Feasibility, efficacy and safety of subcutaneous implantable cardioverter defibrillator in patients with a previous median sternotomy

Funding Acknowledgements

Type of funding sources: None.

Background

Subcutaneous implantable cardioverter defibrillator (S-ICD) has been shown to be an effective therapy for prevention of sudden cardiac death (SCD) with improved outcomes and fewer lead-related complications compared to transvenous cardioverter defibrillator (TV-ICD). Patients who previously underwent cardiac surgery with median sternotomy (MS) may be at risk of SCD and require ICD implantation. However, there are no data on the performance of the S-ICD in this patient cohort.

Purpose

To assess feasibility, periprocedural and long-term complications associated with implantation of S-ICD in patients with a previous MS.

Methods

All 128 patients who received a S-ICD at our Centre were enrolled in the study. Baseline and procedural characteristics and complications were collected and retrospectively analyzed. Long-term outcomes were considered as appropriate and inappropriate shocks (IAS), and complications during follow-up. To estimate arrhythmia-free survival, Kaplan–Meier curves were constructed. Cox regression was performed to analyze multivariate predictors of recurrences.

Results

Among 128 patients (79.7% male sex; mean age 50±15 years), 18 of them had a previous MS. Coronary artery disease was present in 26.6% of the total population, while not ischemic aetiology was present in the 75.4% of them; among this cohort, the most prevalent pathology was hypertrophic cardiomyopathy (21.9%). Primary prevention cohort was the 61.1% in the MS group and the 77.3% in the no MS group. S-ICD implant was successful in 100% of cases. No periprocedural complications were registered. After a median follow up of 3.9 years, no one of the 101 patients had sternal complications. There were no differences in delivery of appropriate shocks (12.5% in MS group vs 7.69% in no MS group, p=0.583) neither in delivery of IAS (6.25% in MS group vs 9.89% in no MS group, p=0.594). At the univariate analysis on IAS there were no differences between the group with or without MS (10% vs 16.38%, p=0.594), but there were significative differences between patients with or without arrhythmogenic right ventricular dysplasia (ARVC; 20% vs 2%, p=0.006), between patients with or without diabetes (30% vs 9.89%, p=0.03), between patients with or without chronic obstructive pulmonary disease (30% vs 4.39%, p=0.002) and between patients who used to smoke and patient who did not (40% vs 16.48%, p=0.03). At multivariate analysis, advanced age (hazard ratio 1.033; 95% CI, 1.014 to 1.053; p=0.001) and ARVC (hazard ratio 5.133; 95% CI, 1.515 to 17.399; p=0.009) were significantly associated with delivery of IAS.

Conclusion

Implanting a S-ICD is feasible, safe and effective as in patients without a previous MS; in patients who underwent a S-ICD, a previous MS is not associated with a major risk of sternal complications or delivery of IAS; advanced age and ARVC are independently associated with a major risk of delivery of IAS.

Clinical usefulness of technetium-99m-HMPAO-labeled leukocyte scan in prosthetic vascular graft infection

The infection of a prosthetic vascular graft (PVGI), although rare, is the most severe complication in reconstructive vascular surgery. The early diagnosis of this complication reduces the death rate from surgery. Aortofemoral graft infections differ clinically from peripheral graft infections in significant ways. The aim of this article is to evaluate separately the reliability of the 99mTc-HMPAO-labeled leukocyte scan or white blood cell count (WBC) in the early detection of both aortofemoral and peripheral graft infections.

METHODS

One hundred sixty-two WBCs were performed on 129 consecutive patients with suspected aortofemoral (122 scans) and peripheral (40 scans) graft infection and in a 12-patient control group. Patients with suspected PVGI were categorized into three groups on the basis of their signs and symptoms on readmission: (a) patients with specific signs of graft infection (Group A); (b) patients with nonspecific signs of graft infection (Group B); and (c) patients with anastomotic aneurysms (Group C). Gram's stains of the perigraft exudate and graft cultures were performed and used as the gold standard in patients who underwent surgery. An 18-mo clinical follow-up was done to assess the presence or absence of graft infection in patients who did not have surgery.

