Regional myocardial metabolic rate of oxygen measured by O2-15 inhalation and positron emission tomography in patients with cardiomyopathy

Quantification of myocardial oxygen extraction fraction: A proof-of-concept study

PURPOSE

To demonstrate a proof of concept for the measurement of myocardial oxygen extraction fraction (mOEF) by a cardiovascular magnetic resonance technique.

METHODS

The mOEF measurement was performed using an electrocardiogram-triggered double-echo asymmetric spin-echo sequence with EPI readout. Seven healthy volunteers (22-37 years old, 5 females) were recruited and underwent the same imaging scans at rest on 2 different days for reproducibility assessment. Another 5 subjects (23-37 years old, 4 females) underwent cardiovascular magnetic resonance studies at rest and during a handgrip isometric exercise with a 25% of maximal voluntary contraction. Both mOEF and myocardial blood volume values were obtained in septal regions from respective maps.

RESULTS

The reproducibility was excellent for the measurements of mOEF in septal myocardium (coefficient of variation: 3.37%) and moderate for myocardial blood volume (coefficient of variation: 19.7%). The average mOEF and myocardial blood volume of 7 subjects at rest were 0.61 ± 0.05 and 11.0 ± 4.3%, respectively. The mOEF agreed well with literature values that were measured by PET in healthy volunteers. In the exercise study, there was no significant change in mOEF (0.61 ± 0.06 vs 0.62 ± 0.07) or myocardial blood volume (12 ± 6% vs 13 ± 4%) from rest to exercise, as expected.

CONCLUSION

The implemented cardiovascular magnetic resonance method shows potential for the quantitative assessment of mOEF in vivo. Future technical work is needed to improve image quality and to further validate mOEF measurements.

Quantification of myocardial oxygenation in heart failure using blood-oxygen-level-dependent T2* magnetic resonance imaging: Comparison with cardiopulmonary exercise test

PURPOSE

Quantification of myocardial oxygenation (MO) in heart failure (HF) has been less than satisfactory. This has necessitated the use of invasive techniques to measure MO directly or to determine the oxygen demand during exercise using the cardiopulmonary exercise (CPX) test. We propose a new quantification method for MO using blood-oxygen-level-dependent (BOLD) myocardial T2* magnetic resonance imaging (M-T2* MRI), and investigate its correlation with CPX results.

METHODS

Thirty patients with refractory HF who underwent cardiac MRI and CPX test for heart transplantation, and 24 healthy, age-matched volunteers as controls were enrolled. M-T2* imaging was performed using a 3-Tesla and multi-echo gradient-echo sequence. M-T2* was calculated by fitting the signal intensity data for the mid-left ventricular septum to a decay curve. M-T2* was measured under room-air (T2*-air) and after inhalation of oxygen for 10min at a flow rate of 10L/min (T2*-oxy). MO was defined as the difference between the two values (ΔT2*). Changes in M-T2* at the two conditions and ΔT2* between the two groups were compared. Correlation between ΔT2* and CPX results was analyzed using the Pearson coefficient.

RESULTS

T2*-oxy was significantly greater than T2*-air in patients with HF (29.9±7.3ms vs. 26.7±6.0ms, p<0.001), whereas no such difference was observed in controls (25.5±4.0ms vs. 25.4±4.4ms). ΔT2* was significantly greater for patients with HF than for controls (3.2±4.5ms vs. -0.1±1.3ms, p<0.001). A significant correlation between ΔT2* and CPX results (peak VO₂, r=-0.46, p<0.05; O₂ pulse, r=-0.54, p<0.005) was observed.

CONCLUSION

ΔT2* is increased T2*-oxy is greater in patients with HF, and is correlated with oxygen metabolism during exercise as measured by the CPX test. Hence, ΔT2* can be used as a surrogate marker of MO instead of CPX test.

