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Jha DK, Mahato A, Jain A, Bohra V, Tiwari A. A Prospective Comparative Study between 99mTc MIBI Myocardial Perfusion Single-Photon Emission Computed Tomography and Dobutamine Stress Echocardiography to Detect Viable Myocardium in Patients with Coronary Artery Disease. Indian J Nucl Med 2023; 38:224-230. [PMID: 38046959 PMCID: PMC10693357 DOI: 10.4103/ijnm.ijnm_91_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/16/2022] [Accepted: 09/22/2022] [Indexed: 12/05/2023] Open
Abstract
Introduction The objective of this study was to compare 99mTc MIBI myocardial perfusion SPECT and Dobutamine Stress Echocardiography (DSE) in detecting viable myocardium in patients with Coronary Artery Disease. Materials and Methods Total of 50 patients who with CAD and poor LV function were idenitifed on 2D Echo using 16 segment cardiac model. These patients underwent 99mTc MIBI myocardial perfusion SPECT and Dobutamine Stress Echocardiography and the results were compared with the gold standard 18F-FDG PET-CT findings. Results A Total of 550 dysfunctional segments were identified in datasets of 50 patients on 2D echo. No significant difference was noted between the pairwise positive outcome of viable segment between MIBI SPECT and DSE (p=0.875). MIBI SPECT showed a sensitivity of 86.5% and specificity of 90.0% when compared with 18F-FDG PET-CT which was comparable with DSE having a sensitivity of 87.6% and specificity of 90.7%. Conclusion 99mTc MIBI SPECT is an effective good alternative for evaluation of viable myocardial segments in patients with dysfunctional myocardium and can be considered especially in elderly or obese patients and patients with lung disease having poor echocardiographic imaging window due to lack of an optimal acoustic window.
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Affiliation(s)
- Deepak Kumar Jha
- Department of Nuclear Medicine, Army Hospital R and R, New Delhi, India
| | - Abhishek Mahato
- Department of Nuclear Medicine, Lucknow, Uttar Pradesh, India
| | - Anurag Jain
- Department of Nuclear Medicine, Lucknow, Uttar Pradesh, India
| | - Vijay Bohra
- Department of Cardiology and Command Hospital, Lucknow, Uttar Pradesh, India
| | - Awadhesh Tiwari
- Department of Nuclear Medicine, Lucknow, Uttar Pradesh, India
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Blach A, Kwiecinski J. The Role of Positron Emission Tomography in Advancing the Understanding of the Pathogenesis of Heart and Vascular Diseases. Diagnostics (Basel) 2023; 13:1791. [PMID: 37238275 PMCID: PMC10217133 DOI: 10.3390/diagnostics13101791] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Cardiovascular disease remains the leading cause of morbidity and mortality worldwide. For developing new therapies, a better understanding of the underlying pathology is required. Historically, such insights have been primarily derived from pathological studies. In the 21st century, thanks to the advent of cardiovascular positron emission tomography (PET), which depicts the presence and activity of pathophysiological processes, it is now feasible to assess disease activity in vivo. By targeting distinct biological pathways, PET elucidates the activity of the processes which drive disease progression, adverse outcomes or, on the contrary, those that can be considered as a healing response. Given the insights provided by PET, this non-invasive imaging technology lends itself to the development of new therapies, providing a hope for the emergence of strategies that could have a profound impact on patient outcomes. In this narrative review, we discuss recent advances in cardiovascular PET imaging which have greatly advanced our understanding of atherosclerosis, ischemia, infection, adverse myocardial remodeling and degenerative valvular heart disease.
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Affiliation(s)
- Anna Blach
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, 40-055 Katowice, Poland
- Nuclear Medicine Department, Voxel Diagnostic Center, 40-514 Katowice, Poland
| | - Jacek Kwiecinski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, 04-628 Warsaw, Poland
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Chaudhari AJ, Badawi RD. Application-specific nuclear medical in vivoimaging devices. Phys Med Biol 2021; 66. [PMID: 33770765 DOI: 10.1088/1361-6560/abf275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/26/2021] [Indexed: 11/11/2022]
Abstract
Nuclear medical imaging devices, such as those enabling photon emission imaging (gamma camera, single photon emission computed tomography, or positron emission imaging), that are typically used in today's clinics are optimized for assessing large portions of the human body, and are classified as whole-body imaging systems. These systems have known limitations for organ imaging, therefore application-specific devices have been designed, constructed and evaluated. These devices, given their compact nature and superior technical characteristics, such as their higher detection sensitivity and spatial resolution for organ imaging compared to whole-body imaging systems, have shown promise for niche applications. Several of these devices have further been integrated with complementary anatomical imaging devices. The objectives of this review article are to (1) provide an overview of such application-specific nuclear imaging devices that were developed over the past two decades (in the twenty-first century), with emphasis on brain, cardiac, breast, and prostate imaging; and (2) discuss the rationale, advantages and challenges associated with the translation of these devices for routine clinical imaging. Finally, a perspective on the future prospects for application-specific devices is provided, which is that sustained effort is required both to overcome design limitations which impact their utility (where these exist) and to collect the data required to define their clinical value.
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Affiliation(s)
- Abhijit J Chaudhari
- Department of Radiology, University of California Davis, Sacramento, CA 95817, United States of America.,Center for Molecular and Genomic Imaging, University of California Davis, Davis, CA 95616, United States of America
| | - Ramsey D Badawi
- Department of Radiology, University of California Davis, Sacramento, CA 95817, United States of America.,Department of Biomedical Engineering, University of California Davis, Davis, CA 95616, United States of America
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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Aboul Enein F, Allaaboun S, Khayyat S, Andijani M, Alkhuzai MM, Aljunied AA, Al Adhreai M. Association Between Myocardial Scar Burden and Left Ventricular Ejection Fraction in Ischemic Cardiomyopathy. Cureus 2020; 12:e12110. [PMID: 33364136 PMCID: PMC7749857 DOI: 10.7759/cureus.12110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background This study was conducted to assess the relationship between scar burden (extent and severity) and the follow-up left ventricular ejection fraction (LVEF). Methods Patients were referred for viability assessment with late gadolinium enhancement (LGE) on cardiovascular magnetic resonance imaging. To measure the transmural extent of LGE in each segment (scar score), we used a five-point scale system. Baseline ejection fraction (EF) and at follow-up were recorded. LVEF classified as non-severe and severely depressed. Results The study included 178 patients (males: 88.8%; mean age: 57.1±10.02 years; mean baseline LVEF: 28.61±10.39). In patients with severe baseline LVEF, the mean scar percentage was higher than that in patients who had non-severe LVEF (38.8±19.41 vs. 24.61±21.21; p˂0.001). On linear regression analysis, aldosterone antagonist and total scar score significantly predicted follow-up ejection fraction (EF) (B=-7.083, p˂0.001 and B=-3.038, p=0.038, respectively). Left anterior descending artery (LAD) territory viability and baseline EF significantly predicted change in EF in patients with LVEF ≤ 35% (B=5.389, p=0.009 and B=-0.581, p˂0.001, respectively). On binary regression analysis for the prediction of at least 5% improvement in EF in patients with baseline EF ≤ 35%, baseline EF and LAD viability were significant (B=-0.15, p=0.014 and B=1.042 and p=0.054, respectively). Conclusions The extent of myocardial scar and viability of LAD territory are identified as the important and independent parameters for the predictions of improvement in EF even after adjustment for demographics and baseline EF and following the standards of care medication.
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Garcia MJ, Kwong RY, Scherrer-Crosbie M, Taub CC, Blankstein R, Lima J, Bonow RO, Eshtehardi P, Bois JP. State of the Art: Imaging for Myocardial Viability: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2020; 13:e000053. [PMID: 32833510 DOI: 10.1161/hci.0000000000000053] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A substantial proportion of patients with acute myocardial infarction develop clinical heart failure, which remains a common and major healthcare burden. It has been shown that in patients with chronic coronary artery disease, ischemic episodes lead to a global pattern of cardiomyocyte remodeling and dedifferentiation, hallmarked by myolysis, glycogen accumulation, and alteration of structural proteins. These changes, in conjunction with an impaired global coronary reserve, may eventually become irreversible and result in ischemic cardiomyopathy. Moreover, noninvasive imaging of myocardial scar and hibernation can inform the risk of sudden cardiac death. Therefore, it would be intuitive that imaging of myocardial viability is an essential tool for the proper use of invasive treatment strategies and patient prognostication. However, this notion has been challenged by large-scale clinical trials demonstrating that, in the modern era of improved guideline-directed medical therapies, imaging of myocardial viability failed to deliver effective guidance of coronary bypass surgery to a reduction of adverse cardiac outcomes. In addition, current available imaging technologies in this regard are numerous, and they target diverse surrogates of structural or tissue substrates of myocardial viability. In this document, we examine these issues in the current clinical context, collect current evidence of imaging technology by modality, and inform future directions.
