anthopleurin-A stimulated the rate of 22Na entry into cells by a factor of 3.17 +/- 1.65, and EDTA stimulated the rate of entry by a factor of 29.5 +/- 13.0. The EDTA-induced 22Na entry was inhibited 86 +/- 11% by verapamil. From this we draw three conclusions: The major pathway for thallium uptake is the Na-K pump. The rate of uptake by this route, like the rate of K+ uptake, is governed by the rate of cellular sodium influx; A residual ouabain-insensitive uptake route also exists which appears to require ATP but not a monovalent ion gradient; Removal of Mg and Ca induces a verapamil-sensitive monovalent channel activity which is both massive and reversible.

[Estimation of radiation dose produced by impurities in nuclear medicine studies using Tl-201 chloride]

Radionuclide impurities can significantly increase the absorbed dose in Nuclear Medicine examinations. The aim of this study is to evaluate the dose of Tl-200 and Tl-202 in patients injected with Tl-201 for myocardial scintigraphy. All relevant nuclear and biological data are reported; Thallium distribution in the body is then discussed with particular regard to the gastro-intestinal tract. Since MIRD Committee has not published "S" values for Tl-200 and Tl-202, these have been calculated by a computer code and are reported. The absorbed dose for these Thallium isotopes is presented. For example, kidney doses in Gy/GBq are 0.29 (Tl-200), 0.27 (Tl-201) and 0.97 (Tl-202). The total dose increase for a 2% presence of Tl-202 is about 11%.

Implications of abnormal right ventricular thallium uptake in acute myocardial infarction

The correlates of abnormal right ventricular (RV) thallium uptake were examined in 116 patients with documented acute myocardial infarction (AMI) who underwent predischarge thallium-201 scintigraphy at rest, radionuclide angiography and 24-hour ambulatory electrocardiography. The patients were separated into 2 groups: patients group 1 (n = 31) had increased RV thallium uptake and those in group 2 (n = 85) had no such uptake. The 2 groups were comparable in age, type and site of AMI, peak creatine kinase level, systolic blood pressure and heart rate. However, compared with group 2, group 1 had a lower mean left ventricular (LV) ejection fraction (33 +/- 15% vs 39 +/- 14%, p less than 0.05), higher prevalence of increased lung thallium uptake (45% vs 22%, p less than 0.02), more extensive LV perfusion defects (4.4 +/- 2.9 vs 3.0 +/- 3.0 segments, p less than 0.03) and more complex ventricular arrhythmias (55% vs 35%, p less than 0.05). At a mean follow-up of 6 months, 17 patients (8 in group 1 and 9 in group 2) died from cardiac causes. Actuarial life-table analysis showed that the survival rate was better in group 2 than in group 1 (Mantel-Cox statistics = 4.62, p = 0.03). Thus, patients with AMI and abnormal RV thallium uptake have worse LV function, more complex ventricular arrhythmias and worse prognosis.

Effect of exercise position during stress testing on cardiac and pulmonary thallium kinetics and accuracy in evaluating coronary artery disease

We compared the effects of symptom-limited upright and supine exercise on 201Tl distribution and kinetics in the heart and lungs of 100 consecutive patients. Our analysis was based on data obtained with a digital gamma camera in the 45 degrees left anterior oblique position at 5, 40, 240, and 275 min postadministration of [201Tl]chloride. We found significant differences in the results at the 5- and 40-min intervals; viz, higher cardiac and lower pulmonary thallium activity after upright exercise in 94 subjects at both intervals, and greater variability in total and regional cardiac thallium kinetics after supine exercise. With supine exercise, the relatively low initial cardiac activity, relatively high lung activity, and the greater variability in thallium kinetics combined to make interpretation of quantitative data and cardiac images difficult and less accurate with respect to detection of coronary artery disease. These observations have important implications for the interpreting physician when thallium stress tests are performed in the supine position.

