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Clinical Investigations |
1 Department of Cardiology, University Hospital Leiden, Leiden, The Netherlands
2 Department of Molecular and Medical Pharmacology (Nuclear Medicine) and Radiological Sciences, UCLA School of Medicine, Los Angeles, California
3 Department of Cardiology, ThoraxCenter Rotterdam, Rotterdam, The Netherlands
4 Department of Clinical Epidemiology/Statistics, ThoraxCenter Rotterdam, Rotterdam, The Netherlands
201Tl imaging and dobutamine echocardiography (DE) can both identify viable myocardium. Prediction of functional outcome after revascularization remains suboptimal with either technique because of the relatively low specificity of 201Tl and low sensitivity of DE. This study was undertaken to develop an optimal testing strategy for prediction of postrevascularization functional outcome. Methods: Seventy-three patients (mean [±SD] left ventricular ejection fraction [LVEF], 32% ± 8%) underwent DE and resting 201Tl SPECT (4-h delayed imaging) before surgical revascularization. Dysfunctional segments with 201Tl activity 
50% or with contractile reserve were considered viable. LVEF was assessed before and 3–6 mo after revascularization. Results: Analysis of receiver operator characteristic curves showed that the optimum criteria to predict improvement (5%) in LVEF after revascularization were 6 viable dysfunctional segments (using a 16-segment model) on 201Tl and 4 segments on DE. Sensitivity and specificity were 84% and 63% for 201Tl (P < 0.05 vs. DE) and 63% and 85% for DE (P < 0.05 vs. 201Tl). Changing the 201Tl criteria to improve specificity to 78% (8 segments) yielded a low sensitivity of 44%, and changing the DE criteria to improve sensitivity to 84% (2 segments) lowered specificity to 56%. Two sequential testing strategies were explored to achieve optimal sensitivity and specificity. In strategy 1, 33 (45%) of 73 patients with an intermediate likelihood of viability by 201Tl (5–8 viable segments) underwent DE. In strategy 2, 31 (42%) of 73 patients with an intermediate likelihood of viability by DE (2–4 viable segments) underwent 201Tl. For strategy 1, sensitivity did not change significantly (69%), whereas specificity was improved significantly (93%, P < 0.01 vs. 201Tl). For strategy 2, sensitivity improved significantly (78%, P < 0.05 vs. DE) and specificity remained unchanged (80%). Conclusion: Sequential testing by 201Tl SPECT and DE in a subgroup of patients with an intermediate likelihood of viability by either test significantly enhanced prediction of postrevascularization improvement of LVEF.
Key Words: 201Tl imaging • dobutamine echocardiography • myocardial viability
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