Prognostic utility of myocardial blood flow assessed by N-13 ammonia positron emission tomography in patients with idiopathic dilated cardiomyopathy

doi:10.1016/S0002-9149(99)00329-X

The American Journal of Cardiology

Volume 84, Issue 4, 15 August 1999, Pages 434-439

https://doi.org/10.1016/S0002-9149(99)00329-X Get rights and content

Abstract

Previous studies in patients with idiopathic dilated cardiomyopathy (IDC) have suggested that myocardial perfusion is impaired and spatially heterogeneous in such cases. Our objective was to identify any association between an abnormality in myocardial perfusion and the prognosis of patients with IDC. We collected data on N-13 ammonia positron emission tomography (PET) studies performed in 26 patients with IDC (9 nonsurvivors, 17 survivors) and in 8 normal control subjects. Regional myocardial blood flow (rMBF) was quantified using N-13 ammonia positron emission tomography and the Simple flow model. The spatial heterogeneity of myocardial perfusion was assessed by calculating the coefficient of variance of rMBF. Mean rMBF of the survivors was significantly lower (0.54 ± 0.13 ml/min/g) than that of control subjects (0.66 ± 0.06 ml/min/g) (p = 0.03 vs control), but did not differ significantly between nonsurvivors (0.58 ± 0.15 ml/min/g) and control subjects. The coefficient of variance of rMBF was significantly higher in nonsurvivors than in either survivors or control subjects (0.24 ± 0.08 vs 0.15 ± 0.08, p = 0.007, and 0.16 ± 0.05, p = 0.03, respectively). The probability of 3-year survival (Kaplan-Meier method) was 33.0% in subjects whose coefficient of variance of rMBF was above the median compared with 90.0% in subjects whose coefficient of variance of rMBF was below the median (p = 0.01). The probability of 3-year survival did not differ among subjects whose mean rMBF was above versus below the median (61.5% vs 62.9%, respectively). The results suggest that the prognosis of patients with IDC is associated with the spatial heterogeneity of myocardial perfusion, not with initial absolute rMBF.

Section snippets

Subjects

In this retrospective cohort study, we evaluated 26 patients (22 men and 4 women, mean age 49 ± 15 years) who had experienced at least 1 episode of acute congestive heart failure or ventricular tachycardia related to IDC between 1990 and 1996. These patients satisfied the following criteria: (1) reduced left ventricular function with an ejection fraction <50%; (2) patients without regional wall thinning (<7 mm) or hypertrophy (>11 mm) by echographic examinations; (3) no evidence of myocardial

Results

The mean duration of follow-up was 2.23 ± 0.90 years (range 1 to 6). Nine of the 26 patients died during the follow-up period. These deaths were considered to be related to heart disease (5 cases of congestive heart failure and 4 cases of ventricular arrhythmia). For analysis of data, patients were divided into nonsurvivors (n = 9) and survivors (n = 17), and their clinical characteristics are listed in Table I. The nonsurvivors and survivors showed no significant differences in ejection

Discussion

The major finding of the present study was that an increase in the coefficient of variance of rMBF predicted cardiovascular mortality in patients with IDC. We also found that there was no association between prognosis and myocardial blood flow in these subjects. These results suggest that prognosis of patients in our study population was associated with the spatial heterogeneity of myocardial perfusion, not with the initial absolute rMBF.

Acknowledgements

We are grateful to Keiko Imazeki, PhD, and Yutaka Itoh, RT (The Department of Radiology, Chiba University School of Medicine), for their technical assistance in the preparation of N-13 ammonia.