The role of capillary transit time heterogeneity in myocardial oxygenation and ischemic heart disease

Ischemic heart disease (IHD) is characterized by an imbalance between oxygen supply and demand, most frequently caused by coronary artery disease (CAD) that reduces myocardial perfusion. In some patients, IHD is ascribed to microvascular dysfunction (MVD): microcirculatory disturbances that reduce myocardial perfusion at the level of myocardial pre-arterioles and arterioles. In a minority of cases, chest pain and reductions in myocardial flow reserve may even occur in patients without any other demonstrable systemic or cardiac disease. In this topical review, we address whether these findings might be caused by impaired myocardial oxygen extraction, caused by capillary flow disturbances further downstream. Myocardial blood flow (MBF) increases approximately linearly with oxygen utilization, but efficient oxygen extraction at high MBF values is known to depend on the parallel reduction of capillary transit time heterogeneity (CTH). Consequently, changes in capillary wall morphology or blood viscosity may impair myocardial oxygen extraction by preventing capillary flow homogenization. Indeed, a recent re-analysis of oxygen transport in tissue shows that elevated CTH can reduce tissue oxygenation by causing a functional shunt of oxygenated blood through the tissue. We review the combined effects of MBF, CTH, and tissue oxygen tension on myocardial oxygen supply. We show that as CTH increases, normal vasodilator responses must be attenuated in order to reduce the degree of functional shunting and improve blood-tissue oxygen concentration gradients to allow sufficient myocardial oxygenation. Theoretically, CTH can reach levels such that increased metabolic demands cannot be met, resulting in tissue hypoxia and angina in the absence of flow-limiting CAD or MVD. We discuss these predictions in the context of MVD, myocardial infarction, and reperfusion injury.

11C-Acetate clearance as an index of oxygen consumption of the right myocardium in idiopathic pulmonary arterial hypertension: a validation study using 15O-labeled tracers and PET

Idiopathic pulmonary arterial hypertension (IPAH) results in increased right ventricular (RV) workload and oxygen demand. It has been shown that myocardial oxygen consumption (MVO2) of the hypertrophied right ventricle of IPAH patients can be measured using PET and (15)O-labeled tracers. This method is, however, not very suitable for routine clinical practice. The purpose of the present study was to assess whether MVO2 can also be determined in the right ventricle of IPAH patients from the clearance of (11)C-acetate, a simple method that is in use for MVO2 measurements of the left myocardium.

METHODS

Seventeen of 26 IPAH patients performed the total PET study. Nine other patients were scanned only for (11)C-acetate. (15)O-H2O, (15)O-O2, and (15)O-CO scans were used to derive RV flow, oxygen extraction fraction, and blood volume, respectively, from which RV MVO2 was calculated. The rate of clearance determined by monoexponential curve fitting (K(mono)) and the efflux rate constant k2 were derived from the (11)C-acetate scan. The RV rate-pressure product was also determined by means of right heart catheterization, as an index of the RV MVO2, and was calculated as the product of systolic pulmonary artery pressure and heart rate.

RESULTS

Both (11)C-acetate clearance rates, K(mono) (R(2) = 0.41, P = 0.006) and k2 (R(2) = 0.45, P = 0.003), correlated with RV MVO2. They also correlated with RV rate-pressure product (K(mono), R(2) = 0.41, P = 0.0005; k2, R(2) = 0.48, P < 0.0001).

CONCLUSION

(11)C-acetate clearance rates correlated moderately with quantitative RV MVO2 measurements in IPAH. Therefore, (11)C-acetate PET can be used only as an index of RV oxidative metabolism in IPAH patients.

The association of rate pressure product (RPP) and myocardial perfusion imaging (MPI) findings: a preliminary study

Introduction: The product of heart rate and systolic blood pressure, termed as rate-pressure product (RPP), is a very reliable indicator of myocardial oxygen demand and is widely used clinically. There have been previous attempts to describe the relationship between RPP and the onset of pain in angina pectoris. The current study aimed to evaluate the association between RPP results and scan findings.