Effect of ischemia-related metabolic factors on thallium exchange in cultured rat myocardial cells

Failure of the myocardium to take up Thallium-201 is widely used as a diagnostic marker for ischemia or infarction. Although this is commonly related to a reduction in coronary flow or myocardial perfusion, other possible metabolic factors are poorly understood. The present studies investigated the influence of various interventions, designed to simulate the metabolic consequences of ischemia, on thallium-204 uptake and release in cultured myocardial cells. In these cells, where thallium exchanged rapidly (t 1/2 = 5 min.), and 60% of thallium uptake occurred via the sodium pump, thallium uptake was markedly influence by changes in extracellular potassium. Increasing extracellular potassium from a physiologic level of 5 mM to those levels reported to occur in ischemic myocardium (7.5 mM to 18 mM) effected a 25% to 60% reduction in thallium influx. The decrease in thallium influx produced by increasing extracellular potassium was rapid (30 sec.) in onset and readily reversible by restoring extracellular potassium towards normal. Changes in extracellular pH in the range 6.4 to 8.0 had no demonstrable effect on thallium uptake despite the fact that this was accompanied by similar, although less marked, changes in intracellular pH. Addition of adenine nucleosides, adenosine, inosine and hypoxanthine, to the incubating solution in concentrations from 1 nM to 0.1 mM had no effect on thallium influx or efflux in the cells. This observation held true even when 10 microM dipyridamole was used to inhibit nucleoside uptake by the cells. Addition of 1 mM 2, 4-dinitrophenol or 4 mM potassium cyanide to the cultures maximally inhibited 42% of the thallium influx within 30 min.(ABSTRACT TRUNCATED AT 250 WORDS)

Abnormal thallium kinetics in postoperative coarctation of the aorta: evidence for diffuse hypertension-induced vascular pathology

After operative correction of congenital coarctation of the aorta, patients continue to have excess cardiovascular mortality, including manifestations of ischemic heart disease. Previous morphologic studies support the concept of direct hypertensive vascular injury in these patients. To determine whether abnormalities of myocardial perfusion were present in an asymptomatic group of patients with coarctation repair, 18 men and 9 women with a mean age of 26 years (range 19 to 41) were studied between 2 and 25 years after operative correction. Stress electrocardiography and quantitative thallium imaging by a circumferential profile technique were used. These patients were compared with a normal group, statistically defined as having a less than 1% prevalence of significant obstructive coronary artery disease. The postoperative coarctation group demonstrated a reduction in global thallium redistribution in each view analyzed. As compared with findings in the control subjects, thallium washout in the anterior view (41.9 versus 48.6%, p = 0.02) and left anterior oblique projection (40.5 versus 48.2%, p = 0.007) was significantly diminished. Although the postoperative coarctation group had a lower thallium redistribution rate in the lateral view (41.4 versus 46.3%, p = 0.09) this difference did not reach statistical significance because of the intrinsic variability of this projection. Plots of the median percent thallium washout revealed independence from circumferential profile angle, indicating global abnormalities in perfusion. No correlation between clinical variables and thallium kinetics could be established, suggesting marked individual variability in the development of this vascular lesion. The observation of abnormal thallium kinetics in patients with coarctation repair may have consequences for long-term follow-up and therapy.

Characterization of the monovalent cation activator binding site of S-adenosylmethionine synthetase by 205Tl NMR of enzyme-bound Tl+

The structure of the binding site for the monovalent cation activator of S-adenosylmethionine (AdoMet) synthetase from Escherichia coli has been characterized by 205Tl NMR of enzyme-bound Tl+. The chemical shift of the enzyme-Tl+ complex is 176 ppm downfield from aquo Tl+, a shift which is typical only of Tl+ complexes with solely oxygen ligands. The 205Tl resonance shifts upfield to 85 ppm in the enzyme-Mg(II)-Tl+ complex, to 38 ppm in the enzyme-Tl+-AdoMet complex and to 34 ppm in the enzyme-Tl+-AdoMet-Mg(II) complex. The 205Tl chemical shift of enzyme-bound Tl+ was not altered by binding of either methionine, or the Mg(II)-ATP analog Mg(II)-adenyl-5'-yl imidodiphosphate, or Mg(II)-pyrophosphate to the enzyme-Tl+-Mg(II) complex. The NMR data suggest that the substrates or products of the enzyme do not coordinate to the monovalent cation activator and imply that monovalent cation activation results from alterations in protein conformation.