RESULTS

In patients with suspected aortofemoral graft infections, the overall sensitivity, specificity and accuracy of WBCs (Groups A, B, C) were 100%, 92.5% and 97.5%, respectively, whereas sensitivity, specificity and accuracy calculated in the patients with nonspecific signs of graft infection (Groups B, C) were 100%, 92.3% and 96.9%, respectively. In patients with suspected peripheral graft infections, sensitivity, specificity and accuracy were 100%.

CONCLUSION

The white blood cell scan seems a reliable diagnostic method for early diagnosis of PVGI, and it is more useful in aortofemoral graft infections.

99Tcm-sestamibi scintimammography in patients with suspicious breast lesions: comparison of SPET and planar images in the detection of primary tumours and axillary lymph node involvement

Planar scintimammography with 99Tcm-sestamibi (99Tcm-MIBI) has been shown to be useful in diagnosing breast carcinoma. The aim of this study was to compare single photon emission tomography (SPET) and planar imaging for scintimammography with 99Tcm-MIBI in the detection of primary breast cancer and axillary lymph node involvement. Sixty-three females with mammographically suspicious lesions and 12 controls were evaluated. Dynamic images were acquired commencing immediately after the injection of the radiopharmaceutical, followed by multiple planar images in the supine and prone positions plus SPET supine imaging. A final histopathological diagnosis was achieved after surgery. A total of 66 breast lesions were considered. No focal uptake of 99Tcm-MIBI was observed in the breasts or axillas of the controls. In the patients with breast cancer, the sensitivity was 92.9% (39/42) for SPET, 71.4% (30/42) for supine and 85.7% (36/42) for prone planar imaging, respectively; the specificity was 87.5% for SPET and 91.6% for the planar scans. Metastatic axillary lymph node involvement was seen in 19 patients: the sensitivity was 84.2% (16/19) for SPET and 63.2% (12/19) for planar images; the specificity was 91.3% and 95.7% respectively. Our results confirm the high diagnostic accuracy of 99Tcm scintimammography in the diagnosis of breast cancer, and suggest that SPET is more sensitive than planar images, especially in detecting axillary lymph node involvement.

Technetium-99m sestamibi myocardial tomography based on dipyridamole echocardiography testing in hypertensive patients with chest pain

The non-invasive diagnosis of coronary artery disease in hypertensives with chest pain is an important clinical concern because all exercise-dependent tests display limited feasibility and diagnostic accuracy; by contrast, dipyridamole echocardiography testing has been shown to have a similar feasibility and accuracy in hypertensive and normotensive subjects. The aim of this study was to evaluate the diagnostic capability of technetium-99m sestamibi tomography based on dipyridamole echocardiography testing in hypertensives with chest pain, and to compare the scintigraphic results with those of coronary angiography, exercise electrocardiography and dipyridamole echocardiography. Forty subjects with mild to moderate hypertension, chest pain and no previous myocardial infarction were submitted to 99mTc-sestamibi tomography (at rest and after high-dose dipyridamole echocardiography) and to exercise electrocardiography testing. At coronary angiography 22 patients (group A) had significant epicardial coronary artery disease (>/=70% stenosis of at least one major vessel) and 18 normal main coronary vessels (group B). Dipyridamole 99mTc-sestamibi imaging was positive in 21/22 patients of group A and in 5/18 of group B. Dipyridamole echocardiography was positive in 18/22 patients of group A and in 5/18 of group B. Exercise electrocardiography was positive in 15/22 patients of group A and in 11/18 of group B. Four out of five subjects in group B with positive results in all the tests showed a slow run-off of angiographic contrast medium, probably due to small-vessel disease. Significant epicardial coronary artery disease in hypertensives with chest pain is unlikely when dipyridamole 99mTc-sestamibi tomography is negative. When scintigraphy is positive, either epicardial coronary artery disease or a small-vessel disease condition is possible. The association of scintigraphy with dipyridamole echocardiography testing allows the assessment of contractile function and myocardial perfusion by a single pharmacological stress.