Materials and methods: In total, 497 patients with suspected coronary artery disease (CAD) underwent gated, single-photon emission computed tomography (SPECT) imaging with dipyridamole, exercise, or dobutamine stress, and were included in this study. Baseline and maximum heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and electrocardiogram (ECG) results were recorded. The rate-pressure product (RPP) was calculated as the product of heart rate and systolic arterial pressure for both baseline and maximum measures. The difference between the RPP max and the basal RPP is known as the RPP reserve. Researchers also obtained semi-quantitative analyses of myocardial perfusion imaging (MPI), using gated software, demographic information, risk factors of CAD, and pretest likelihoods of CAD using nomograms.

Result: Four hundred and ninety-seven cases, including 426 patients with dipyridamole stress, 59 with exercise stress, and 12 with dobutamine stress, underwent myocardial perfusion imaging. Scan results were positive in 194 (45.5%) and negative in 232 (54.5%) patients with dipyridamole stress. In patients with exercise stress, the scan was positive in 24 (40.7%) cases and negative in 35 (59.3%) cases. In dobutamine stressed patients, the scan was positive in 6 (50%) cases and negative in the 6 remaining cases. Dipyridamole stress resulted in a significant difference between HR at rest and at maximum (28.95 ± 24.53, p-value<0.0001), between systolic BP at rest and maximum (6.75 ± 12.50, p-value<0.0001) and between diastolic BP at rest and maximum (1.45 ± 5.80; p-value<0.0001). There was a significant correlation between sum stress scores (SSS) and reserved RPP (r= −0.12, p-value<0.001) which, in dipyridamole patients, was r=−0.18, p-value=0.0001). In addition, there was a significant association between reserved RPP and risk of CAD (p-value<0.001). In the patients with dipyridamole stress, the ejection fraction (EF) change (odds ratio =0.92; 95% CI: 0.86-0.98; p=0.01), reserve RPP (odds ratio =1.00; 95% CI: 1.00-1.00; p=0.04), risk of CAD (odds ratio =5.80; 95% CI: 3.21-10.50; p<0.0001) and age (odds ratio =0.94; 95% CI: 0.89-0.98; p=0.01) were associated significantly with MPI results, using multiple logistic regressions.

Conclusion. The study demonstrated that RPP is associated with MPI findings using gated SPECT imaging with dipyridamole stress. However, to confirm this preliminary result, further studies are mandatory.

Quantification of global myocardial oxygenation in humans: initial experience

PURPOSE

To assess the feasibility of our newly developed cardiovascular magnetic resonance (CMR) methods to quantify global and/or regional myocardial oxygen consumption rate (MVO2) at rest and during pharmacologically-induced vasodilation in normal volunteers.

METHODS

A breath-hold T2 quantification method is developed to calculate oxygen extraction fraction (OEF) and MVO2 rate at rest and/or during hyperemia, using a two-compartment model. A previously reported T2 quantification method using turbo-spin-echo sequence was also applied for comparison. CMR scans were performed in 6 normal volunteers. Each imaging session consisted of imaging at rest and during adenosine-induced vasodilation. The new T2 quantification method was applied to calculate T2 in the coronary sinus (CS), as well as in myocardial tissue. Resting CS OEF, representing resting global myocardial OEF, and myocardial OEF during adenosine vasodilation were then calculated by the model. Myocardial blood flow (MBF) was also obtained to calculate MVO2, by using a first-pass perfusion imaging approach.

RESULTS

The T2 quantification method yielded a hyperemic OEF of 0.37 +/- 0.05 and a hyperemic MVO2 of 9.2 +/- 2.4 micromol/g/min. The corresponding resting values were 0.73 +/- 0.05 and 5.2 +/- 1.7 micromol/g/min respectively, which agreed well with published literature values. The MVO2 rose proportionally with rate-pressure product from the rest condition. The T2 sensitivity is approximately 95% higher with the new T2 method than turbo-spin-echo method.

CONCLUSION

The CMR oxygenation method demonstrates the potential for non-invasive estimation of myocardial oxygenation, and should be explored in patients with altered myocardial oxygenation.