Dobutamine-stress electrocardiographically gated positron emission tomography for detection of viable but dysfunctional myocardium

doi:10.1016/S1071-3581(99)90100-9

Journal of Nuclear Cardiology

Volume 6, Issue 6, November–December 1999, Pages 626-632

https://doi.org/10.1016/S1071-3581(99)90100-9 Get rights and content

Abstract

Purpose. This study was performed to determine whether low-dose dobutamine stress electrocardiography (ECG)-gated fluorine-18 fluorodeoxyglucose (FDG)—positron emission tomography (PET) can assess wall motion and identify myocardium without contractile reserve despite preserved FDG uptake.

Methods. Fifty-three patients with myocardial infarction and normal sinus rhythm underwent ECG-gated FDG-PET and transthoracie echocardiography. Wall motion of 10 segments of the left ventricle was graded as normal, hypokinetic, or akinetic/dyskinetic.

Results. In 365 (76%) of 480 segments, assessment of wall motion was concordant between the 2 modalities. In 30 patients dobutamine-stress ECG-gated FDG-PET was performed. In 13 (50%) of 26 dysfunctional segments with normal FDG uptake, 16 (36%) of 44 dysfunctional segments with mildly reduced FDG uptake and 12 (25%) of 48 dysfunctional segments with moderately reduced FDG uptake, wall motion was improved by dobutamine infusion.

Conclusion. Assessment of left ventricular wall motion with ECG-gated FDG-PET is feasible, and dobutamine stress ECG-gated FDG-PET can simultaneously identify metabolic viability and contractile reserve.

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Our objectives were to investigate the accuracy of global and regional left ventricular (LV) function parameters determined from gated fluorine 18 deoxyglucose (FDG) positron emission tomography (PET) and to determine whether this approach complements viability imaging data for tissue characterization. Nongated FDG-PET is a clinical standard for viability imaging, but LV function is often determined with other techniques, which increases patient burden, expenditure, and co-registration errors. Better tissue characterization may be achieved if data were acquired with one test.
Forty-eight patients with LV dysfunction (including 35 with ejection fraction [EF] ≤35%) underwent perfusion/FDG imaging with gating of the FDG images and radionuclide angiography (RNA) 6 ± 6 days apart. Regional function (wall motion/thickening) and viability pattern (normal, mismatch, nontransmural scar, and transmural scar) were determined for 301 segments. Global EFs from FDG-PET (29.3% ± 11.5%) and RNA (31.1% ± 10.4%) were well correlated: EF_FDG-PET = 0.91 × EF_RNA + 0.91 (r = 0.83, P < .00001). Regional wall motion concordance between PET and RNA with three wall motion scores was 67% with moderate agreement (κ = 0.50, P < .001). PET viability was also determined for each segment. The relative frequency of normal motion compared with abnormal motion decreased with worsening viability classification. Of the normal segments, 96 of 139 (69%) had reduced wall motion, suggesting repetitively stunned myocardium. Segments classified as normal or mismatch had a higher frequency of normal wall thickening (65% and 52%) than wall motion (31% and 17%). No segments classified as transmural scar exhibited normal wall thickening.
Gated FDG-PET accurately measures global LV function. Regional function can also be determined with reasonable accuracy. This approach also provides precise co-registration of function with metabolic information and thus improved tissue characterization of the myocardium. Gated FDG-PET has the potential to assist in optimizing management of this patient population.
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Background. Technetium-99m-labeled myocardial perfusion tracers allow simultaneous assessment of myocardial perfusion and left ventricular function by electrocardiography-gated scan. This study was performed to determine whether dobutamine stress electrocardiography-gated tetrofosmin single photon emission computed tomography (SPECT) can identify viable (as defined by positron emission tomography [PET]) but dysfunctional myocardium with contractile reserve. Methods and Results. Thirty-five patients with myocardial infarction underwent resting electrocardiography-gated SPECT and fluorodeoxyglucose (FDG) PET. The relative uptakes of tetrofosmin (%tetrofosmin) and FDG (%FDG) were calculated. Wall motion in 9 left ventricular segments was assessed at rest and during dobutamine stress on a 3-dimensional cine-mode display created with automatic left ventricular function analysis software. A total of 129 dysfunctional segments were analyzed. Forty-five (48.9%) of 92 segments with %tetrofosmin of 50% or greater and only 4 (10.8%) of 37 segments with %tetrofosmin less than 50% had contractile reserves (P < .0001). The sensitivity, specificity, and predictive accuracy of %tetrofosmin of 50% or greater for detecting %FDG of 50% or greater were 85.7%, 74%, and 82.9%, respectively. The incidence of the presence of contractile reserve rose with increasing magnitude of %FDG. The sensitivity, specificity, and predictive accuracy of the presence of contractile reserve for detecting %FDG of 50% or greater were 43.9%, 80.6%, and 52.7%, respectively. Conclusions. Dobutamine stress electrocardiography-gated SPECT can identify viable (as defined by PET) but dysfunctional myocardium with contractile reserve.
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Patient monitoring is a major indication for cardiac nuclear medicine procedures. Stress myocardial perfusion scintigraphy was initially used for diagnosis, but monitoring patients with coronary artery disease has become more common. Stress myocardial perfusion scintigraphy has been shown to provide a considerable amount of incremental prognostic information, which may be useful in selecting patients for therapy. In patients being considered for revascularization, fluorodeoxyglucose can be used to identify regions of dysfunctional but viable myocardium, even within regions that show fixed defects on stress perfusion imaging. It can be used to select a group of patients who will improve function with revascularization and who may have an improved outcome. Thus, cardiac nuclear medicine plays a pivotal role in monitoring patients with coronary artery disease.
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Original articleDobutamine-stress electrocardiographically gated positron emission tomography for detection of viable but dysfunctional myocardium

Abstract

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Identification and differentiation of resting myocardial ischemia and infarction in man with positron computed tomography, 18F-labeled fluorodeoxyglucose and N-13 ammonia

Circulation

Original article
Dobutamine-stress electrocardiographically gated positron emission tomography for detection of viable but dysfunctional myocardium