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Imbert L, Roch V, Merlin C, Djaballah W, Cachin F, Perrin M, Claudin M, Verger A, Boutley H, Karcher G, Marie PY. Low-dose dual-isotope procedure planed for myocardial perfusion CZT-SPECT and assessed through a head-to-head comparison with a conventional single-isotope protocol. J Nucl Cardiol 2018; 25:2016-2023. [PMID: 28512723 DOI: 10.1007/s12350-017-0914-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/28/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE OF THE REPORT This study aimed at assessing an original low-dose dual-isotope procedure in which the abnormal stress Tc-99m Sestamibi SPECT is followed by rest Tl-201 SPECT, along with a head-to-head comparison with a single-isotope procedure. METHODS AND RESULTS One hundred two patients, referred for a low-dose stress-SPECT with Sestamibi (123 ± 20 MBq) on a CZT camera and for whom a rest Sestamibi SPECT was warranted, had an additional Tl-201 rest-SPECT (52 ± 5 MBq) between stress and rest Sestamibi SPECT recordings. Tl-201 images were processed for spill-over and scatter corrections, and uptake differences with stress Sestamibi SPECT were analyzed: (1) for rest acquisitions from Tl-201 (dual-isotope procedure) and from Sestamibi (single-isotope procedure) and (2) in segments for which a diagnosis of ischemia, infarct, or normal perfusion was achieved. Mean effective dose was 8.3 mSv for dual-isotope but would decrease to 5.7 mSv for an expected rate of 37% of patients for whom rest-SPECT is not warranted. After a further background correction of Tl-201 images, the rest-stress difference in myocardial uptake was equivalent between dual- and single-procedures for identifying ischemic segments (respective areas-under-curves: 0.83 ± 0.03 and 0.81 ± 0.03). CONCLUSION This original dual-isotope procedure provides acceptable radiation doses and consistent results, as compared with conventional single-isotope.
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Affiliation(s)
- Laetitia Imbert
- CHRU-Nancy, Université de Lorraine, Department of Nuclear Medicine, 54000, Nancy, France.
- Nancyclotep Experimental Imaging Platform, 54000, Nancy, France.
- INSERM, Université de Lorraine, UMR 947, IADI, 54000, Nancy, France.
- Department of Radiotherapy, Lorraine Cancerology Institute, 54500, Vandoeuvre, France.
| | - Véronique Roch
- CHRU-Nancy, Université de Lorraine, Department of Nuclear Medicine, 54000, Nancy, France
- Nancyclotep Experimental Imaging Platform, 54000, Nancy, France
| | - Charles Merlin
- Department of Nuclear Medicine, Jean Perrin Centre, Université d'Auvergne, 63011, Clermont-Ferrand, France
- INSERM, Université d'Auvergne, UMR 990, IMTV, 63000, Clermont-Ferrand, France
| | - Wassila Djaballah
- CHRU-Nancy, Université de Lorraine, Department of Nuclear Medicine, 54000, Nancy, France
- Nancyclotep Experimental Imaging Platform, 54000, Nancy, France
| | - Florent Cachin
- Department of Nuclear Medicine, Jean Perrin Centre, Université d'Auvergne, 63011, Clermont-Ferrand, France
- INSERM, Université d'Auvergne, UMR 990, IMTV, 63000, Clermont-Ferrand, France
| | - Mathieu Perrin
- CHRU-Nancy, Université de Lorraine, Department of Nuclear Medicine, 54000, Nancy, France
- Nancyclotep Experimental Imaging Platform, 54000, Nancy, France
| | - Marine Claudin
- CHRU-Nancy, Université de Lorraine, Department of Nuclear Medicine, 54000, Nancy, France
- Nancyclotep Experimental Imaging Platform, 54000, Nancy, France
| | - Antoine Verger
- CHRU-Nancy, Université de Lorraine, Department of Nuclear Medicine, 54000, Nancy, France
- Nancyclotep Experimental Imaging Platform, 54000, Nancy, France
- INSERM, Université de Lorraine, UMR 947, IADI, 54000, Nancy, France
| | - Henri Boutley
- Nancyclotep Experimental Imaging Platform, 54000, Nancy, France
- University of Lorraine, Faculty of Medicine, 54000, Nancy, France
| | - Gilles Karcher
- CHRU-Nancy, Université de Lorraine, Department of Nuclear Medicine, 54000, Nancy, France
- Nancyclotep Experimental Imaging Platform, 54000, Nancy, France
- University of Lorraine, Faculty of Medicine, 54000, Nancy, France
| | - Pierre-Yves Marie
- CHRU-Nancy, Université de Lorraine, Department of Nuclear Medicine, 54000, Nancy, France
- Nancyclotep Experimental Imaging Platform, 54000, Nancy, France
- INSERM, Université de Lorraine, UMR 1116, DCAC, 54000, Nancy, France
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Label-free Evaluation of Myocardial Infarct in Surgically Excised Ventricular Myocardium by Raman Spectroscopy. Sci Rep 2018; 8:14671. [PMID: 30279495 PMCID: PMC6168494 DOI: 10.1038/s41598-018-33025-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/20/2018] [Indexed: 12/20/2022] Open
Abstract
Understanding the viability of the ischemic myocardial tissue is a critical issue in determining the appropriate surgical procedure for patients with chronic heart failure after myocardial infarction (MI). Conventional MI evaluation methods are; however, preoperatively performed and/or give an indirect information of myocardial viability such as shape, color, and blood flow. In this study, we realize the evaluation of MI in patients undergoing cardiac surgery by Raman spectroscopy under label-free conditions, which is based on intrinsic molecular constituents related to myocardial viability. We identify key signatures of Raman spectra for the evaluation of myocardial viability by evaluating the infarct border zone myocardium that were excised from five patients under surgical ventricular restoration. We also obtain a prediction model to differentiate the infarcted myocardium from the non-infarcted myocardium by applying partial least squares regression-discriminant analysis (PLS-DA) to the Raman spectra. Our prediction model enables identification of the infarcted tissues and the non-infarcted tissues with sensitivities of 99.98% and 99.92%, respectively. Furthermore, the prediction model of the Raman images of the infarct border zone enabled us to visualize boundaries between these distinct regions. Our novel application of Raman spectroscopy to the human heart would be a useful means for the detection of myocardial viability during surgery.
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Anavekar NS, Chareonthaitawee P, Narula J, Gersh BJ. Revascularization in Patients With Severe Left Ventricular Dysfunction: Is the Assessment of Viability Still Viable? J Am Coll Cardiol 2017; 67:2874-87. [PMID: 27311527 DOI: 10.1016/j.jacc.2016.03.571] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/18/2016] [Accepted: 03/18/2016] [Indexed: 11/17/2022]
Abstract
Myocardial viability assessment is typically reserved for patients with coronary artery disease and significant left ventricular dysfunction. In this setting, there is myocardial adaptation to an altered physiological state that is potentially reversible. Imaging can characterize different parameters of cardiac function; however, despite previously published appraisals of different imaging modalities, there is still uncertainty regarding the role of these tests in clinical practice. The purpose of this review is to reflect on the physiological basis of myocardial viability, discuss the imaging tests available that characterize myocardial viability, and summarize the current published reports on the use of these tests in clinical practice.
