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Prognostic Value of Rest ²⁰¹Tl-Dipyridamole Stress ^99mTc-Sestamibi Gated SPECT for Predicting Patient-Based Clinical Outcomes After Bypass Surgery in Patients with Ischemic Left Ventricular Dysfunction

¹ Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, Korea
² Department of Thoracic Surgery, Seoul National University College of Medicine, Seoul, Korea

We investigated the postoperative prognostic value of preoperative myocardial SPECT for predicting clinical outcomes, including event-free survival and functional improvement. Methods: A total of 123 patients with ischemic heart disease and left ventricular dysfunction were enrolled. The ratio of men to women was 103:20, and the mean (±SD) age was 61 ± 8 y. The disease involved 3 vessels in 95 patients, 2 vessels in 27 patients, and 1 vessel in 1 patient. Rest ²⁰¹Tl-dipyridamole stress ^99mTc-sestamibi gated 24-h-delayed SPECT was performed before and 3–4 mo after bypass surgery. With a 20-segment model, a dysfunctional segment was defined as that with systolic wall thickening of <20%. Dysfunctional but viable segments were defined for each viability predictor, including rest thallium uptake of >60%, reversibility score (rest perfusion minus stress perfusion) of >7, systolic wall thickening of >10%, and 24-h-delayed thallium uptake of >60%. Global left ventricular functional improvement was defined as a 5% increase in the left ventricular ejection fraction (LVEF) or a 10-mL decrease in the end-systolic volume (ESV). A long-term follow-up evaluation was performed by chart reviews and telephone interviews over a period of up to 6 y. Cardiac events were defined as cardiac death, myocardial infarction, or heart failure requiring hospitalization. Results: After bypass surgery, the LVEF was improved from 36.4% ± 8.8% (mean ± SD) to 44.3% ± 11.1%, and the ESV was improved from 96.6 ± 46.7 mL (mean ± SD) to 75.1 ± 44.0 mL. Global left ventricular function was improved in 96 patients but not improved in 27. Rest thallium uptake (4 segments) and reversibility (5 segments) were found to be significant variables in the receiver-operating-characteristic (ROC) curve analysis, with area-under-the-curve (AUC) values of 0.755 (P < 0.05) and 0.735 (P < 0.05), respectively. The values for preserved systolic wall thickening and delayed thallium uptake had no statistical significance. Using a multivariate logistic function, we created a single variable consisting of rest thallium uptake and reversibility; this variable had better prediction power than any other single variable (AUC value for the ROC curve, 0.794). Patients with a higher logistic function value (0.84) showed better event-free survival than did those with a lower logistic function value (<0.84) (log-rank test, P < 0.05). Conclusion: The number of viable segments should be >4 for rest ²⁰¹Tl SPECT or >5 for the reversibility parameter for the prediction of global functional improvement in a patient-based evaluation. With a logistic function created from these parameters, the long-term clinical prognosis after bypass surgery could be predicted by the presence of viability on preoperative rest-stress myocardial SPECT.

Key Words: gated SPECT • prognosis • patient-based approach

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