99mTc-HMPAO granulocyte scintigraphy in the early detection of postoperative asymptomatic recurrence in Crohn's disease

The usefulness of 99mTc-HMPAO scintigraphy in the early detection of postoperative recurrence of Crohn's disease was evaluated in 17 patients undergoing ileocecal resection and prospectively followed up for one year. Scintigraphy was performed 6 and 12 months after surgery and recurrence assessed by colonoscopy within two weeks. As controls, four patients with ileocecal resection for cecal carcinoma were studied. To perform scintigraphy, autologous granulocytes were labeled with 99mTc-HMPAO, injected, and tau-camera images acquired after 30 min and 3 hr. Six months after surgery, 4/8 Crohn's disease patients showed endoscopic recurrence, and 30-min scintigraphy was positive only in these four patients (four true positives, four true negatives). At 12 months, endoscopic recurrence was detected in 10/14 Crohn's disease patients, and 30-min scintigraphy was positive in 9/14 patients (eight true positives, three true negatives, two false negatives, one false positive). Scintigraphy at 3 hr showed a lower specificity in detecting CD recurrence both at 6 and 12 months. The endoscopic and 30-min scintigraphic score were significantly correlated both at 6 and 12 months (P = 0.007; P = 0.04). Scintigraphy was negative in 4/4 controls at 30 min (four true negatives) and positive in 1/4 (one false positive) at 3 hr. We conclude that 99mTc-HMPAO scintigraphy at 30 min is a sensitive technique for the early detection of Crohn's disease recurrence in patients under regular follow-up after surgery.

Somatostatin receptor scintigraphy of malignant somatostatinoma with indium-111-pentetreotide

This article describes the visualization of a pancreatic somatostatinoma and liver metastases using 111In-pentetreotide imaging in a patient with somatostatinoma syndrome. A 61-yr-old woman with gallbladder stones, diabetes, weight loss, diarrhea and steatorrhea, immunohistochemical diagnosis of somatostatinoma (liver biopsy) and high plasma values of somatostatin was studied by somatostatin receptor scintigraphy. Six sites of focal abnormal 111In-pentetreotide hyperfixation were found: three in the liver and three in the pancreatic area. This case report demonstrates that in vivo detection of somatostatinoma with somatostatin receptor imaging is possible in the presence of high levels of circulating somatostatin, suggesting that receptor downregulation has not occurred.

Scintimammography with technetium-99m tetrofosmin in suspected breast cancer

BACKGROUND

Scintimammography with Tc-99m sestamibi has recently demonstrated a clinical usefulness in the evaluation of patients with breast lesions. The aim of this study was to assess the potential role of scintimammography using Tc-99m tetrofosmin in the detection of breast cancer.

MATERIALS AND METHODS

Fifty-five patients (age range: 33-76 years) with suspicious breast abnormalities detected by mammography, and ten controls were examined. Dynamic images (1-20 min post-injection of the radiopharmaceutical) followed by three planar views were performed. Final diagnosis was achieved by hystology after surgery or excisional biopsy.

RESULTS

A total of 59 breast lesions were considered. The sensitivity of Tc-99m tetrofosmin scintimammography for detection of primary breast cancer was 93.1% (27/29) and the specificity was 93.3% (28/30). No focal uptake was observed in both breasts of the control population.

CONCLUSIONS

Tc-99m tetrofosmin scintimammography has high diagnostic accuracy in detecting breast cancer and may have a clinical role as complement to conventional mammography.

A three center study on the diagnostic accuracy of 99mTc-MIBI scintimammography

In order to assess specificity and sensitivity of the prone scintimammography (PSM) in a large series with 99m-Tc MIBI, we performed a three-center study; 420 patients were studied; after mammography all the patients were submitted to PSM and biopsy and/or operation. PSM was considered positive if hot spot within the breast was observed. In palpable masses sensitivity was 0.98 and specificity 0.89, non palpable masses showed a sensitivity of 0.62 and a specificity of 0.91. When the cancers were stratified for T category the sensitivity was 0.28 in T1a 0.26 in the group of T1a carcinomas, 0.56 in T1b 0.95 in T1c and 0.97 T2 tumors. Physical factors such as attenuation. Compton scattering from chest, as well as biological factors have a role in breast tumor imaging. In the tumors smaller than 1 cm biological factors are probably involved too.