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Affiliation(s)
- Nandan S Anavekar
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Jagat Narula
- Division of Cardiovascular Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
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Obeid S, Attinger-Toller A, Taramasso M, Pedrazzini G, Suetsch G, Landolt F, Karbeyaz F, Rodriguez H, Sürder D, Moccetti T, Nietlispach F, Maisano F. SYNTAX score II in patients with coronary artery disease undergoing percutaneous mitral repair with the MitraClip. Int J Cardiol 2017; 236:375-380. [DOI: 10.1016/j.ijcard.2017.02.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/26/2017] [Accepted: 02/13/2017] [Indexed: 10/20/2022]
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Intra-procedural determination of viability by myocardial deformation imaging: a randomized prospective study in the cardiac catheter laboratory. Clin Res Cardiol 2017; 106:629-644. [PMID: 28321497 DOI: 10.1007/s00392-017-1099-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 03/01/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The benefit of revascularization for functional recovery depends on the presence of viable myocardial tissue. OBJECTIVE Myocardial deformation imaging allows determination of myocardial viability. METHODS In a first approach, we assessed the optimal cutoff value to determine preserved viability by layer-specific echocardiographic myocardial deformation imaging at rest and low-dose dobutamine (DSE) echocardiography: regional endocardial circumferential strain (eCS) <-19% at rest was as accurate as eCS at DSE. In a main study, 123 patients (66% men, age 59 ± 6 years) with relevant coronary stenoses and corresponding severe regional myocardial dysfunction were included and randomized in 2 groups after coronary angiography: group A: intra-procedural myocardial deformation imaging in the cardiac catheter laboratory (CLab), determination of myocardial viability by regional eCS <-19%, in case of positive viability immediate coronary intervention in the same session. Group B: two-step determination of myocardial viability by cardiovascular magnetic resonance (CMR), in case of positive viability coronary intervention. After 18 months follow-up an analysis of the endpoints regarding cardiovascular events, left ventricular (LV) function, and comparison of cost was performed. RESULTS Group A (N = 61) and group B (N = 62) showed no differences concerning localization of the coronary stenosis, comorbidities, or medical therapy. Cardiovascular events at 18-month follow-up were as follows: group A 13% (N = 10) vs. group B 14% (N = 9, p = 0.288); improvement of LV function: group A: +7 ± 2% vs. group B: +7 ± 3%, p = 0.963; costs: group A: 3096 Dollar vs. group B: 6043 Dollar, p < 0.001. CONCLUSION Intra-procedural determination of myocardial viability by myocardial deformation imaging in the CLab is feasible, safe, and cost effective and may become an emerging alternative to the current practice of two-stage viability diagnostics.
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Phase analysis of gated myocardial perfusion single-photon emission computed tomography after coronary artery bypass graft surgery: reflection of late reverse remodeling in patients with patent grafts after coronary artery bypass graft surgery. Nucl Med Commun 2016; 37:1139-47. [PMID: 27341412 DOI: 10.1097/mnm.0000000000000565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Phase analysis using gated myocardial perfusion single-photon emission computed tomography (GMPS) is a tool used to assess left ventricular (LV) dyssynchrony. We attempted to investigate the role of LV dyssynchrony assessed by GMPS using phase analysis for the late LV function after coronary artery bypass graft surgery (CABG) in patients with patent grafts. METHODS A total of 45 patients who received off-pump CABG with patent graft 1 year after CABG and preserved perfusion reserve were enrolled retrospectively. All patients underwent GMPS before and 3 months and 1 year after CABG. Using the Emory Cardiac Toolbox, both phase histogram bandwidth (PBW) and phase SD derived by phase analysis were used for the analysis, in addition to the conventional perfusion parameters. For the evaluation of LV function, transthoracic echocardiography was also performed. RESULTS All of the patients showed perfusion improvement (paired t-test, P<0.05) after CABG. Nonetheless, 30 of 45 patients showed LV dyssynchrony 3 months after CABG. One year after CABG, however, 25 out of 45 patients showed reverse remodeling. Among those patients with reverse remodeling, 19 patients had shown LV 3 months after CABG. Using stepwise logistic regression with forward selection, PBW 3 months after CABG could predict reverse remodeling 1 year after CABG (odds ratio 1.03, P<0.05). Using receiver operating characteristic analysis, PBW 3 months after CABG had the largest area under the curve to detect reverse remodeling 1 year after CABG with a cut-off value of 82 (sensitivity 0.95, specificity 0.56, P<0.001). CONCLUSION Postoperative LV dyssynchrony assessed by GMPS using phase analysis may reflect late reverse remodeling and potential of further functional improvement in patients with patent grafts and preserved perfusion reserve after CABG.
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Patel HC, Ellis SG. Role of revascularization to improve left ventricular function. Heart Fail Clin 2015; 11:203-14. [PMID: 25834970 DOI: 10.1016/j.hfc.2014.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Coronary revascularization to improve left ventricular (LV) function and improve mortality in patients with ischemic cardiomyopathy remains controversial, especially in the absence of angina or ischemia. A large body of observational evidence suggests that patients with dysfunctional but viable myocardium may experience improvement in mortality and LV function after revascularization. However, results of randomized trials conducted in the last decade dispute the value of viability testing or coronary revascularization in improving outcomes of patients with ischemic cardiomyopathy. However, because of the numerous methodological limitations of these studies, clinical equipoise persists regarding the role of coronary revascularization in certain patients.
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Affiliation(s)
- Harsh C Patel
- Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Stephen G Ellis
- Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Echocardiographic Evaluation of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Elfigih IA, Henein MY. Non-invasive imaging in detecting myocardial viability: Myocardial function versus perfusion. IJC HEART & VASCULATURE 2014; 5:51-56. [PMID: 28785612 PMCID: PMC5497170 DOI: 10.1016/j.ijcha.2014.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/08/2014] [Indexed: 01/29/2023]
Abstract
Coronary artery disease (CAD) is the most prevalent and single most common cause of morbidity and mortality [1] with the resulting left ventricular (LV) dysfunction an important complication. The distinction between viable and non-viable myocardium in patients with LV dysfunction is a clinically important issue among possible candidates for myocardial revascularization. Several available non-invasive techniques are used to detect and assess ischemia and myocardial viability. These techniques include echocardiography, radionuclide images, cardiac magnetic resonance imaging and recently myocardial computed tomography perfusion imaging. This review aims to distinguish between the available non-invasive imaging techniques in detecting signs of functional and perfusion viability and identify those which have the most clinical relevance in detecting myocardial viability in patients with CAD and chronic ischemic LV dysfunction. The most current available studies showed that both myocardial perfusion and function based on non-invasive imaging have high sensitivity with however wide range of specificity for detecting myocardial viability. Both perfusion and function imaging modalities provide complementary information about myocardial viability and no optimum single imaging technique exists that can provide very accurate diagnostic and prognostic viability assessment. The weight of the body of evidence suggested that non-invasive imaging can help in guiding therapeutic decision making in patients with LV dysfunction.
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Affiliation(s)
| | - Michael Y. Henein
- Canterbury Christ Church University, Canterbury, UK
- Heart Centre and Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Mohammadi S, Kalavrouziotis D, Cresce G, Dagenais F, Dumont E, Charbonneau E, Voisine P. Bilateral internal thoracic artery use in patients with low ejection fraction: is there any additional long-term benefit? Eur J Cardiothorac Surg 2014; 46:425-31; discussion 431. [PMID: 24554069 DOI: 10.1093/ejcts/ezu023] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The use of bilateral internal thoracic arteries (BITA) has been associated with improved long-term outcomes following coronary artery bypass graft (CABG) surgery. The objective of this study was to evaluate the impact of BITA use on long-term survival among patients with low ejection fraction (EF) undergoing CABG. METHODS Between April 1991 and October 2011, 2035 consecutive patients underwent primary BITA grafting. Among them, there were 129 patients with left ventricular EF ≤40%. During the same time period, 1666 primary CABGs were performed using a single internal thoracic artery (SITA) in patients with EF ≤40%. A propensity score optimal matching algorithm was used to create the matched SITA and BITA groups (n = 111 in each group). Also, Cox regression multivariable analyses were performed to determine the independent risk factors for long-term mortality. The date of death was obtained from provincial vital statistics. RESULTS There was no difference in operative mortality between matched BITA and SITA (n = 2, 1.8% vs n = 1, 0.9%, respectively, P = 0.6) groups. The mean follow-up was 8.6 ± 5.1 and 7.7 ± 5.5 years for BITA and SITA groups, respectively (P = 0.2). Five-, 10- and 15-year survival rates were 93.7, 77.5 and 59.0% in the matched BITA patients vs 82.8, 68.1 and 65.2% in the matched SITA patients (P = 0.3). In multivariate analysis, the independent risk factors for late mortality among hospital survivors were: insulin-dependent diabetes [adjusted hazard ratio (HR): 3.4, 95% confidence interval (CI): 1.4-8.4, P = 0.008], perioperative intra-aortic balloon pump insertion (HR: 3.2, 95% CI: 1.5-6.9, P = 0.004), postoperative deep sternal wound infection (HR: 7.4, 95% CI: 2.2-24.1, P = 0.001) and neurological complications (HR: 3.5, 95% CI: 1.4-8.4, P = 0.006). Choice of BITA versus SITA was not an independent predictor of long-term mortality (P = 0.3). CONCLUSIONS The use of a second internal thoracic artery (ITA) does not prolong late survival in patients with low EF undergoing CABG compared with a propensity-matched group of SITA graft patients.
