Agreement and disagreement between “metabolic viability” and “contractile reserve” in akinetic myocardium

doi:10.1016/S1071-3581(99)90003-X

Journal of Nuclear Cardiology

Volume 6, Issue 4, July–August 1999, Pages 383-388

https://doi.org/10.1016/S1071-3581(99)90003-X Get rights and content

Abstract

Background. In patients with chronic coronary artery disease and depressed left ventricular function, assessment of residual viability in akinetic myocardium is important for therapeutic management. Intact perfusion, preserved metabolism, and presence of contractile reserve are different aspects of cellular viability. However, not all viable cells exhibit all characteristics; it is thought that contractile reserve is less often preserved compared with metabolic activity or intact perfusion. In this study we performed a direct comparison between perfusion imaging with thallium-201 single photon emission computed tomography (SPECT), metabolic imaging with F18-fluorodeoxyglucose SPECT, and assessment of contractile reserve with low-dose dobutamine echocardiography in akinetic myocardium.

Methods and Results. Forty patients with depressed left ventricular function (mean left ventricular ejection fraction 31% ± 16%) were studied. Resting echocardiography showed akinesis in 165 (32%) segments. Most (n = 154, 93%) of these segments demonstrated resting hypoperfusion. F18-fluorodeoxyglucose imaging revealed a perfusion-metabolism mismatch in 41 segments and a match in 113 segments. Contractile reserve was present in 33 (80%) of the segments with a perfusion-metabolism mismatch and in 7 (6%) segments with a match (P <.0005). Of the 11 segments with normal perfusion, only 5 (45%) showed contractile reserve. The agreement between SPECT and dobutamine echocardiography was 87%. Although 94% of the segments that were nonviable on scintigraphy did not show contractile reserve, the disagreement between SPECT and dobutamine echocardiography was caused mainly by the absence of contractile reserve in 27% of the segments that were viable on scintigraphy.

Conclusion. This study shows a good agreement between SPECT and dobutamine echocardiography, although a substantial number of segments with preserved viability on SPECT do not exhibit contractile reserve, indicating underestimation of viability by dobutamine echocardiography compared with F18-fluorodcoxyglucose imaging.

