Relation of End-Diastolic Wall Thickness and the Residual Rim of Viable Myocardium by Magnetic Resonance Imaging to Myocardial Viability Assessed by Fluorine-18 Deoxyglucose Positron Emission Tomography

doi:10.1016/j.amjcard.2005.09.074

The American Journal of Cardiology

Volume 97, Issue 4, 15 February 2006, Pages 452-457

https://doi.org/10.1016/j.amjcard.2005.09.074 Get rights and content

End-diastolic wall thickness (EDWT) and thickness of the residual non–contrast-enhanced myocardial rim have been suggested as markers for the assessment of myocardial viability by cardiovascular magnetic resonance (CMR) imaging. This study compared these parameters as derived from contrast-enhanced CMR images for the prediction of myocardial viability as determined by fluorine-18 deoxyglucose positron emission tomography (FDG-PET). Twenty-two patients with ischemic cardiomyopathy (ejection fraction 31 ± 11%) were investigated. For contrast-enhanced CMR imaging, a standard inversion-recovery sequence was used. FDG-PET was performed using a hyperinsulinemic-euglycemic clamp. Data were analyzed with a 17-segment model. Of 146 severely dysfunctional segments, 112 were assessed as viable and 34 as nonviable by nuclear imaging. Using receiver-operator characteristic analysis, areas under the curve were 0.95 for unenhanced myocardial rim (95% confidence interval 0.92 to 0.98) and 0.86 for EDWT (95% confidence interval 0.80 to 0.93, p <0.001 vs unenhanced myocardial rim) for the prediction of viability as assessed by FDG-PET. Cutoffs of 5.4 mm for EDWT and 3.0 mm for unenhanced myocardial rim were found to optimally differentiate viability by FDG-PET. In 25 segments with divergent results, 94% of segments with an EDWT ≤5.4 mm and an unenhanced myocardial rim >3.0 mm were scored as viable by FDG-PET, whereas 57% of segments with an EDWT >5.4 mm and an unenhanced myocardial rim ≤3.0 mm were scored nonviable with the reference technique. In conclusion, unenhanced myocardial rim is superior to EDWT for the prediction of myocardial viability as determined by FDG-PET and may be clinically useful for assessment of myocardial viability in patients with ischemic cardiomyopathy and regional wall thinning.

Section snippets

Patients

Twenty-two patients with long-term ischemic heart disease, decreased left ventricular function (mean ejection fraction 31 ± 11%), and clinical indication for assessment of myocardial viability underwent CE-CMR imaging and FDG-PET. The patient population has been described in detail previously.⁹ Each patient gave informed consent and the study was approved by the institutional ethics committee.

Magnetic resonance imaging

Images were acquired on a 1.5-T whole body scanner (Magnetom Sonata, Siemens, Erlangen, Germany), with

Results

A total of 146 segments showed severe dysfunction (wall motion score ≥3) by cine CMR imaging. Of these, 112 segments (77%) were viable and 34 (23%) were nonviable by FDG-PET. Viable segments by FDG-PET showed a larger EDWT (6.6 ± 1.8 mm) and a larger unenhanced myocardial rim (5.7 ± 2.5 mm) compared with nonviable segments (EDWT 4.5 ± 0.9 mm and unenhanced myocardial rim 1.3 ± 1.2 mm, p <0.0001 for the EDWT and unenhanced myocardial rim vs viable segments). FDG uptake by PET was related to

Discussion

The results of this study demonstrate that unenhanced myocardial rim is superior to EDWT for the prediction of myocardial viability as assessed by FDG-PET. Although a EDWT ≤5.4 mm has previously been suggested to represent nonviable tissue,1, 2 our findings demonstrate that a thinner EDWT does not exclude myocardial viability as defined by FDG-PET.

In the present study, we found a threshold of EDWT of 5.4 mm to optimally discriminate viable from nonviable segments as defined by FDG-PET. This

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Cited by (18)