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Affiliation(s)
- Siamak Mohammadi
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - Dimitri Kalavrouziotis
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - Giovanni Cresce
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - François Dagenais
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - Eric Dumont
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - Eric Charbonneau
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - Pierre Voisine
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
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Hutyra M, Skala T, Kaminek M, Horak D, Kocher M, Tudos Z, Jarkovsky J, Precek J, Taborsky M. Speckle tracking echocardiography derived systolic longitudinal strain is better than rest single photon emission tomography perfusion imaging for nonviable myocardium identification. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 157:12-21. [DOI: 10.5507/bp.2012.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 07/09/2012] [Indexed: 11/23/2022] Open
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Nagel E, Schuster A. Myocardial viability: dead or alive is not the question! JACC Cardiovasc Imaging 2012; 5:509-12. [PMID: 22595158 DOI: 10.1016/j.jcmg.2012.03.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 03/26/2012] [Indexed: 12/27/2022]
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21
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Hutyra M, Skála T, Kamínek M, Horák D, Köcher M, Tüdös Z, Jarkovský J, Přeček J, Táborský M. Comparison of two-dimensional longitudinal strain with rest single photon emission tomography perfusion imaging for transmural scar identification in patients with ischemic left ventricular systolic dysfunction. Int J Cardiol 2012; 156:331-2. [DOI: 10.1016/j.ijcard.2012.01.086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 01/28/2012] [Indexed: 10/28/2022]
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22
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Imaging in the Management of Ischemic Cardiomyopathy. J Am Coll Cardiol 2012; 59:359-70. [DOI: 10.1016/j.jacc.2011.08.076] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 07/18/2011] [Accepted: 08/02/2011] [Indexed: 11/17/2022]
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23
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Tomasello SD, Costanzo L, Galassi AR. Coronary revascularization strategies in patients with chronic heart failure. Interv Cardiol 2011. [DOI: 10.2217/ica.10.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Nagel E, Schuster A. Shortening without contraction: new insights into hibernating myocardium. JACC Cardiovasc Imaging 2010; 3:731-3. [PMID: 20633851 DOI: 10.1016/j.jcmg.2010.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 05/03/2010] [Indexed: 11/25/2022]
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25
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van der Wall EE, Reiber JHC. Assessment of left ventricular function: visual or quantitative? Int J Cardiovasc Imaging 2010; 27:573-7. [PMID: 20981573 PMCID: PMC3101355 DOI: 10.1007/s10554-010-9735-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 10/13/2010] [Indexed: 01/08/2023]
Affiliation(s)
- E. E. van der Wall
- Department of Cardiology, Leiden University Medical Center, P.O. Box 9600, Leiden, Netherlands
| | - J. H. C. Reiber
- Department of Cardiology, Leiden University Medical Center, P.O. Box 9600, Leiden, Netherlands
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Assessment of left ventricular volumes; reliable by gated SPECT? Int J Cardiovasc Imaging 2010; 27:635-8. [PMID: 20924791 PMCID: PMC3101353 DOI: 10.1007/s10554-010-9717-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 09/23/2010] [Indexed: 11/24/2022]
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Prediction of long-term reverse left ventricular remodeling after revascularization or medical treatment in patients with ischemic cardiomyopathy: a comparative study between SPECT and MRI. Int J Cardiovasc Imaging 2010; 27:343-53. [PMID: 20725789 DOI: 10.1007/s10554-010-9677-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Accepted: 07/24/2010] [Indexed: 10/19/2022]
Abstract
Patients with ischemic heart disease and depressed left ventricular (LV) ejection fraction (LVEF) develop varying degrees of LV remodeling after cardiac surgical revascularization. Fifty-three patients with stable ischemic heart disease and impaired LV function (LVEF 34.9 ± 4%) were prospectively followed up for 24 months. Thirty-seven patients underwent coronary artery bypass grafting (CABG), 16 patients were treated conservatively. Cardiac magnetic resonance imaging (MRI) and SPECT were performed at baseline and after 12 and 24 months of follow-up. The patients were divided into responders and non-responders depending on the degree of LVEF improvement at 24 months follow-up (>5%-responders). MRI with ≤5 segments with DE/wall thickness ratio (DEWTR) ≥50% predicted LV reverse remodeling with a sensitivity of 86% and a specificity of 75% (AUC 0.81). An MRI finding of ≤2 segments with the DEWTR ≥75% had a corresponding sensitivity of 71% and specificity of 67% (AUC 0.75) while fixed perfusion defect on SPECT <16.5% of LV predicted reverse remodeling with a sensitivity of 64% and a specificity of 69% (AUC 0.64). A preoperative number of segments with the DE/wall thickness ratio of ≥50 and ≥75% obtained by MRI, was found to be a better predictor of left ventricular reverse remodeling than fixed perfusion defect by SPECT. No other MRI or SPECT parameter predicted LVEF improvement at 24 months after CABG.
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Morton G, Schuster A, Perera D, Nagel E. Cardiac magnetic resonance imaging to guide complex revascularization in stable coronary artery disease. Eur Heart J 2010; 31:2209-15. [DOI: 10.1093/eurheartj/ehq256] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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The Use of Nuclear Imaging to Assess the Myocardial Viability. J Saudi Heart Assoc 2010; 22:157-8. [DOI: 10.1016/j.jsha.2010.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Accepted: 04/23/2010] [Indexed: 11/22/2022] Open
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Positron emission tomography for the assessment of myocardial viability: an evidence-based analysis. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2010; 10:1-80. [PMID: 23074393 PMCID: PMC3377573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
In July 2009, the Medical Advisory Secretariat (MAS) began work on Non-Invasive Cardiac Imaging Technologies for the Assessment of Myocardial Viability, an evidence-based review of the literature surrounding different cardiac imaging modalities to ensure that appropriate technologies are accessed by patients undergoing viability assessment. This project came about when the Health Services Branch at the Ministry of Health and Long-Term Care asked MAS to provide an evidentiary platform on effectiveness and cost-effectiveness of non-invasive cardiac imaging modalities.After an initial review of the strategy and consultation with experts, MAS identified five key non-invasive cardiac imaging technologies that can be used for the assessment of myocardial viability: positron emission tomography, cardiac magnetic resonance imaging, dobutamine echocardiography, and dobutamine echocardiography with contrast, and single photon emission computed tomography.A 2005 review conducted by MAS determined that positron emission tomography was more sensitivity than dobutamine echocardiography and single photon emission tomography and dominated the other imaging modalities from a cost-effective standpoint. However, there was inadequate evidence to compare positron emission tomography and cardiac magnetic resonance imaging. Thus, this report focuses on this comparison only. For both technologies, an economic analysis was also completed.The Non-Invasive Cardiac Imaging Technologies for the Assessment of Myocardial Viability is made up of the following reports, which can be publicly accessed at the MAS website at: www.health.gov.on.ca/mas or at www.health.gov.on.ca/english/providers/program/mas/mas_about.htmlPOSITRON EMISSION TOMOGRAPHY FOR THE ASSESSMENT OF MYOCARDIAL VIABILITY: An Evidence-Based AnalysisMAGNETIC RESONANCE IMAGING FOR THE ASSESSMENT OF MYOCARDIAL VIABILITY: An Evidence-Based Analysis OBJECTIVE The objective of this analysis is to assess the effectiveness and safety of positron emission tomography (PET) imaging using F-18-fluorodeoxyglucose (FDG) for the assessment of myocardial viability. To evaluate the effectiveness of FDG PET viability imaging, the following outcomes are examined: the diagnostic accuracy of FDG PET for predicting functional recovery;the impact of PET viability imaging on prognosis (mortality and other patient outcomes); andthe contribution of PET viability imaging to treatment decision making and subsequent patient outcomes. CLINICAL NEED CONDITION AND TARGET POPULATION LEFT VENTRICULAR SYSTOLIC DYSFUNCTION AND HEART FAILURE: Heart failure is a complex syndrome characterized by the heart's inability to maintain adequate blood circulation through the body leading to multiorgan abnormalities and, eventually, death. Patients with heart failure experience poor functional capacity, decreased quality of life, and increased risk of morbidity and mortality. In 2005, more than 71,000 Canadians died from cardiovascular disease, of which, 54% were due to ischemic heart disease. Left ventricular (LV) systolic dysfunction due to coronary artery disease (CAD) is the primary cause of heart failure accounting for more than 70% of cases. The prevalence