New aspects of cellular thallium uptake: Tl+-Na+-2Cl(-)-cotransport is the central mechanism of ion uptake

Cellular uptake mechanisms of 201Tl+ were studied in Ehrlich mouse ascites tumor cells. 201Tl+ passes the cell membrane of tumor cells using three transport systems: the ATPase, the Tl+-Na+-2Cl(-)-cotransport, and the Ca++-dependent ion channel. In the case of 201Tl+ the main route for entering the cells was the cotransport, its importance increasing with the age of the cells; in parallel, the ATPase activity was reduced. In contrast, the transport capacities of the ATPase and the cotransport were of the same magnitude in the case of 42K+ and 86Rb+. This change in ion distribution was not brought about by varying velocity relations but by changing the number of transport systems in the cell membrane. There was no relationship between transport rates and diameters of the ions. 201Tl+ distribution is proportional to that of K+ with a higher intracellular concentration of about 30%. Under physiological conditions the cotransport was reversible suggesting the ability to regulate steady state during varying extracellular ion concentrations. Cells and medium were two compartments, kinetically seen. Due to the significant difference of transport capacities between the three systems with the respective ions the term "potassium-thallium-analogy" may be misleading as it erroneously assumes identical uptake conditions.

Ouabain-insensitive, halide-sensitive Tl+ uptake by canine iliac arteries

Ouabain-insensitive Tl+ uptake by canine iliac arteries was studied. A significant fraction was halide-sensitive, with Br- substituting well for Cl-. The halide-sensitive component was inhibited by diuretics (MK196, bumetanide), PCMBS, low temperatures and external cations K+, Rb+. External but not internal Na+ was necessary for the uptake process. The process was not sensitive to disulphonic stilbenes. The halide-sensitive uptake appears to represent the operation of a (Na+/K+/Cl-)-cotransport process in arteries.

Hemodynamic determinants of thallium-201 lung uptake in patients during atrial pacing stress

The present investigation was undertaken to define the hemodynamic determinants of lung uptake of thallium-201 (TI-201) in man during stress. Graded tachycardia was induced by atrial pacing with continuous hemodynamic monitoring in 21 patients (6 normal, 15 with coronary artery disease). At peak pacing, 80 MEq (2.2 mCi) of TI-201 was injected intravenously and imaging commenced within 5 minutes. Lung activity was expressed as a percentage of peak myocardial activity on the anterior image (Lung TI-201 Index). The influence of rest, peak and post pacing hemodynamic parameters including cardiac index, pulmonary capillary wedge pressure, left ventricular end-diastolic pressure, pulmonary artery pressure, and heart rate on Lung TI-201 Index was examined using step-wise multiple regression. Change in cardiac index from rest to peak pacing was negatively correlated, while pulmonary capillary wedge pressure at peak pacing was positively correlated to Lung TI-201 Index (combined r value of 0.75). No other parameter had a significant correlation. In summary, lung uptake of TI-201 activity during atrial pacing stress appears to depend on: changes in cardiac output which may determine tissue contact time and thus influence extraction efficiency, and hydrostatic pressure in the pulmonary capillary bed.

The (F)utility of the thallium-201 quantitative lung/myocardial ratio in the detection of coronary artery disease

Exercise-induced increases in pulmonary uptake of thallium-201 (201Tl) have been associated with exercise-induced myocardial dysfunction. To evaluate this phenomenon more replicably, a quantitative semi-automated computer program was used to generate, from anterior exercise and delayed views, lung-myocardial ratios (LMR) of 201Tl uptake in 78 patients [40 normal, 38 with coronary artery disease (CAD)]. Patients with CAD had a significantly higher mean exercise lung myocardial ratio (EXLMR) than normals (30.8 vs. 27.3; P less than 0.003). In patients with adequate exercise (greater than or equal to 85% of an age-adjusted maximal heart rate), the EXLMRs of CAD patients were significantly higher than those of normals (29.7 vs. 25.5; P = 0.003). However, this difference between CAD and normal patients was not apparent in a patient subgroup with submaximal exercise levels (less than 85% of an age-adjusted maximal heart rate). In both normal and CAD patients, EXLMR decreased with increasing exercise levels (r = -0.555; P = 0.007). In patients with 201Tl scans lacking visually defined perfusion defects (visually normal), an elevated LMR detected 60% of CAD cases with 81% specificity. A considerably elevated EXLMR in patients achieving adequate exercise should suggest the presence of CAD, even if there are no visually apparent cardiac perfusion defects. With submaximal exercise, however, the EXLMR is not a useful discriminator between CAD patients and normals.

