Technetium-99m-labeled myocardial perfusion agents: Are they better than thallium-201?

Clinical Applications for Radiotracer Imaging of Lower Extremity Peripheral Arterial Disease and Critical Limb Ischemia

Peripheral arterial disease (PAD) is an atherosclerotic occlusive disease of the non-coronary vessels that is characterized by lower extremity tissue ischemia, claudication, increased prevalence of lower extremity wounds and amputations, and impaired quality of life. Critical limb ischemia (CLI) represents the severe stage of PAD and is associated with additional risk for wound formation, amputation, and premature death. Standard clinical tools utilized for assessing PAD and CLI primarily focus on anatomical evaluation of peripheral vascular lesions or hemodynamic assessment of the peripheral circulation. Evaluation of underlying pathophysiology has traditionally been achieved by radiotracer-based imaging, with many clinical investigations focusing on imaging of skeletal muscle perfusion and cases of foot infection/inflammation such as osteomyelitis and Charcot neuropathic osteoarthropathy. As advancements in hybrid imaging systems and radiotracers continue to evolve, opportunities for molecular imaging of PAD and CLI are also emerging that may offer novel insight into associated complications such as peripheral atherosclerosis, alterations in skeletal muscle metabolism, and peripheral neuropathy. This review summarizes the pros and cons of radiotracer-based techniques that have been utilized in the clinical environment for evaluating lower extremity ischemia and common pathologies associated with PAD and CLI.

SPECT and PET imaging of angiogenesis and arteriogenesis in pre-clinical models of myocardial ischemia and peripheral vascular disease

Purpose

The extent of neovascularization determines the clinical outcome of coronary artery disease and other occlusive cardiovascular disorders. Monitoring of neovascularization is therefore highly important. This review article will elaborately discuss preclinical studies aimed at validating new nuclear angiogenesis and arteriogenesis tracers. Additionally, we will briefly address possible obstacles that should be considered when designing an arteriogenesis radiotracer.

Methods

A structured medline search was the base of this review, which gives an overview on different radiopharmaceuticals that have been evaluated in preclinical models.

Results

Neovascularization is a collective term used to indicate different processes such as angiogenesis and arteriogenesis. However, while it is assumed that sensitive detection through nuclear imaging will facilitate translation of successful therapeutic interventions in preclinical models to the bedside, we still lack specific tracers for neovascularization imaging. Most nuclear imaging research to date has focused on angiogenesis, leaving nuclear arteriogenesis imaging largely overlooked.

Conclusion

Although angiogenesis is the process which is best understood, there is no scarcity in theoretical targets for arteriogenesis imaging.

Assessment of coronary flow reserve using a combination of planar first-pass angiography and myocardial SPECT: Comparison with myocardial (15)O-water PET

Coronary flow reserve (CFR), defined as the ratio of maximum coronary flow increase from baseline resting blood flow, is one of the most sensitive parameters to detect early signs of coronary arteriosclerosis at the microvascular level. Myocardial perfusion PET is a well-established technology for CFR measurement, however, availability is still limited. The aim of this study is to introduce and validate myocardial flow reserve measurement by myocardial perfusion SPECT.

METHODS

Myocardial perfusion SPECT at rest and ATP stress (0.16mg/Kg/min) was performed in 10 patients with known coronary artery disease. Immediately after the injection of Tc-99m sestamibi (MIBI), left ventricular (LV) dynamic planar angiographic data were obtained for 90s. Coronary flow reserve index as measured by MIBI SPECT (CFRMIBI) was calculated as follows: CFRMIBI=CmsSbmb/CmbSbms, where subscripts b, s, Cm, and Sbm indicate baseline, during stress, myocardial counts with MIBI SPECT, and integral of LV counts with first pass angiography, respectively. Additionally, standard stress/rest (15)O-water PET to estimate CFR was performed in all patients as standard of reference.

RESULTS

CFRMIBI increased in conjunction with CFR, but underestimated blood flow at high flow rates. The relationship between CFRMIBI (Y) and CFRPET (X) was well fitted as follows: Y=1.40x(1-exp(1.79/x)) (r=0.84).

CONCLUSIONS

The index of CFRMIBI reflects the CFR by (15)O-water PET but underestimates flow at high flows, maybe as a reflection of pharmacokinetic limitations of MIBI.

Novel Applications of Radionuclide Imaging in Peripheral Vascular Disease

Peripheral vascular disease (PVD) is a progressive atherosclerotic disease that leads to stenosis or occlusion of blood vessels supplying the lower extremities. Current diagnostic imaging techniques commonly focus on evaluation of anatomy or blood flow at the macrovascular level and do not permit assessment of the underlying pathophysiology associated with disease progression or treatment response. Molecular imaging with radionuclide-based approaches can offer novel insight into PVD by providing noninvasive assessment of biological processes such as angiogenesis and atherosclerosis. This article discusses emerging radionuclide-based imaging approaches that have potential clinical applications in the evaluation of PVD progression and treatment.