of heart failure was estimated at one percent of the Canadian population in 1989. Since then, the increase in the older population has undoubtedly resulted in a substantial increase in cases. Heart failure is associated with a poor prognosis: one-year mortality rates were 32.9% and 31.1% for men and women, respectively in Ontario between 1996 and 1997. TREATMENT OPTIONS IN GENERAL, THERE ARE THREE OPTIONS FOR THE TREATMENT OF HEART FAILURE: medical treatment, heart transplantation, and revascularization for those with CAD as the underlying cause. Concerning medical treatment, despite recent advances, mortality remains high among treated patients, while, heart transplantation is affected by the limited availability of donor hearts and consequently has long waiting lists. The third option, revascularization, is used to restore the flow of blood to the heart via coronary artery bypass grafting (CABG) or through minimally invasive percutaneous coronary interventions (balloon angioplasty and stenting). Both methods, however, are associated with important perioperative risks including mortality, so it is essential to properly select patients for this procedure. MYOCARDIAL VIABILITY Left ventricular dysfunction may be permanent if a myocardial scar is formed, or it may be reversible after revascularization. Reversible LV dysfunction occurs when the myocardium is viable but dysfunctional (reduced contractility). Since only patients with dysfunctional but viable myocardium benefit from revascularization, the identification and quantification of the extent of myocardial viability is an important part of the work-up of patients with heart failure when determining the most appropriate treatment path. Various non-invasive cardiac imaging modalities can be used to assess patients in whom determination of viability is an important clinical issue, specifically: dobutamine echocardiography (echo),stress echo with contrast,SPECT using either technetium or thallium,cardiac magnetic resonance imaging (cardiac MRI), andpositron emission tomography (PET). DOBUTAMINE ECHOCARDIOGRAPHY Stress echocardiography can be used to detect viable myocardium. During the infusion of low dose dobutamine (5 - 10 μg/kg/min), an improvement of contractility in hypokinetic and akentic segments is indicative of the presence of viable myocardium. Alternatively, a low-high dose dobutamine protocol can be used in which a biphasic response characterized by improved contractile function during the low-dose infusion followed by a deterioration in contractility due to stress induced ischemia during the high dose dobutamine infusion (dobutamine dose up to 40 ug/kg/min) represents viable tissue. Newer techniques including echocardiography using contrast agents, harmonic imaging, and power doppler imaging may help to improve the diagnostic accuracy of echocardiographic assessment of myocardial viability. STRESS ECHOCARDIOGRAPHY WITH CONTRAST Intravenous contrast agents, which are high molecular weight inert gas microbubbles that act like red blood cells in the vascular space, can be used during echocardiography to assess myocardial viability. These agents allow for the assessment of myocardial blood flow (perfusion) and contractile function (as described above), as well as the simultaneous assessment of perfusion to make it possible to distinguish between stunned and hibernating myocardium. SPECT: SPECT can be performed using thallium-201 (Tl-201), a potassium analogue, or technetium-99 m labelled tracers. When Tl-201 is injected intravenously into a patient, it is taken up by the myocardial cells through regional perfusion, and Tl-201 is retained in the cell due to sodium/potassium ATPase pumps in the myocyte membrane. The stress-redistribution-reinjection protocol involves three sets of images. The first two image sets (taken immediately after stress and then three to four hours after stress) identify perfusion defects that may represent scar tissue or viable tissue that is severely hypoperfused. The third set of images is taken a few minutes after the re-injection of Tl-201 and after the second set of images is completed. These re-injection images identify viable tissue if the defects exhibit significant fill-in (> 10% increase in tracer uptake) on the re-injection images. The other common Tl-201 viability imaging protocol, rest-redistribution, involves SPECT imaging performed at rest five minutes after Tl-201 is injected and again three to four hours later. Viable tissue is identified if the delayed images exhibit significant fill-in of defects identified in the initial scans (> 10% increase in uptake) or if defects are fixed but the tracer activity is greater than 50%. There are two technetium-99 m tracers: sestamibi (MIBI) and tetrofosmin. The uptake and retention of these tracers is dependent on regional perfusion and the integrity of cellular membranes. Viability is assessed using one set of images at rest and is defined by segments with tracer activity greater than 50%. CARDIAC MAGNETIC RESONANCE IMAGING Cardiac magnetic resonance imaging (cardiac MRI) is a non-invasive, x-ray free technique that uses a powerful magnetic field, radio frequency pulses, and a computer to produce detailed images of the structure and function of the heart. Two types of cardiac MRI are used to assess myocardial viability: dobutamine stress magnetic resonance imaging (DSMR) and delayed contrast-enhanced cardiac MRI (DE-MRI). DE-MRI, the most commonly used technique in Ontario, uses gadolinium-based contrast agents to define the transmural extent of scar, which can be visualized based on the intensity of the image. Hyper-enhanced regions correspond to irreversibly damaged myocardium. As the extent of hyper-enhancement increases, the amount of scar increases, so there is a lower the likelihood of functional recovery. CARDIAC POSITRON EMISSION TOMOGRAPHY Positron emission tomography (PET) is a nuclear medicine technique used to image tissues based on the distinct ways in which normal and abnormal tissues metabolize positron-emitting radionuclides. Radionuclides are radioactive analogs of common physiological substrates such as sugars, amino acids, and free fatty acids that are used by the body. The only licensed radionuclide used in PET imaging for viability assessment is F-18 fluorodeoxyglucose (FDG). During a PET scan, the radionuclides are injected into the body and as they decay, they emit positively charged particles (positrons) that travel several millimetres into tissue and collide with orbiting electrons. (ABSTRACT TRUNCATED)
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Magnetic resonance imaging (MRI) for the assessment of myocardial viability: an evidence-based analysis. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2010; 10:1-45. [PMID: 23074392 PMCID: PMC3426228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
UNLABELLED In July 2009, the Medical Advisory Secretariat (MAS) began work on Non-Invasive Cardiac Imaging Technologies for the Assessment of Myocardial Viability, an evidence-based review of the literature surrounding different cardiac imaging modalities to ensure that appropriate technologies are accessed by patients undergoing viability assessment. This project came about when the Health Services Branch at the Ministry of Health and Long-Term Care asked MAS to provide an evidentiary platform on effectiveness and cost-effectiveness of noninvasive cardiac imaging modalities.After an initial review of the strategy and consultation with experts, MAS identified five key non-invasive cardiac imaging technologies that can be used for the assessment of myocardial viability: positron emission tomography, cardiac magnetic resonance imaging, dobutamine echocardiography, and dobutamine echocardiography with contrast, and single photon emission computed tomography.A 2005 review conducted by MAS determined that positron emission tomography was more sensitivity than dobutamine echocardiography and single photon emission tomography and dominated the other imaging modalities from a cost-effective standpoint. However, there was inadequate evidence to compare positron emission tomography and cardiac magnetic resonance imaging. Thus, this report focuses on this comparison only. For both technologies, an economic analysis was also completed.A summary decision analytic model was then developed to encapsulate the data from each of these reports (available on the OHTAC and MAS website).The Non-Invasive Cardiac Imaging Technologies for the Assessment of Myocardial Viability is made up of the following reports, which can be publicly accessed at the MAS website at: www.health.gov.on.ca/mas or at www.health.gov.on.ca/english/providers/program/mas/mas_about.htmlPOSITRON EMISSION TOMOGRAPHY FOR THE ASSESSMENT OF MYOCARDIAL VIABILITY: An Evidence-Based AnalysisMAGNETIC RESONANCE IMAGING FOR THE ASSESSMENT OF MYOCARDIAL VIABILITY: An Evidence-Based Analysis OBJECTIVE The objective of this analysis is to assess the effectiveness and cost-effectiveness of cardiovascular magnetic resonance imaging (cardiac MRI) for the assessment of myocardial viability. To evaluate the effectiveness of cardiac MRI viability imaging, the following outcomes were examined: the diagnostic accuracy in predicting functional recovery and the impact of cardiac MRI viability imaging on prognosis (mortality and other patient outcomes). CLINICAL NEED CONDITION AND TARGET POPULATION LEFT VENTRICULAR SYSTOLIC DYSFUNCTION AND HEART FAILURE: Heart failure is a complex syndrome characterized by the heart's inability to maintain adequate blood circulation through the body leading to multiorgan abnormalities and, eventually, death. Patients with heart failure experience poor functional capacity, decreased