Single photon emission computerized tomography increases the sensitivity of indium-111-pentetreotide scintigraphy in detecting abdominal carcinoids

Somatostatin (sms) receptors have been identified in carcinoids (c), so enabling their visualization with 111In-pentetreotide scintigraphy. The aim of this study was to evaluate if single photon emission computerized tomography (SPECT) can increase the sensitivity of sms receptor scintigraphy in the detection of abdominal c. 26 patients (pts) with a present, or previously operated, abdominal carcinoid were submitted to SPECT over the abdomen and multiple planar views after the injection of 111In-pentetreotide. Magnetic resonance imaging and computed tomography were also performed. In 19 pts abnormal sites of uptake were found by SPECT which localized 13 abdominal extrahepatic (in 11 pts) and 45 hepatic lesions (in 15 pts). No pathologic accumulation was seen in 7 pts in complete remission after surgery. Planar images visualized 7 abdominal extrahepatic (in 6 pts) and 26 liver tumor sites (in 10 pts), conventional procedures detected 5 abdominal extrahepatic (in 4 pts) and 36 hepatic lesions (in 10 pts). 111In-pentetreotide SPECT is more sensitive than planar scanning and conventional methods to detect abdominal c, and so may play a major role in the early and accurate mapping of tumour spread.

Technetium-99m sestamibi imaging in the detection of axillary lymph node involvement in patients with breast cancer

BACKGROUND

The status of the axillary lymph nodes is the most important prognostic factor in breast cancer, and the findings of axillary node dissection remain the gold standard for the patients staging and prognosis. The aim of this study was to evaluate the usefulness of Tc-99m sestamibi scintigraphy in the detection of axillary node involvement.

MATERIALS AND METHODS

Forty-nine patients (age range: 32-72 years) with breast cancer were studied. Dynamic images (1-20 minutes post-injection of the radiopharmaceutical) followed by multiple planar views and tomographic images were performed. Final diagnosis was achieved by histology after surgery.

RESULTS

Metastatic axillary lymph node involvement was present in 21 patients: sensitivity was 81% (17/21) for tomographic and 61.9% (13/21) for planar images; specificity was 92.9% (26/28) and 96.4% (27/28), respectively.

CONCLUSIONS

Tc-99m sestamibi imaging is a promising noninvasive method to detect axillary node metastases in patients with breast cancer, tomography appears more sensitive than planar views.

Myocardial scintigraphy with 99mTc-sestamibi in children with Kawasaki disease

Kawasaki disease (KD) is a systemic vasculitis syndrome of early childhood. It involves particularly the coronary arteries and may cause aneurysms and thrombotic occlusions. Echocardiography is the most useful method of detecting coronary aneurysms. Nevertheless, obstructive lesions are difficult to evaluate and often need invasive coronary angiography. An important feature of this disease is the possibility of finding coronary pathology several years after the onset. This characteristic makes KD an important cause of coronary artery disease (CAD) in young adults. Thus patients with KD and previously diseased coronary arteries should be kept under long-term control. However, coronary angiography is invasive and cannot be performed repeatedly, especially in young patients. As an alternative, thallium 201 scintigraphy has been employed, but its low-energy photons are suboptimal for standard gamma-camera imaging, particularly in children aged less than three years. To verify the usefulness of a noninvasive assessment of myocardial perfusion, the authors used rest and dipyridamole 99mTc-Sestamibi scan in 15 children (ranging from one to six years of age) with Kawasaki's cardiac involvement. Coronary aneurysms have been demonstrated by echocardiography in 12 patients; 8 patients were also submitted to cardiac catheterization. The sensitivity of 99mTc-Sestamibi imaging for detection of overall coronary lesions was 88% and the specificity was 93%. These data suggest that rest/dipyridamole 99mTc-Sestamibi scintigraphy is an accurate and noninvasive method for the detection and follow-up of Kawasaki's cardiac damage even in patients aged one year.