Myocardial thallium-201 kinetics during coronary occlusion and reperfusion: influence of method of reflow and timing of thallium-201 administration

Thallium-201 (201Tl) uptake and redistribution kinetics were examined in an open-chest canine preparation of occlusion and reperfusion. Seven dogs (group I) underwent 3 hr of sustained occlusion and received 1.5 mCi of 201Tl after 40 min of occlusion of the left anterior descending coronary artery (LAD). Group II (n = 18) underwent 60 min of LAD occlusion followed by sudden and total release of the ligature. Group IIa (n = 8) received intravenous 201Tl during occlusion of the LAD, whereas group IIb (n = 10) received intravenous 201Tl at the time of peak reflow. Group III dogs (n = 26) also underwent 60 min of LAD occlusion that was followed by gradual reflow through a residual critical stenosis. Animals in this group also received 201Tl either before (IIIa; n = 16) or after reflow was established (IIIb; n = 10). In group I, the relative 201Tl gradient (nonischemic minus ischemic activity) decreased from 88 +/- 8% (mean +/- SEM) to 59 +/- 6% during 3 hr of coronary occlusion (p = .034). After rapid and total reperfusion (group IIa), this gradient decreased from 71 +/- 6% during occlusion to 26 +/- 5% after reflow (p less than .001). After slow reperfusion through a residual stenosis (group IIIa), the gradient decreased from 81 +/- 5% to 31 +/- 5% (p less than .001) (p = .56 compared with group IIa). In rapidly reperfused dogs receiving intravenous thallium during peak reflow (IIb), initial 201Tl activity in the ischemic zone was 155 +/- 20% of initial normal activity and fell to 93 +/- 13% of normal after 2 hr of reperfusion. Similarly, in dogs reperfused slowly through a critical stenosis (IIIb), which received 201Tl during reflow, 201Tl activity soon after reflow was 94 +/- 4% of initial normal and decreased to 80 +/- 6% at 2 hr of reperfusion (p = .10). Histochemical evidence of necrosis was present in the biopsy region in 80% of the 20 dogs subjected to triphenyl tetrazolium chloride (TTC) staining. Microsphere-determined transmural blood flow was similar in all groups during LAD occlusion and final flows after 2 hr were comparable in all subgroups undergoing reflow. Ischemic zone flow (% normal) was significantly higher at the time of 201Tl administration in groups IIb (192 +/- 25%) and IIIb (110 +/- 5%), which received 201Tl during reflow, than in groups IIa (31 +/- 9%) and IIIa (22 +/- 5%), which received 201Tl during occlusion.(ABSTRACT TRUNCATED AT 400 WORDS)

Thallium scintigraphy in the evaluation of portal systemic shunting. The problem of rectal absorption

Thallium-201 scintigraphy is an attractive method for studying the portal systemic shunting. However, the technique is sometimes hampered by a low rectal absorption. The present work shows that cirrhotic patients present a significantly lower activity in the regions of interest in relation to the low absorption of the tracer as compared with non-cirrhotic subjects (p less than 0.01). This study also demonstrates that the dilution of the tracer in a large volume cannot be envisaged in order to increase the surface contact and secondarily the absorption, because part of the tracer can reach the inferior vena cava via portal systemic communications in the lower part of the rectum. Oral administration of the thallium was also attempted but this route cannot be used in relation to its poor absorption and due to the difficulty in separating liver from intestinal activity. The study also shows that even in the case of low activity in the regions of interest, the interpretation of the test in cirrhotic patients is usually possible on the condition that the curves of radioactivity in the liver and cardiac areas are ascending. Using these criteria, only 6.7% of the tests were in fact not interpretable in this study.