quality of life, and increased risk of morbidity and mortality. In 2005, more than 71,000 Canadians died from cardiovascular disease, of which, 54% were due to ischemic heart disease. Left ventricular (LV) systolic dysfunction due to coronary artery disease (CAD) () is the primary cause of heart failure accounting for more than 70% of cases. The prevalence of heart failure was estimated at one percent of the Canadian population in 1989. Since then, the increase in the older population has undoubtedly resulted in a substantial increase in cases. Heart failure is associated with a poor prognosis: one-year mortality rates were 32.9% and 31.1% for men and women, respectively in Ontario between 1996 and 1997. TREATMENT OPTIONS IN GENERAL, THERE ARE THREE OPTIONS FOR THE TREATMENT OF HEART FAILURE: medical treatment, heart transplantation, and revascularization for those with CAD as the underlying cause. Concerning medical treatment, despite recent advances, mortality remains high among treated patients, while, heart transplantation is affected by the limited availability of donor hearts and consequently has long waiting lists. The third option, revascularization, is used to restore the flow of blood to the heart via coronary artery bypass grafting (CABG) or, in some cases, through minimally invasive percutaneous coronary interventions (balloon angioplasty and stenting). Both methods, however, are associated with important perioperative risks including mortality, so it is essential to properly select patients for this procedure. MYOCARDIAL VIABILITY Left ventricular dysfunction may be permanent, due to the formation of myocardial scar, or it may be reversible after revascularization. Reversible LV dysfunction occurs when the myocardium is viable but dysfunctional (reduced contractility). Since only patients with dysfunctional but viable myocardium benefit from revascularization, the identification and quantification of the extent of myocardial viability is an important part of the work-up of patients with heart failure when determining the most appropriate treatment path. Various non-invasive cardiac imaging modalities can be used to assess patients in whom determination of viability is an important clinical issue, specifically: dobutamine echocardiography (echo),stress echo with contrast,SPECT using either technetium or thallium,cardiac magnetic resonance imaging (cardiac MRI), andpositron emission tomography (PET). DOBUTAMINE ECHOCARDIOGRAPHY Stress echocardiography can be used to detect viable myocardium. During the infusion of low dose dobutamine (5 - 10 µg/kg/min), an improvement of contractility in hypokinetic and akentic segments is indicative of the presence of viable myocardium. Alternatively, a low-high dose dobutamine protocol can be used in which a biphasic response characterized by improved contractile function during the low-dose infusion followed by a deterioration in contractility due to stress induced ischemia during the high dose dobutamine infusion (dobutamine dose up to 40 ug/kg/min) represents viable tissue. Newer techniques including echocardiography using contrast agents, harmonic imaging, and power doppler imaging may help to improve the diagnostic accuracy of echocardiographic assessment of myocardial viability. STRESS ECHOCARDIOGRAPHY WITH CONTRAST Intravenous contrast agents, which are high molecular weight inert gas microbubbles that act like red blood cells in the vascular space, can be used during echocardiography to assess myocardial viability. These agents allow for the assessment of myocardial blood flow (perfusion) and contractile function (as described above), as well as the simultaneous assessment of perfusion to make it possible to distinguish between stunned and hibernating myocardium. SPECT: SPECT can be performed using thallium-201 (Tl-201), a potassium analogue, or technetium-99 m labelled tracers. When Tl-201 is injected intravenously into a patient, it is taken up by the myocardial cells through regional perfusion, and Tl-201 is retained in the cell due to sodium/potassium ATPase pumps in the myocyte membrane. The stress-redistribution-reinjection protocol involves three sets of images. The first two image sets (taken immediately after stress and then three to four hours after stress) identify perfusion defects that may represent scar tissue or viable tissue that is severely hypoperfused. The third set of images is taken a few minutes after the re-injection of Tl-201 and after the second set of images is completed. These re-injection images identify viable tissue if the defects exhibit significant fill-in (> 10% increase in tracer uptake) on the re-injection images. The other common Tl-201 viability imaging protocol, rest-redistribution, involves SPECT imaging performed at rest five minutes after Tl-201 is injected and again three to four hours later. Viable tissue is identified if the delayed images exhibit significant fill-in of defects identified in the initial scans (> 10% increase in uptake) or if defects are fixed but the tracer activity is greater than 50%. There are two technetium-99 m tracers: sestamibi (MIBI) and tetrofosmin. The uptake and retention of these tracers is dependent on regional perfusion and the integrity of cellular membranes. Viability is assessed using one set of images at rest and is defined by segments with tracer activity greater than 50%. CARDIAC POSITRON EMISSION TOMOGRAPHY Positron emission tomography (PET) is a nuclear medicine technique used to image tissues based on the distinct ways in which normal and abnormal tissues metabolize positron-emitting radionuclides. Radionuclides are radioactive analogs of common physiological substrates such as sugars, amino acids, and free fatty acids that are used by the body. The only licensed radionuclide used in PET imaging for viability assessment is F-18 fluorodeoxyglucose (FDG). During a PET scan, the radionuclides are injected into the body and as they decay, they emit positively charged particles (positrons) that travel several millimetres into tissue and collide with orbiting electrons. This collision results in annihilation where the combined mass of the positron and electron is converted into energy in the form of two 511 keV gamma rays, which are then emitted in opposite directions (180 degrees) and captured by an external array of detector elements in the PET gantry. Computer software is then used to convert the radiation emission into images. The system is set up so that it only detects coincident gamma rays that arrive at the detectors within a predefined temporal window, while single photons arriving without a pair or outside the temporal window do not active the detector. This allows for increased spatial and contrast resolution. CARDIAC MAGNETIC RESONANCE IMAGING Cardiac magnetic resonance imaging (cardiac MRI) is a non-invasive, x-ray free technique that uses a powerful magnetic field, radio frequency pulses, and a computer to produce detailed images of the structure and function of the heart. (ABSTRACT TRUNCATED)
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Non-invasive cardiac imaging technologies for the assessment of myocardial viability: a summary of evidence-based analyses. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2010; 10:1-24. [PMID: 23074391 PMCID: PMC3377565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Section 13: Evaluation and Therapy for Heart Failure in the Setting of Ischemic Heart Disease. J Card Fail 2010. [DOI: 10.1016/j.cardfail.2010.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Spadafora M, Varrella P, Acampa W, Spirito M, Nappi C, Mansi L, Miletto P, Rosato G, Cuocolo A. Direct imaging of viable myocardium by gated SPECT in patients with ischaemic left ventricular dysfunction. Eur J Nucl Med Mol Imaging 2010; 37:1730-5. [PMID: 20419371 DOI: 10.1007/s00259-010-1463-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 03/29/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of the study was to evaluate a novel polar map of myocardial viability obtained by gated SPECT imaging to predict functional recovery after revascularization in patients with ischaemic left ventricular (LV) dysfunction. METHODS The study group comprised 17 patients (15 men, mean age 58 +/- 9 years) with ischaemic LV dysfunction (ejection fraction <or=40%) who underwent nitrate-enhanced gated SPECT before and 6 months after coronary revascularization. A parametric image of viable myocardium (VIA) was obtained using a semiautomated method to subtract the point-to-point motion polar map from the perfusion polar map. A parametric image of segments with functional recovery (REC) was obtained by subtracting the baseline motion polar map from the motion polar map after revascularization. RESULTS Of the total 340 segments, 248 (73%) were considered viable on the basis of the VIA map. After revascularization, of 248 dysfunctional viable segments 186 (75%) showed an improvement in LV function. An increase in LV ejection fraction (from 30 +/- 10% to 42 +/- 11%, p < 0.01) and a decrease in end-diastolic volume (from 207 +/- 74 ml to 174 +/- 74 ml, p < 0.01) were observed after revascularization. Overall concordance between the VIA map and the REC map was 85%, with a k value of 0.63. Sensitivity, specificity, and positive and negative predictive values of the VIA map for predicting functional recovery were 89%, 75%, 91% and 71%, respectively. CONCLUSION The proposed polar map of myocardial viability obtained by gated SPECT imaging accurately predicts functional recovery after coronary revascularization. Thus, a direct quantitative image of viability obtained from perfusion/function matching may be helpful for clinical decision-making in patients with ischaemic LV dysfunction.