Radiotracer imaging of peripheral vascular disease

Peripheral vascular disease (PVD) is an atherosclerotic disease affecting the lower extremities, resulting in skeletal muscle ischemia, intermittent claudication, and, in more severe stages of disease, limb amputation and death. The evaluation of therapy in this patient population can be challenging, as the standard clinical indices are insensitive to assessment of regional alterations in skeletal muscle physiology. Radiotracer imaging of the lower extremities with techniques such as PET and SPECT can provide a noninvasive quantitative technique for the evaluation of the pathophysiology associated with PVD and may complement clinical indices and other imaging approaches. This review discusses the progress in radiotracer-based evaluation of PVD and highlights recent advancements in molecular imaging with potential for clinical application.

Studies of the myocardial uptake and excretion mechanisms of a novel 99mTc heart perfusion agent

INTRODUCTION

(99m)Tc-TMEOP is a novel heart perfusion radiotracer exhibiting high initial and persistent heart uptake associated with rapid blood and liver clearance. This study aimed at determining the mechanisms of myocardial localization and fast liver clearance of (99m)Tc-TMEOP.

METHODS

Subcellular distribution of (99m)Tc-TMEOP was determined in excised rat heart tissue by differential centrifugation. The effect of cyclosporin A on the pharmacokinetic behaviour of (99m)Tc-TMEOP was evaluated by both ex vivo biodistribution and in vivo planar imaging studies.

RESULTS

Subcellular distribution studies showed that more than 73% of (99m)Tc-TMEOP was associated with the mitochondrial fraction. Comparison with subcellular distribution of (99m)Tc-sestamibi showed no significant difference in the mitochondrial accumulation between the two tracers. Biodistribution studies in the presence of cyclosporin A revealed an increase in kidneys and liver uptake of (99m)Tc-TMEOP, suggesting the involvement of multidrug resistance transporters in determining its pharmacokinetic profile.

CONCLUSIONS

The heart uptake mechanism of (99m)Tc-TMEOP is similar to that of the other reported monocationic (99m)Tc cardiac agents and is associated with its accumulation in the mitochondria. Cyclosporin A studies indicate that the fast liver and kidney clearance kinetics is mediated by P-glycoprotein (Pgp), supporting the potential interest of this radiotracer for imaging Pgp function associated with multidrug-resistant tumours.

Accelerated BMIPP uptake immediately after reperfused ischemia in the isolated rat heart model

OBJECTIVE

123I-beta-methyl iodophenyl pentadecanoic acid (BMIPP) can visualize myocardial fatty acid metabolism and has extensive potential for diagnosing cardiac diseases such as acute coronary syndrome in the clinical setting. Increased BMIPP uptake with decreased perfusion occasionally occurs under acute reperfusion ischemia and the kinetics of BMIPP remain unclear. The present study uses the isolated rat heart model to measure kinetic changes in BMIPP under acute reperfusion ischemia.

METHODS

Male Wistar rats were allotted to normal control (NG), mild (MG) and severe (SG) ischemia groups. The hearts were perfused according to the Langendorff method at a constant flow rate, and BMIPP wash-in and wash-out were studied. No-flow ischemia was applied for 15 and 30 min to the MG and SG groups, followed immediately by the wash-in and wash-out study. Whole heart radioactivity was determined using an external gamma detector throughout the experiment. Rates of myocardial uptake (K1, mL/min) and clearance (k2, min(-1)) were generated using a compartmental model analysis. The same procedures and protocols were performed using (99m)Tc-sestamibi (MIBI) as a perfusion study.

RESULTS

Perfusion pressure significantly increased and mean heart rate significantly decreased in the severe ischemia group (heart rate: 244 ± 76, 304 ± 105 and 94 ± 140 bpm; perfusion pressure: 67 ± 13, 101 ± 31 and 160 ± 84 mmHg for NG, MG and SG, respectively). MIBI-K1 significantly decreased, whereas BMIPP-K1 increased in the MG and SG groups (MIBI-K1: 3.45 ± 1.10, 1.95 ± 0.82, and 1.05 ± 0.13 mL/min; BMIPP-K (1): 3.06 ± 0.88, 3.91 ± 0.87, and 4.94 ± 1.51 mL/min for NG, MG and SG, respectively) with an inverse relationship to the severity of ischemia. MIBI-k2 increased markedly in severe ischemia (NG vs. MG: p < 0.05), whereas BMIPP-k2 did not change in the ischemic groups (MIBI-k2: 0.00072 ± 0.0011, 0.00038 ± 0.00076 and 0.043 ± 0.033; BMIPP-k2: 0.0056 ± 0.0028, 0.0029 ± 0.0010 and 0.0037 ± 0.0022 min(-1) for NG, MG and SG, respectively).

CONCLUSION

Myocardial BMIPP uptake increased immediately upon reperfusion after no-flow ischemia, and was inversely related to the severity of ischemia. The increased uptake was not due to reduced clearance, but to accelerated extraction.