Efficient one-step direct labelling of recombinant antibodies with technetium-99m

High-affinity bacterially expressed antibody fragments can nowadays be cloned from established hybridomas or, more conveniently, isolated directly from antibody libraries displayed on filamentous phage. Such antibodies can be tagged with C-terminal peptide tags containing one cysteine residue, which represents a convenient functionalisation site for a number of applications, including technetium-99m labelling. Here we describe a simple one-step method for 99mTc labelling of cysteine-tagged recombinant antibodies with more than 50% radionuclide incorporation. The labelled antibodies displayed full retention of immuoreactivity and good stability.

Scintigraphic evaluation of disease activity in rheumatoid arthritis: a comparison of technetium-99m human non-specific immunoglobulins, leucocytes and albumin nanocolloids

Technetium-99m-labelled, non-specific, polyclonal, human immunoglobulin G (99mTc-hIG) has been used to quantify synovial inflammation in rheumatoid arthritis. A comparison was carried out between the scintigraphic results obtained with this tracer, 99mTc-hexamethylpropylene amine oxime-labelled white blood cells (99mTc-WBC) and 99mTc-albumin nanocolloids (99mTc-NC). Twenty patients affected by rheumatoid arthritis and suffering from clinically active synovitis were studied with 99mTc-hIG. The number and sites of the involved joints had been previously assessed on the basis of the presence of pain and/or swelling. A radiological examination had already been carried out on all the joints. Two days after the 99mTc-hIG scan, 10 patients (group 1) underwent 99mTc-WBC scintigraphy and the other 10 (group 2) underwent a 99mTc-NC scan. The results show that the results of 99mTc-hIG and 99mTc-NC scans are in agreement with clinical examinations in the majority of cases. However, a certain number of positive joint scans corresponding to negative clinical examinations was found. The numerical distribution of these results according to the radiological stages seems to show that 99mTc-hIG is more useful than 99mTc-NC in the initial phases of the disease. The 99mTc-WBC scan was negative in a consistent percentage of the joints previously assessed as clinically and 99mTc-hIG scan positive.

Immunoscintigraphy of adenocarcinomas by means of radiolabeled F(ab')2 fragments of an anti-carcinoembryonic antigen monoclonal antibody: a multicenter study

F(ab')2 fragments of anti-carcinoembryonic antigen (CEA) monoclonal antibody F023C5, determined to be more suitable than intact IgG and Fab fragments for immunoscintigraphy, were labeled with 131I or conjugated to DTPA for instant 111In-labeling, and administered i.v. (2-3 mCi/0.5 mg) to 509 patients in 11 nuclear medicine departments: 284 patients had gastrointestinal adenocarcinomas, 204 had nongastrointestinal adenocarcinomas and 21 were control; serum CEA was elevated in 169 patients, normal in 115, and not determined in 225. The following results were obtained: (a) no adverse reactions; (b) tumor imaging in 324 patients (in particular, in 81.5% CEA-seropositive and in 69.0% CEA-seronegative patients); (c) no significant difference in sensitivity among the results of the 11 departments; (d) no significant difference in overall sensitivity between 131I-and 111In-labeled immunoradiopharmaceuticals; (e) the fraction of documented lesions imaged was 73.3% in CEA-seropositive and 53.7% in CEA-seronegative patients; (f) the detection of liver metastases was hampered, particularly when using the 111In-labeled reagent, by nonspecific radioactivity uptake; (g) the major cause of negative immunoscintigraphy results was a lack of CEA in tumor lesions, as documented by immunohistochemistry; (h) lesion size is also important since the sensitivity was 64% for lesions up to 2 cm in diameter and 84% for larger lesions; (i) many "unexpected" radiolocalizations were recorded. Most were identified as occult tumor lesions. In 35 patients, this finding contributed to the early detection of tumor recurrences.