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van der Wall EE, Siebelink HM, Scholte AJ, Bax JJ. Positron emission tomography; viable tool in patients pre-CABG? Int J Cardiovasc Imaging 2010; 26:661-4. [PMID: 20358291 PMCID: PMC2898113 DOI: 10.1007/s10554-010-9612-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 03/05/2010] [Indexed: 11/30/2022]
Affiliation(s)
- E. E. van der Wall
- Department of Cardiology, Leiden University Medical Center, P.O. Box 9600, Leiden, Netherlands
| | - H. M. Siebelink
- Department of Cardiology, Leiden University Medical Center, P.O. Box 9600, Leiden, Netherlands
| | - A. J. Scholte
- Department of Cardiology, Leiden University Medical Center, P.O. Box 9600, Leiden, Netherlands
| | - J. J. Bax
- Department of Cardiology, Leiden University Medical Center, P.O. Box 9600, Leiden, Netherlands
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Tajouri TH, Chareonthaitawee P. Myocardial viability imaging and revascularization in chronic ischemic left ventricular systolic dysfunction. Expert Rev Cardiovasc Ther 2010; 8:55-63. [PMID: 20014935 DOI: 10.1586/erc.09.157] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The high rate of periprocedural morbidity and mortality associated with revascularization in moderate-to-severe left ventricular systolic dysfunction has provided the rationale for noninvasive viability imaging. The most established viability imaging techniques are PET, single-photon emission computed tomography and dobutamine echocardiography. Cardiac MRI is gaining widespread use and accessibility, and computed tomography is emerging as a promising technique. Each imaging modality has unique advantages but also suffers from limitations. Furthermore, evidence of the impact of viability imaging on patient outcomes has generally been limited to observational studies. Uncertainty remains regarding the optimal treatment strategy in this patient subset. This review describes the current status of viability imaging and revascularization in chronic moderate-to-severe ischemic left ventricular systolic dysfunction.
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Affiliation(s)
- Tanya H Tajouri
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Boehm J, Haas F, Bauernschmitt R, Wagenpfeil S, Voss B, Schwaiger M, Lange R. Impact of preoperative positron emission tomography in patients with severely impaired LV-function undergoing surgical revascularization. Int J Cardiovasc Imaging 2010; 26:423-32. [PMID: 20091350 PMCID: PMC2852592 DOI: 10.1007/s10554-010-9585-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2009] [Accepted: 01/07/2010] [Indexed: 12/03/2022]
Abstract
In patients with ischemic cardiomyopathy, coronary artery bypass grafting (CABG) offers an important therapeutic option but is still associated with high perioperative mortality. Although previous studies suggest a benefit from revascularization for patients with defined viability by a non-invasive technique, the role of viability assessment to determine suitability for revascularization in patients with ischemic cardiomyopathy has not yet been defined. This study evaluates the hypothesis that the use of PET imaging in the decision-making process for CABG will improve postoperative patient survival. We reviewed 476 patients with ischemic cardiomyopathy (LV ejection fraction ≤0.35) who were considered candidates for CABG between 1994 and 2004 on the basis of clinical presentation and angiographic data. In a Standard Care Group, 298 patients underwent CABG. In a second PET-assisted management group of 178 patients, 152 patients underwent CABG (PET-CABG) and 26 patients were excluded from CABG because of lack of viability (PET-Alternatives). Primary endpoint was postoperative survival. There were two in hospital deaths in the PET-CABG (1.3%) and 30 (10.1%) in the Standard Care Group (P = 0.018). The survival rate after 1, 5 and 9.3 years was 92.0, 73.3 and 54.2% in the PET-CABG and 88.9, 62.2 and 35.5% in the Standard Care Group, respectively (P = 0.005). Cox-regression analysis revealed a significant influence on long-term survival of patient selection by viability assessment via PET (P = 0.008), of LV-function (P = 0.017), and age >70 (P = 0.016). Preoperative assessment of myocardial viability via PET identifies patients, who will benefit most from CABG.
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Affiliation(s)
- Johannes Boehm
- Klinik fuer Herz- und Gefaesschirurgie, Deutsches Herzzentrum Muenchen, Technische Universitaet Muenchen, Lazarettstrasse 36, 80636, Munich, Germany.
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Validation of echocardiographic two-dimensional speckle tracking longitudinal strain imaging for viability assessment in patients with chronic ischemic left ventricular dysfunction and comparison with contrast-enhanced magnetic resonance imaging. Am J Cardiol 2009; 104:312-7. [PMID: 19616660 DOI: 10.1016/j.amjcard.2009.03.040] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Revised: 03/24/2009] [Accepted: 03/24/2009] [Indexed: 11/21/2022]
Abstract
The purpose of the present study was to compare longitudinal strain assessed by two-dimensional speckle tracking with scar tissue on contrast-enhanced magnetic resonance imaging (MRI) in patients with chronic ischemic left ventricular (LV) dysfunction. The aim was also to define a cutoff value for regional strain to discriminate between viable myocardium and transmural scar. Ninety patients with chronic ischemic LV dysfunction underwent transthoracic echocardiography to measure global and segmental (regional) longitudinal LV strain using two-dimensional speckle tracking and cine MRI followed by contrast-enhanced MRI to assess segmental LV function and the segmental/global (transmural) extent of scar tissue. The optimal cutoff value for regional strain to discriminate between segments with viable myocardium and segments with transmural scar was also determined. A good correlation was found between global LV strain and the global extent of scar tissue on contrast-enhanced MRI (R = 0.62, p <0.001). The mean segmental strain in segments without scar tissue was -10.4% +/- 5.2% compared with 0.6% +/- 4.9% in segments with transmural scar tissue (p <0.001). A strain value of -4.5% discriminated between segments with viable myocardium and segments with transmural scar tissue on contrast-enhanced MRI with a sensitivity of 81.2% and specificity of 81.6%. In conclusion, global and regional longitudinal strain measured with two-dimensional speckle tracking is associated with the global and regional (transmural) extent of scar tissue on contrast-enhanced MRI. A cutoff value of -4.5% for regional strain discriminated between segments with viable myocardium and those with transmural scar tissue on contrast-enhanced MRI with a sensitivity of 81.2% and specificity of 81.6%.
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Kwon DH, Halley CM, Carrigan TP, Zysek V, Popovic ZB, Setser R, Schoenhagen P, Starling RC, Flamm SD, Desai MY. Extent of left ventricular scar predicts outcomes in ischemic cardiomyopathy patients with significantly reduced systolic function: a delayed hyperenhancement cardiac magnetic resonance study. JACC Cardiovasc Imaging 2009; 2:34-44. [PMID: 19356530 DOI: 10.1016/j.jcmg.2008.09.010] [Citation(s) in RCA: 221] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 08/29/2008] [Accepted: 09/09/2008] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The objective of the study was to determine whether the extent of left ventricular scar, measured with delayed hyperenhancement cardiac magnetic resonance (DHE-CMR), predicts survival in patients with ischemic cardiomyopathy (ICM) and severely reduced left ventricular ejection fraction (LVEF). BACKGROUND Patients with ICM and reduced LVEF have poor survival. Such patients have a high myocardial scar burden. CMR is highly accurate in delineation of myocardial scar. METHODS We studied 349 patients (76% men) with severe ICM (>or=70% disease in >or=1 epicardial coronary, and mean LVEF of 24%) that underwent DHE-CMR (Siemens 1.5-T scanner, Erlangen, Germany), between 2003 and 2006. Scar (quantified as percentage of myocardium) was defined on DHE-MR images as an intensity >2 standard deviations above the viable myocardium. Transmurality score was semiquantitatively recorded in a 17-segment model as: 0 = no scar, 1 = 1% to 25% scar, 2 = 26% to 50%, 3 = 51% to 75%, and 4 = >75%. The LVEF, demographic data, risk factors, need for cardiac transplantation (CTx), and all-cause mortality were recorded. RESULTS The mean age and follow-up were 65 +/- 11 years and 2.6 +/- 1.2 years (median 2.4 years [1.1, 3.5]), respectively. There were 56 events (51 deaths and 5 CTx). Mean scar percentage and transmurality score were higher in patients with events versus those without (39 +/- 22 vs. 30 +/- 20, p = 0.003, and 9.7 +/- 5 vs. 7.8 +/- 5, p = 0.004). On Cox proportional hazard survival analysis, quantified scar was greater than the median (30% of total myocardium), and female gender predicted events (relative risk 1.75 [95% Confidence Interval: 1.02 to 3.03] and relative risk 1.83 [95% Confidence Interval: 1.06 to 3.16], respectively, both p = 0.03). CONCLUSIONS In patients with ICM and severely reduced LVEF, a greater extent of myocardial scar, delineated by DHE-CMR is associated with increased mortality or the need for cardiac transplantation, potentially aiding further risk-stratification.