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Flow reduction was also seen in the subclinical stages and may be a result of microvascular abnormalities. The prognostic value associated with abnormal MBF, MFR, or flow heterogeneity has been demonstrated in small studies of dilated cardiomyopathy.110,111 Aortic stenosis with left ventricular hypertrophy is also associated with coronary microcirculatory dysfunction particularly in the subendocardium despite normal coronary arteries.112
Quantification of myocardial blood flow (MBF) and flow reserve has been used extensively with positron emission tomography (PET) to investigate the functional significance of coronary artery disease. Increasingly, flow quantification is being applied to investigations of microvascular dysfunction in early atherosclerosis and in nonatherosclerotic microvascular disease associated with primary and secondary cardiomyopathies. Fully three-dimensional (3D) acquisition is becoming the standard imaging mode on new equipment, bringing with it certain challenges for cardiac PET, but also the potential for MBF to be measured simultaneously with routine electrocardiography (ECG)-gated perfusion imaging. Existing 3D versus 2D comparative studies support the use of 3D cardiac PET for flow quantification, and these protocols can be translated to PET-CT, which offers a virtually noise-free attenuation correction. This technology combines the strengths of cardiac CT for evaluation of anatomy with cardiac PET for quantification of the hemodynamic impact on the myocardium. High throughput clinical imaging protocols are needed to evaluate the incremental diagnostic and prognostic value of this technology.
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Changes in myocardial blood flow (MBF) and coronary flow reserve (CFR) are independent prognostic risk factors in idiopathic dilated cardiomyopathy (DCM). The aim of this study was to assess the impact of left ventricular unloading using left ventricular assist device (LVAD) combination therapy on resting MBF and CFR in patients with end-stage heart disease.
We studied 11 patients with deteriorating end-stage DCM (New York Heart Association Class 4) treated with LVAD support combined with pharmacologic therapy in a recovery program. Absolute MBF was measured using oxygen-15-labeled water (H₂¹⁵O) positron emission tomography (PET) at rest during LVAD support and 15 minutes after the LVAD was switched off. Data were corrected for rate pressure product (RPP) when appropriate. Hyperemic MBF (intravenous adenosine, 140 μg/kg · min) was also measured in 6 patients with the LVAD switched off. CFR was calculated as the ratio MBF adenosine/MBF LVAD off (corrected). Data are expressed as mean ± SD.
At 317 ± 193 days after device implantation, resting MBF was 0.95 ± 0.29 (LVAD on) and 1.46 ± 0.62 (LVAD off, corrected) ml/min · g (p = 0.01). MBF (LVAD on) was comparable with that of 11 age- and gender-matched normal controls (1.09 ± 0.22 ml/min · g). CFR in the LVAD group was 1.49 ± 0.99 compared with 3.56 ± 1.42 in normal controls (p < 0.01).
During LVAD support, resting MBF (LVAD on) was comparable to MBF in normal controls and increased when the LVAD was switched off. However, CFR was significantly impaired, even though all patients studied showed varying degrees of myocardial recovery. The implications of these findings, particularly in the long term, require further study.
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Severely depressed myocardial blood flow as assessed by PET is a predictor of poor prognosis in patients with idiopathic LV dysfunction independently of the degree of LV functional impairment and of the presence of overt heart failure.22 Others argue that the prognosis of patients with DCM is associated with the spatial heterogeneity of myocardial perfusion, not with initial absolute regional myocardial blood flow.23 We describe for the first time a relationship between QRS duration and the degree of nonviable (scarred) myocardium determined with PET imaging.
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La reserva de flujo coronario (RFC) se reduce no sólo en la cardiopatía isquémica, sino también en otras cardiopatías, con o sin insuficiencia cardíaca. El objetivo del estudio fue comprobar si la gravedad de la insuficiencia cardíaca influye en el deterioro de la RFC.
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El FM máximo y la RFC fueron significativamente más altos en el grupo 4 (1,95 ± 0,58 y 2,40 ± 0,95 ml/min/g) que en el grupo 1 (1,02 ± 0,52 y 1,46 ± 0,48 ml/min/g). La RFC tuvo tendencia a ser mayor en los grupos 2 (1,73 ± 0,72) y 3 (1,89 ± 0,75) que en el grupo 1. No hubo correlación significativa entre la RFC y las siguientes variables: edad, presión arterial sistólica, índice de masa ventricular, índices de volumen y fracción de eyección de ventrículo izquierdo.
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CardiomyopathyPrognostic utility of myocardial blood flow assessed by N-13 ammonia positron emission tomography in patients with idiopathic dilated cardiomyopathy

Abstract

Section snippets

Subjects

Results

Discussion

Acknowledgements

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Metabolic imaging to assess myocardial viability

J Nucl Med

Identification of viable myocardium

Circulation

Clinical outcome of patients with advanced coronary artery disease after viability studies with positron emission tomography

J Am Coll Cardiol

Quantification of regional myocardial blood flow using 13N ammonia and reoriented dynamic positron emission tomographic imaging

Circulation

Validation of nitrogen-13-ammonia tracer kinetic model for quantification of myocardial blood flow using PET

J Nucl Med

Coronary flow reserve by PET simplified for clinical applications using rubidium-82 or nitrogen-13-ammonia

J Nucl Med

Cardiomyopathy
Prognostic utility of myocardial blood flow assessed by N-13 ammonia positron emission tomography in patients with idiopathic dilated cardiomyopathy

Quantification of regional myocardial blood flow using ¹³N ammonia and reoriented dynamic positron emission tomographic imaging