Exposure to low-dose ionizing radiation from medical imaging procedures

BACKGROUND

The growing use of imaging procedures in the United States has raised concerns about exposure to low-dose ionizing radiation in the general population.

METHODS

We identified 952,420 nonelderly adults (between 18 and 64 years of age) in five health care markets across the United States between January 1, 2005, and December 31, 2007. Utilization data were used to estimate cumulative effective doses of radiation from imaging procedures and to calculate population-based rates of exposure, with annual effective doses defined as low (< or = 3 mSv), moderate (> 3 to 20 mSv), high (> 20 to 50 mSv), or very high (> 50 mSv).

RESULTS

During the study period, 655,613 enrollees (68.8%) underwent at least one imaging procedure associated with radiation exposure. The mean (+/-SD) cumulative effective dose from imaging procedures was 2.4+/-6.0 mSv per enrollee per year; however, a wide distribution was noted, with a median effective dose of 0.1 mSv per enrollee per year (interquartile range, 0.0 to 1.7). Overall, moderate effective doses of radiation were incurred in 193.8 enrollees per 1000 per year, whereas high and very high doses were incurred in 18.6 and 1.9 enrollees per 1000 per year, respectively. In general, cumulative effective doses of radiation from imaging procedures increased with advancing age and were higher in women than in men. Computed tomographic and nuclear imaging accounted for 75.4% of the cumulative effective dose, with 81.8% of the total administered in outpatient settings.

CONCLUSIONS

Imaging procedures are an important source of exposure to ionizing radiation in the United States and can result in high cumulative effective doses of radiation.

Influence of the different biokinetics of sestamibi and tetrofosmin on the interpretation of myocardial perfusion imaging in daily practice

AIM

Digestive activity can interfere with the interpretation of myocardial perfusion single photon emission computed tomography using sestamibi or tetrofosmin. Compared with sestamibi, the liver clearance of tetrofosmin is more rapid, but its absolute cardiac uptake is lower. In this study, the activity of sestamibi and tetrofosmin was quantified after exercise or pharmacological stress and at rest to objectify the biokinetic differences and to evaluate whether there is a correlation between quantitative measurements and the visual assessment of image quality.

METHODS

Left ventricular activity and five ratios (R1-R5) of cardiac to adjacent extra-cardiac activity were quantified in 204 sestamibi (68 exercise stress/56 pharmacological stress/80 rest) and 221 tetrofosmin (67 exercise stress/59 pharmacological stress/95 rest) studies. Image quality was assessed by a three-point score (1, good; 2, moderate; 3, poor) and correlated with the heart to left supra-diaphragmatic region (R1) and heart to right supra-diaphragmatic region (R2) ratios.

RESULTS

The mean left ventricular activity was higher for sestamibi, especially at rest (sestamibi, 0.21+/-0.05 counts/pixel/injected MBq; tetrofosmin, 0.16+/-0.042 counts/pixel/injected MBq; P<0.001). By contrast, most ratios were higher with tetrofosmin, particularly for the exercise stress and rest studies. Using the three-point quality scoring, more sestamibi than tetrofosmin studies were scored as 3 (12.2% versus 6.3%), also particularly for the exercise stress and rest studies. A highly significant relationship was found between decreasing R1 and R2 and an increasing quality score, regardless of the radiopharmaceutical used (P values between 0.02 and <0.001).

CONCLUSIONS

Despite a lower cardiac uptake, the more rapid liver clearance of tetrofosmin than sestamibi significantly improves the ratios of cardiac to digestive activity, especially after exercise or at rest. These quantitative differences in biokinetics result in less poor scans with tetrofosmin in daily practice.

Technetium-99m tetrofosmin myocardial perfusion single photon emission computed tomography in syndrome X: a preliminary report

Syndrome X is used to describe patients with chest pain and a normal coronary angiogram. We reviewed technetium-99m tetrofosmin (Tc-99m TF) myocardial perfusion single photon emission computed tomography (SPECT) results and clinical data of 43 syndrome X patients and 30 healthy controls with normal left ventricular ejection fraction and no cardiac abnormalities. The Tc-99m TF myocardial perfusion SPECT results showed 12 (27.9%) syndrome X patients had normal myocardial perfusion and 31 (72.1%) had abnormal myocardial perfusion, including 6 (14.0%) patients with fixed defects. 20 (46.5%) patients with transient defects, and 5 (11.6%) patients with reverse defects. The results of exercise ECG were not related to perfusion defects in Tc-99m TF myocardial perfusion SPECT. In contrast, all of the 30 (100.0%) healthy controls had normal myocardial perfusion SPECT results. We conclude that abnormal Tc-99m TF myocardial perfusion SPECT is common in syndrome X and does not correlate well with the exercise ECG. However, further studies with larger case numbers and long term follow up in patients with myocardial events are necessary to support our findings.