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Affiliation(s)
- Deborah H Kwon
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Jones RH, Velazquez EJ, Michler RE, Sopko G, Oh JK, O'Connor CM, Hill JA, Menicanti L, Sadowski Z, Desvigne-Nickens P, Rouleau JL, Lee KL. Coronary bypass surgery with or without surgical ventricular reconstruction. N Engl J Med 2009; 360:1705-17. [PMID: 19329820 PMCID: PMC3265934 DOI: 10.1056/nejmoa0900559] [Citation(s) in RCA: 528] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgical ventricular reconstruction is a specific procedure designed to reduce left ventricular volume in patients with heart failure caused by coronary artery disease. We conducted a trial to address the question of whether surgical ventricular reconstruction added to coronary-artery bypass grafting (CABG) would decrease the rate of death or hospitalization for cardiac causes, as compared with CABG alone. METHODS Between September 2002 and January 2006, a total of 1000 patients with an ejection fraction of 35% or less, coronary artery disease that was amenable to CABG, and dominant anterior left ventricular dysfunction that was amenable to surgical ventricular reconstruction were randomly assigned to undergo either CABG alone (499 patients) or CABG with surgical ventricular reconstruction (501 patients). The primary outcome was a composite of death from any cause and hospitalization for cardiac causes. The median follow-up was 48 months. RESULTS Surgical ventricular reconstruction reduced the end-systolic volume index by 19%, as compared with a reduction of 6% with CABG alone. Cardiac symptoms and exercise tolerance improved from baseline to a similar degree in the two study groups. However, no significant difference was observed in the primary outcome, which occurred in 292 patients (59%) who were assigned to undergo CABG alone and in 289 patients (58%) who were assigned to undergo CABG with surgical ventricular reconstruction (hazard ratio for the combined approach, 0.99; 95% confidence interval, 0.84 to 1.17; P=0.90). CONCLUSIONS Adding surgical ventricular reconstruction to CABG reduced the left ventricular volume, as compared with CABG alone. However, this anatomical change was not associated with a greater improvement in symptoms or exercise tolerance or with a reduction in the rate of death or hospitalization for cardiac causes. (ClinicalTrials.gov number, NCT00023595.)
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Affiliation(s)
- Robert H Jones
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27710, USA.
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Evangelista L, Acampa W, Petretta M, Ferro A, Ricci F, Luongo L, Daniele S, Punzo G, Cuocolo A. Incremental prognostic value of cardiac single-photon emission computed tomography after nitrate administration in patients with ischemic left ventricular dysfunction. J Nucl Cardiol 2009; 16:38-44. [PMID: 19152127 DOI: 10.1007/s12350-008-9004-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 09/08/2008] [Accepted: 09/12/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND We evaluated the incremental prognostic value of viability assessment by nitrate single-photon emission computed tomography (SPECT) in patients with ischemic left ventricular (LV) dysfunction. METHODS AND RESULTS One hundred and sixty-four patients with previous myocardial infarction and LV dysfunction (ejection fraction 29% +/- 15%) underwent two Tc-99m sestamibi SPECT studies, under control conditions and after sublingual nitrate administration, for evaluation of myocardial viability. In each patient, viability was defined as the presence of > or = 2 severely dysfunctional segments with preserved tracer uptake (> or = 55% of peak activity). Cardiac death, myocardial infarction, and late (> 2 months) revascularization were considered events. Follow-up was 98% complete at a mean period of 30 +/- 24 months. At baseline SPECT, 119 (73%) patients had evidence of viable myocardium, while 45 (27%) did not. Of these latter patients, 18 (40%) had evidence of viability after nitrate administration. Cardiac events occurred in 58 (35%) patients. Cumulative probability of event-free survival was similar in patients with and without viability at baseline SPECT (log rank 0.3, P = NS), while it was lower in patients with viability at nitrate SPECT compared to those without (log rank 6.3, P < .01). The addition of nitrate SPECT data significantly improved the prognostic power of the model including clinical, functional, angiographic, and baseline SPECT data (P < .01). CONCLUSIONS In patients with previous myocardial infarction and LV dysfunction, nitrate SPECT imaging provides incremental prognostic information over those obtained from clinical, functional, angiographic variables, and baseline SPECT data.
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Affiliation(s)
- Laura Evangelista
- SDN Foundation, Institute of Diagnostic and Nuclear Development, Naples, Italy
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Agreement and disagreement between contrast-enhanced magnetic resonance imaging and nuclear imaging for assessment of myocardial viability. Eur J Nucl Med Mol Imaging 2008; 36:594-601. [DOI: 10.1007/s00259-008-1001-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Accepted: 10/17/2008] [Indexed: 10/21/2022]
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Hutyra M, Skala T, Kaminek M, Nemec P. ECHOCARDIOGRAPHIC AND CARDIAC SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY PREDICTORS OF LEFT VENTRICLE REVERSE REMODELING AFTER SURGICAL REVASCULARIZATION IN PATIENTS WITH ISCHEMIC CARDIOMYOPATHY AND LEFT VENTRICLE SYSTOLIC DYSFUNCTION. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2008; 152:129-37. [DOI: 10.5507/bp.2008.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Low-dose dobutamine cardiac magnetic resonance imaging with myocardial strain analysis predicts myocardial recoverability after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2008; 135:1342-7. [DOI: 10.1016/j.jtcvs.2008.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Revised: 12/29/2007] [Accepted: 01/05/2008] [Indexed: 11/19/2022]
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Functional outcome and quality of life after coronary artery bypass surgery in patients with severe heart failure and hibernated myocardium. Nucl Med Commun 2008; 29:215-21. [DOI: 10.1097/mnm.0b013e3282f3add9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Coronary artery disease is the most common underlying cause of heart failure, yet there is little consensus on the role of revascularization in the management of patients with ischemic cardiomyopathy. The concept of recovery of dysfunctional but viable myocardium forms the pathophysiologic basis for the benefit of revascularization. Data from observational studies suggest that patients with coronary disease and left ventricular dysfunction may have improved outcomes after surgical revascularization or percutaneous coronary intervention (PCI) compared to medical treatment. Viability testing may be useful in selecting a population of patients who will receive differential benefit. In the clinical management of patients with heart failure, clinicians face challenging decisions about whether to recommend revascularization especially in patients who do not have angina. As data from randomized trials are awaited, PCI and coronary artery bypass grafting may be considered as complimentary revascularization approaches. Registry data suggest a benefit of coronary artery bypass grafting over PCI in patients with reduced ejection fraction; however, in patients with focal disease and comorbidities including previous surgery, PCI is reasonable, especially if complete revascularization is possible.
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Abstract
Although left ventricular (LV) remodeling may be adaptive in early phases of cardiac injury, continued remodeling is a pathologic process that is associated with poor prognosis and diminished cardiac function. Matrix metalloproteinases (MMPs) are a family of proteolytic enzymes involved in the degradation of myocardial extracellular proteins and have been implicated in adverse cardiac remodeling. There is a growing body of literature that supports the role of specific MMPs in cardiac remodeling in both animal models and clinical studies. Conventional imaging of physiologic indices, such as perfusion and function, have been used to monitor LV remodeling. Recently, the potential advantage of targeted imaging of MMPs has been demonstrated, particularly if this is linked with physiologic imaging.
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Affiliation(s)
- Grace Chung
- Yale University School of Medicine, Nuclear Cardiology, New Haven, CT 06520-8017, USA
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Coulter SA. Echocardiographic Evaluation of Coronary Artery Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Yoshinaga K, Tamaki N. Imaging myocardial metabolism. Curr Opin Biotechnol 2006; 18:52-9. [PMID: 17157495 DOI: 10.1016/j.copbio.2006.11.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Revised: 11/15/2006] [Accepted: 11/28/2006] [Indexed: 11/29/2022]
Abstract
The prevalence of coronary artery disease and heart failure is increasing in modern industrialized countries, fueling the search for novel therapies. Because metabolism and function in the heart are inextricably linked, energy substrate metabolism has provided a potential target for novel therapies and the development of technologies to image myocardial metabolism has been crucial in establishing new therapeutic approaches. Nuclear imaging probes have been used to successfully evaluate aerobic fatty acid metabolism, anaerobic glucose metabolism, and oxidative metabolism and can be used for the accurate, sensitive, and physiological evaluation of therapeutic effects. More recently, with the advent of stem-cell technologies, imaging approaches have been employed to track the fate of stem cells and to monitor the success of these treatments. In the future, our ability to image myocardial metabolism is likely to assist the development of other new therapies to improve the function of the failing heart.
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Affiliation(s)
- Keiichiro Yoshinaga
- Department of Molecular Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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