Thallium circumferential profiles in the detection of coronary artery disease--assessment by receiver operating characteristic curve analysis

Thallium uptake and redistribution in the myocardium was quantitated using circumferential activity profiles. The profiles were determined from images in the LAO 35, LAO 70 and anterior views, obtained after peak exercise and after 3-4 h redistribution. A retention curve was constructed from these profiles, displaying the redistribution profile as a fraction of the stress profile. Normal values were obtained from 21 normal patients and compared to the images from 68 patients suspected of having coronary artery disease (CAD). Of the latter, 20 had normal/non-significant CAD and 48 had 70% or greater stenosis of one or more vessels on coronary angiography. Several methodological variations were examined: calculation of the profiles using the peak or average counts around the ventricle, uniform or interpolative background subtraction, normalisation of the profiles to their peak or mean counts. Receiver operating characteristic (ROC) curves were generated for profiles calculated using these variations and compared with the ROC curves obtained by visual interpretation of both analogue and computer-enhanced images by two experienced observers. The uniform background subtraction method was found to be better than the interpolative method, and normalisation to the mean of each curve was preferable to normalisation to the peak. ROC curves using profiles calculated using the peak myocardial counts were identical to the ROC curves from profiles using the average counts, but the operating points on the two curves differed. Computer enhancement of the digital images resulted in increased sensitivity for CAD without loss of specificity when compared to the interpretation of the analogue images. The circumferential profiles were found to provide a further increase in sensitivity and were highly reproducible.(ABSTRACT TRUNCATED AT 250 WORDS)

Separate effects of ischemia, hypoxia, and contractility on thallium-201 kinetics in rabbit myocardium

The effects of hypoxia and ischemia, as well as altered contractility, on thallium-201 (201TI) kinetics were evaluated in 42 isolated isovolumetrically contracting rabbit hearts. In Group A, three subgroups (n = 7 each) were studied that had either normal flow and oxygenation, hypoxia and normal flow, or ischemic flow and normal perfusate oxygen content. In Group B, three subgroups (n = 7 each) were studied and all hearts had normal flow but the contractile state was either enhanced with isoproterenol or impaired by hypocalcemia. A hemoglobin-free buffer perfusate was used in all experiments and multiple timed collections of arterial and coronary sinus effluent were used to model myocardial isotope activity during 30 min of constant uptake followed by 30 min of tracer clearance. During ischemia, hypoxia and hypocalcemia peak developed pressure and peak positive and negative dP/dt were all significantly reduced when compared to normal hemodynamic parameters (p less than 0.01). As expected, isoproterenol significantly elevated these parameters (p less than 0.04). Myocardial 201TI kinetics were adequately described utilizing a bi-exponential model having a fast and slow component. Only ischemic hearts had significantly lower rate constants for 201TI uptake and clearance than normal hearts (p less than 0.001). The mean (+/- s.d.) myocardial uptake and clearance rates for 201TI (%/min) varied between 4.86 +/- 0.87 and 7.18 +/- 1.45 for the remaining groups of hearts. Therefore, myocardial 201TI kinetics appear to be dominated by coronary flow and may not reflect marked alterations in the metabolic and contractile state. These data suggest that normal 201TI uptake in impaired or hypercontractile cells, receiving normal flow, may not represent normal cellular function.

Influence of peak exercise heart rate on normal thallium-201 myocardial clearance

Measurement of myocardial clearance rates between initial and delayed images is a major justification for adding computer quantification to the interpretation of exercise 201TI images. To clarify the range of normal thallium clearance and its relationship to the level of exercise achieved, exercise thallium images in 89 normal subjects were analyzed: 45 asymptomatic subjects with less than 1% probability of coronary artery disease (CAD) (Group I), and 44 patients with chest pain found to have no significant CAD on angiography (Group II). Mean initial regional thallium uptake was similar in the two groups, but myocardial thallium clearance (mean +/- 1 s.d.) was slower in Group II, expressed as a longer half-life in the myocardium (8.2 +/- 7.6 hr compared with 3.4 +/- 0.7 hr p less than 0.001). Analysis of variance using ten clinical and exercise variables as covariates showed that the slower clearance in Group II was related to a lower peak exercise heart rate (HR) (154 +/- 27 compared with 183 +/- 11, respectively, p less than 0.001). By linear regression analysis, a decrease in peak HR of 1 beat/min was associated with a slower thallium clearance (longer half-life) of 0.05 hr. Using this formula, the clearance value in each patient was then corrected for peak exercise heart rate by decreasing measured clearance by 0.05 hr multiplied by the amount peak exercise heart rate which was below 183 (the mean value in Group I). There were no differences in the "corrected" clearance between the two groups. We conclude that thallium myocardial clearance after exercise is related in part to factors other than the presence of CAD, being slower when peak exercise HR is lower. Therefore, thallium clearance rates alone uncorrected for peak exercise heart rate should be used with caution when diagnosing CAD.