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Under resting conditions, in the presence of severe coronary stenosis or collateral dependency, hypokinesis and even akinesis can occur with hypoperfusion of only the endocardial portion of the myocardium.39 Akinesis or dyskinesis at rest may be due to transmural flow reduction39,40 or previous myocardial infarction, even if not transmural.41 Regional contractile response to exercise or inotropic stress can be used to identify inducible myocardial ischemia.
Non-Invasive Imaging in Coronary Syndromes: Recommendations of The European Association of Cardiovascular Imaging and the American Society of Echocardiography, in Collaboration with The American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance
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Under resting conditions, in the presence of severe coronary stenosis or collateral dependency, hypokinesis and even akinesis can occur with hypoperfusion of only the endocardial portion of the myocardium.39 Akinesis or dyskinesis at rest may be due to transmural flow reduction39,40 or previous myocardial infarction, even if not transmural.41 Regional contractile response to exercise or inotropic stress can be used to identify inducible myocardial ischemia.
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The differentiation between infarcted, non-viable myocardium and myocardium that is still viable has been an area of extensive research and debate over several decades. Despite this, controversy still exists as to the definitions of viable myocardium, the best non-invasive imaging method to use for viability assessment and whether viability is clinically important or not. This chapter will define viability in its different forms, compare and contrast the non-invasive imaging modalities most commonly used, and discuss the clinical context where knowledge of viability may inform clinical decisions at a patient level. Areas of ongoing research and emerging new imaging methods will be highlighted and discussed.
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Consensus is that the changes in LVEF after revascularization are positively correlated with the number of hibernating segments.22 The presence of viability on PET has been shown to predict functional recovery after revascularization even when contractile reserve is exhausted on functional testing.29 Revascularization in patients with significant viability has been shown to improve outcomes, LV function, and functional class.30
Heart failure presents a significant problem in industrialized countries, with a high prevalence, morbidity, and mortality, where it is most frequently caused by coronary artery disease. Revascularization in patients with symptomatic heart failure has been associated with improved cardiovascular outcomes. Predictors of outcome benefit from revascularization include the presence and extent of hibernating myocardium, ischemia, scar, left ventricular ejection fraction, and renal function. Viability is useful in directing the management of patients with ischemic cardiomyopathy. It is especially useful in those with the highest risk where revascularization decisions are the most difficult. In the absence of definitive prospective randomized data on the benefit of routine viability testing in the management of ischemic cardiomyopathy, physicians will likely continue to use viability testing to assist them with their decision-making process. This review article focuses on the value of viability imaging and the modalities of its measurement, which include PET, SPECT, cardiac MRI, and dobutamine echocardiography. These imaging modalities should be seen as complementary rather than competing methods. In any given clinical setting, the indications, comorbidities, availability, local expertise, sensitivity, specificity, and limitations of each modality need to be considered. When advanced imaging (PET and cardiac MRI) are available, they are generally considered the preferred choice because of their overall higher accuracy. Finally, we explore the role of ischemia in patients with viability and the potential role of neurohormonal and viability imaging in deciding the need for implantable cardiac defibrillator as a primary prevention in patients with severe ischemic cardiomyopathy.
Role of echocardiography in the assessment of myocardial viability
2009, American Journal of the Medical Sciences
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In general, DSE tends toward the underestimation of viability while nuclear imaging modalities tend toward the overestimation of viability. A significant number of nonviable LV segments by DSE will be viable by a nuclear imaging modality.50,51 Interestingly, it has been shown that FDG PET-viable segments with contractile reserve by DSE have less severe myocardial cell ultrastructural damage than FDG PET-viable segments without contractile reserve by DSE.52,53
In the assessment of chronic myocardial infarction, echocardiography plays a vital role through the recognition of hibernating yet potentially viable myocardium that could benefit from revascularization. Echocardiography provides information through basic evaluation of cardiac structure and through evaluation of the functional response to dobutamine stress. In addition, a number of newer modalities such as myocardial contrast echocardiography, tissue Doppler imaging, and strain imaging provide further diagnostic capability. This review assesses the role of echocardiography in the identification of patients with chronic myocardial infarction who could benefit from revascularization.
Value of low-dose Dobutamine addition to routine dual isotope gated SPECT myocardial imaging in patients with healed myocardial infarction or abnormal wall thickening by echocardiogram
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This may be attempted in selected cases based on initial imaging findings. Although FDG positron emission tomographic imaging is not a perfect standard for predicting functional recovery after revascularization, it has been used extensively by many investigators as an acceptable metabolic viability marker against which other types of viability markers are compared.7,8,15–18 The combined information from thallium-201 uptake at rest and CR with LDD was found to be more accurate than either marker alone for the detection of myocardial viability, as defined by post-revascularization functional recovery,10,19–21 or by positron emission tomographic FDG imaging,7,8 which was also confirmed in this study.
There is overlap in myocardial viability detection by thallium-201 uptake and contractile reserve (CR) using low-dose dobutamine (LDD). The dual isotope protocol was modified in this study by acquiring thallium-201 images using LDD to enhance viability detection in addition to coronary flow reserve assessment. One hundred twenty-four patients with coronary disease underwent gated single-photon emission computed tomographic thallium-201 imaging at rest with LDD (10 μg/kg/min) during acquisition followed by stress technetium-99m sestamibi myocardial perfusion (MP) imaging with dobutamine, adenosine, or treadmill exercise. F-18-fluorodeoxyglucose (FDG) positron emission tomography was obtained in 41 patients. Myocardial perfusion (MP) imaging was divided into normal, fixed, and ischemic segments, and subclassified by wall motion and/or thickening changes between 1-hour poststress and LDD into normal, fixed, or improved dysfunctional segments (CR present). Mean left ventricular ejection fraction was 39% at 1 hour after stress and 47% with LDD (p <0.001). In dysfunctional myocardium, CR was significantly higher (p <0.001) in ischemic (233 of 368) and fixed segments (150 of 335) than in normal MP segments (43 of 220). Combined MP and CR analysis showed higher accuracy and negative predictive value in identifying FDG-viable myocardium than either method alone, whereas a high positive predictive value was maintained, similar to both markers. Quantitative analysis showed significant increased wall motion and thickening with LDD compared with 1 hour after stress, which was highest in ischemic segments and lowest in fixed segments. Thus, LDD dual isotope is a practical protocol that improves viability detection by simultaneous MP and CR analysis in addition to coronary flow reserve assessment in 1 study. Moreover, it requires no extra imaging time or radioactivity than the routine protocol.

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Original articleAgreement and disagreement between “metabolic viability” and “contractile reserve” in akinetic myocardium

Abstract

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Mechanisms of chronic regional postischemic dysfunction in humans

Assessment of myocardial viability by dobutamine stress echocardiography

Curr Opin Cardiol

Current diagnostic techniques of assessing myocardial viability in hibernating and stunned myocardium

Circulation

Predicting recovery of severe regional ventricular dysfunction: comparison of resting scintigraphy with 201TI and 99Tc-sestamibi

Circulation

Potential and limitations of Tc-99m sestamibi scintigraphy for the diagnosis of myocardial viability

Herz

FDG-SPECT: correlation with FDG-PET

J Nucl Med

Comparison of myocardial uptake of 18F-fluorodeoxyglucose imaged with positron emission tomography and single photon emission computed tomography in dyssynergic myocardium

J Nucl Med

Recommendation for quantification of the left ventricle by two-dimensional echocardiography

J Am Soc Echocardiogr

Original article
Agreement and disagreement between “metabolic viability” and “contractile reserve” in akinetic myocardium

Comparison of myocardial uptake of ¹⁸F-fluorodeoxyglucose imaged with positron emission tomography and single photon emission computed tomography in dyssynergic myocardium