Myocardial kinetics of thallium-201 after stress in normal and perfusion-reduced canine myocardium

Despite the emerging use of quantitative computer programs for assessing myocardial thallium uptake and clearance after exercise, little is known about the kinetics of thallium after exercise stress. Accordingly, 11 mongrel dogs with experimental left anterior descending coronary stenoses were given thallium during norepinephrine infusion to simulate exercise. The infusion was discontinued and thallium activity was monitored regionally using miniature radiation detectors for 3 hours. Heart rate, arterial pressure and double product all increased significantly during norepinephrine infusion. The mean fractional myocardial thallium clearance was lower (0.47 +/- 0.03 [+/- standard error of the mean]) for the stenosis zone than for the no-stenosis zone (0.57 +/- 0.03) (p less than 0.0001). The stress blood flow ratio (stenosis/no-stenosis zone = 0.27 +/- 0.06) was significantly lower than the final thallium activity ratio (0.68 +/- 0.07) (p less than 0.001), consistent with thallium redistribution occurring over the 3-hour period. Myocardial thallium activity in the stenosis zone peaked in a mean of 2.2 minutes, then washed out biexponentially with a final decay constant of 0.0035 +/- 0.0005 min-1. Myocardial thallium activity in the no-stenosis zone peaked within 1 minute in all dogs, then washed out biexponentially, with a final decay constant of 0.0043 +/- 0.0003 (p less than 0.001 compared with stenosis zone). In conclusion, fractional clearance of thallium can differentiate myocardium distal to a coronary artery stenosis from that supplied by a normal coronary vessel.

Effect of hyperaemia on thallium-201 redistribution in normal canine myocardium

The specific effect of hyperaemia on thallium redistribution is not known. Therefore we evaluated the effect of initial (group A) and delayed (group B) hyperaemia on thallium kinetics in normal canine myocardium. In group A dogs (n = 14) adenosine was infused into the left circumflex artery (LCx) prior to thallium injection and was continued for either 5, 30 or 120 min after thallium administration. In group B dogs (n = 10) LCx adenosine was begun 10 min post thallium injection and continued for 2 h. Radioactive microspheres were injected simultaneously with thallium and just prior to death in all but the 5 min experiments. The region of the left anterior descending artery (LAD) served as a normal control for each heart. The mean LCx/LAD flow ratio in all group A hearts was 3.81 +/- 1.24 (SD) and the final thallium LCx/LAD ratios averaged 2.29 +/- 0.26, 1.52 +/- 0.27 and 0.93 +/- 0.16 at 5, 30 and 120 min respectively, which represents a significant redistribution of thallium (p less than 0.05). In group B hearts, the mean LCx/LAD flow ratio was 1.06 +/- 0.07 during thallium injection and after LCx adenosine infusion the flow ratio rose to 2.91 +/- 0.75 (p less than 0.001). This resulted in a final thallium LCx/LAD ratio of 0.96 +/- 0.07 which was significantly less than the initial microsphere determined flow ratio (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Decrease in the ability to detect elevated lung thallium due to delay in commencing imaging after exercise

Post-exercise elevation of the lung/myocardial thallium ratio and a high lung clearance rate between initial and delayed images have been reported to be markers for exercise-induced left ventricular (LV) dysfunction associated with coronary artery disease (CAD). We performed thallium exercise tests on 60 patients, 42 with CAD, in order to determine the effect of delaying initial imaging on detection of elevated lung thallium. In addition to images obtained at 2 minutes and at 2 hours after exercise, 18-minute images were also obtained to simulate such a delay. Because of rapid isotope clearance in those with initially elevated lung activity, there was decreased sensitivity of both the initial lung/myocardial ratio and lung thallium clearance for detecting CAD, using the 18-minute image as the initial post exercise study. We conclude that initial imaging should be done in the anterior view early after exercise to optimize detection of elevated lung thallium.

Effects of anoxia and ischemia on thallium exchange in rabbit myocardium

We investigated the effects of anoxia and ischemia on thallium (201Tl) exchange using isolated rabbit interventricular septa. Anoxia for 20 or 40 min caused a decrease in 201Tl tissue uptake due to an increased efflux of 201Tl with a smaller increase in 201Tl influx. Between 40 and 60 min of anoxia, the increased efflux of 201Tl was reversed and the increase in 201Tl influx was absent. After 60 min of reoxygenation, septa made anoxic for 20-60 min recovered at least 95% of the Tl lost. Mechanical recovery, however, was still significantly depressed. Reperfusion after total ischemia for 20-60 min was followed by resumption of 201Tl uptake despite continued mechanical dysfunction. Efflux rates during reperfusion after ischemia were significantly different from preischemic values but not in a predictable way. This unpredictability complicates interpretation of clinical 201Tl redistribution studies. These results represent important differences from those reported previously using 42K [Am. J. Physiol. 232 (Heart Circ. Physiol. 1): H85-H94 and H564-H570, 1977]. Anoxia did not increase the influx of 42K. Also, 60 min of ischemia resulted in progressive losses of 42K. This implies there are different sensitivities and/or mechanisms for Tl compared with K uptake. Our results are consistent with 201Tl uptake by severely damaged and nonviable cells.

Conductance and selectivity properties of a substate of the rabbit sarcoplasmic reticulum channel

In this paper I describe the occurrence and properties of a subconductance state of the cation-selective channel of the sarcoplasmic reticulum. The substate conductance is 60% of the major state conductance in every salt solution examined. When single channel conductance is plotted vs. ion concentration (for potassium or thallium salt solutions) the Michaelis-Menten constant is nearly the same for both conductance states, while the maximum conductance is reduced for the subconductance state. Both conductance states show anomalous conductance behavior in mixed potassium-thallium solutions that may be modeled in the same way. These results indicate that the ionic selectivity of the channel is the same for both open states.

An evaluation of the efficacy of charcoal haemoperfusion in the treatment of three cases of acute thallium poisoning

The efficacy of intermittent charcoal haemoperfusion in combination with forced diuresis and Prussian blue therapy was evaluated in three cases of thallium poisoning. At a blood flow of 300 ml/min the average blood clearance values obtained with haemoperfusion were 72 +/- 11 ml/min (mean +/- SD) at a starting blood concentration above 2 mg/l and 120 +/- 23 ml/min (mean +/- SD) below this blood level. As a result of the combined intensive treatment, the thallium half-lives in blood observed during the period monitored were only 25-41 h. Removal of thallium by haemoperfusion is faster per unit of time than simultaneous excretion by forced diuresis. When forced diuresis was combined with intermittent (4-20 h intervals) haemoperfusion therapy, the total elimination by each technique was about equivalent over the period of combined treatment. Saturation of the Adsorba 300 C columns occurred during treatment. As a result, the clearance obtained did decrease to half the initial value in 2-3 h. As this decrease in efficacy is related to the blood concentration, haemoperfusion is more efficient at lower blood concentrations. This is in contradistinction to forced diuresis, of which the excretion is proportional to the blood concentration.

Acute thallium intoxication: kinetic study of the relative efficacy of several antidotal treatments in rats

Rats were administered a sublethal dose of thallium (12.35 mg/kg as aqueous thallous sulfate, Tl2SO4, equivalent to 10 mg Tl+/kg per os) on day 0. Urine and feces were collected separately every day for 8 days and analyzed by atomic absorption spectroscopy. Based on information in the literature, five antidotal treatments (dithizone, activated charcoal, furosemide, Prussian Blue, and a combination of Prussian Blue and furosemide) were compared with controls for their efficacy in reducing the total thallium body load. In the control group (C,n = 10) of an approximate administered dose of 2 mg, after 8 days 411 micrograms (21%) had been eliminated in the urine and 641 micrograms (32%) in the feces, making a total of 1,052 micrograms (53%). In the treated groups the effects were very significant and in accord with the mode of action of the antidotes: furosemide (a diuretic) only enhanced urinary elimination; activated charcoal and Prussian Blue (unabsorbed adsorbents) only increased fecal elimination; dithizone increased only urinary elimination, whereas combined treatment with Prussian Blue and furosemide increased elimination by both routes. At the end of 8 days the control group had only eliminated 53% of the dose; this was increased to 99% by dithizone, 93% by activated charcoal, 64% by furosemide, 82% by Prussian Blue and 92% by combining furosemide and Prussian Blue. In view of the inherent toxicity of dithizone, it is suggested that treatment with a combination of Prussian Blue-furosemide or with activated charcoal should be adequate.(ABSTRACT TRUNCATED AT 250 WORDS)

Thallium concentrations in body fluids and tissues in a fatal case of thallium poisoning

A fatal case of thallium poisoning is described in which the thallium concentration was quantitated in plasma and urine during treatment and in tissue samples obtained on postmortem examination. As ileus paralyticus and the onset of renal failure were already manifested on admission of the patient, charcoal hemoperfusion and this technique in combination with hemodialysis were applied which showed to be tenfold more effective than the simultaneous renal elimination. The highest thallium concentration was found in the heart and not in kidneys as reported previously in animal experiments. Evidence is presented that thallium distribution in kidneys is dose dependent.

Kinetics of thallium exchange in cultured rat myocardial cells

The kinetics of thallium exchange in cultured rat myocardial cells were studied and compared to those of potassium in the same tissue. Studies were carried out using low concentrations (10 nM to 5 microM) of thallium-204, approximating those likely to be encountered during clinical myocardial scintigraphy. Both thallium uptake and release could be described by a single exponential with a half-time of exchange which was approximately half that of potassium and which was largely independent of extracellular thallium concentration. Some 60% of thallium uptake occurred via an "active" or ouabain-inhibitable mechanism which, in the absence of extracellular potassium, could be activated by low concentrations (10 nM to 5 microM) of thallium. The apparent Km for thallium on this active transport mechanism was 2-7 microM. Increasing extracellular potassium from 0-10 mM caused significant, concentration-dependent decreases in both the total and the active component of the thallium influx. Similarly nonradioactive thallium (0.10 microM to 0.10 mM) caused a concentration-dependent decrease in active potassium influx. Analysis of these results by both Lineweaver-Burk plots and Dixon plots confirmed competitive inhibition, potassium on thallium influx and vice versa, for the active component of the fluxes, and noncompetitive in the remainder. These findings indicate that active transport accounts for the greater portion of the influx of thallium and potassium, and that this active transport occurs via a common mechanism.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of the transport of 42K+, 22Na+, 201Tl+, and [99mTc(dmpe)2 X Cl2]+ using human erythrocytes

The ability of isolated human erythrocytes to exchange Na+ for K+ via (Na+ + K+)-ATPase was used to study the characteristics and interactions of the transport of both alkali metal and synthetic monovalent cations. Both efflux and influx studies were carried out and the results showed that: (1) Efflux of 22Na+ from human erythrocytes was stimulated by the addition of either of K+, or Tl+ at 10 mM and inhibited by the addition of ouabain. Unlabeled K+ and the addition of [99Tc(dmpe)2 X Cl2]+ (dmpe, 1,2-bis(dimethylphosphino)ethane) at 5 mM had no effect on 22Na+ efflux. (2) Influx of 42K+ was inhibited by the addition of ouabain, unlabeled K+, or Tl+. 201Tl+ influx was more rapid and of a greater magnitude than 42K+ influx. [99Tc(dmpe)2 X Cl2]+ had no effect on 42K+ uptake. (3) Influx of 201Tl+ was inhibited by ouabain and by the addition of unlabeled Tl+. Addition of [99Tc(dmpe)2 X Cl2]+ at 5 mM resulted in an inhibition of 201Tl+ influx. (4) [99Tc(dmpe)2 X Cl2]+ influx resembled that of 42K+ with respect to rate and magnitude. Influx of [99mTc(dmpe)2 X Cl2]+ was shown to be unaffected by ouabain, unlabeled K+ or Tl+. Addition of 5 mM [99Tc(dmpe)2 X Cl2]+ initially had no effect on [99mTc(dmpe)2 X Cl2]+ influx, however, a time-dependent stimulation of the influx of the [99mTc(dmpe)2 X Cl2]+ was observed. We conclude that the influx of the various alkali, metal and synthetic monovalent cations into erythrocytes is mediated by different mechanisms. Most clearly, the influx of [99mTc(dmpe)2 X Cl2]+ is not by a mechanism similar to that of utilized by K+ or Tl+.