The role of Cardiovascular Magnetic Resonance in Interventional Cardiology
2022, Annales de Cardiologie et d'Angeiologie
L'imagerie par résonance magnétique cardiovasculaire est devenue une aide précieuse pour le cardiologue interventionnel à la fois dans l'exploration et pour guider le traitement de la maladie coronaire, mais également pour l'exploration de certaines pathologies cardiaques structurelles. Les principales séquences utilisées sont standardisées, acquises lors d'apnées courtes le plus souvent, et comprennent le mode ciné (steady-state free precession), l'imagerie de perfusion dynamique du myocarde lors de l'injection d'un agent de contraste, puis l'imagerie de rehaussement tardif pour la mise en évidence des substrats. Des examens de moins de 30 minutes sont désormais réalisables en routine dans la plupart des indications. Plus récemment, les cartographies paramétriques du T1 et du T2 du myocarde sont prometteuses pour une analyse fine de la caractérisation tissulaire du myocarde (œdème, séquelle fibreuse macroscopique, fibrose interstitielle diffuse). Les aspects techniques ne sont volontairement pas abordés afin de se concentrer sur les applications cliniques.
Cardiovascular magnetic resonance has emerged as a very helpful tool for the interventional cardiologists not only in the assessment and treatment of coronary artery disease, but also in the evaluation of various structural cardiac diseases. The main pulse sequences are standardised, acquired during short breath-holds, and include steady-state free precession cines, dynamic myocardial first-pass perfusion imaging during contrast injection, and late enhancement imaging for the identification of myocardial substrates. Less than 30-minute CMR studies are now available for the most common clinical indications. More recently, T1 and T2 parametric myocardial maps are promising for detailed myocardial tissue characterisation (edema, replacement fibrosis, diffuse interstitial fibrosis). Technical aspects will not be addressed with particular emphasis on clinical applications.
Contractile reserve in segments with nontransmural infarction in chronic dysfunctional myocardium using low-dose dobutamine CMR
2010, JACC: Cardiovascular Imaging
Citation Excerpt :
EDWT was divided into 3 groups; <6 mm (6), 6 to 8 mm, and >8 mm. The thickness of the unenhanced rim (Fig. 1) was defined as the mean wall thickness of the nonenhanced area of a segment and was also divided into 3 groups; <3 mm (13), 3 to 6 mm, and >6 mm. Segmental wall thickening of only the unenhanced rim (SWTUR) was measured quantitatively in segments with an intermediate TEI (between 25% and 75%) and divided into 2 groups: dysfunctional (SWTUR: <45%) and normokinetic (SWTUR: >45%).
This study sought to quantify contractile reserve of chronic dysfunctional myocardium, in particular in segments with intermediate transmural extent of infarction (TEI), using low-dose dobutamine cardiac magnetic resonance (CMR) in patients with a chronic total coronary occlusion (CTO).
Recovery of dysfunctional segments with intermediate TEI after percutaneous coronary intervention is variable and difficult to predict, and may be related to contractility of the unenhanced rim.
Fifty-one patients (mean age 60 ± 9 years, 76% male) with a CTO underwent CMR at baseline and 35 patients underwent CMR at follow-up to quantify segmental wall thickening (SWT) at rest during 5 and 10 μg/kg/min dobutamine, and at follow-up. Delayed-enhancement CMR was performed to quantify TEI. Dysfunctional segments were stratified according to TEI, end-diastolic wall thickness (EDWT), or unenhanced rim thickness, and SWT was quantified. Segments with an intermediate TEI (25% to 75%) were further stratified according to baseline SWT of the unenhanced rim (SWT_UR) (<45% and >45%), and SWT was quantified. For each parameter, odds ratio (OR) and diagnostic performance for the prediction of contractile reserve were calculated.
Significant contractile reserve was present in dysfunctional segments with EDWT >6 mm, unenhanced rim thickness >3 mm, or TEI of <25%; only TEI had significant relation with contractile reserve (OR: 0.98; 95% confidence interval [CI]: 0.96 to 0.99; p = 0.02). In segments with intermediate TEI (n = 58), mean SWT did not improve significantly. However, segments with SWT_UR <45% showed contractile reserve and improved at follow-up, whereas segments with SWT_UR >45% were unchanged. SWT_UR had a significant relation with contractile reserve (OR: 0.98; 95% CI: 0.97 to 0.99; p = 0.02).
CMR quantification of transmurality of infarcted myocardium allows the assessment of the potential of dysfunctional segments to improve in function during dobutamine of most segments. However, in segments with intermediate TEI, measurement of baseline contractility of the epicardial rim better identifies which segments maintain contractile reserve.
Analysis of the number of patients needed to treat by coronary revascularisation in relation to the presence of myocardial viability in gated SPECT images: a prospective cohort study from a nuclear cardiology unit
2009, Revista Espanola de Medicina Nuclear
Evaluar el número de sujetos que es necesario tratar (NNT) mediante revascularización coronaria (RC) para obtener 1 supervivencia, en relación con la presencia o ausencia de viabilidad miocárdica en las imágenes de la gated-SPECT (tomografía computarizada por emisión de fotón único, del inglés single photon emission computed tomography) de perfusión miocárdica, de pacientes con miocardiopatía de origen isquémico (MOI).
Se estudiaron consecutivamente 198 pacientes con MOI mediante gated-SPECT de reposo con compuestos tecneciados. Se analizó la mortalidad cardíaca en 4 grupos: viables con RC (n = 50); no viables con tratamiento médico (TM) (n = 90); no viables con RC (n = 18), y no viables con TM (n = 40).
Durante un seguimiento medio de 2,3 años la mortalidad cardíaca en los pacientes con criterios gammagráficos de viabilidad miocárdica revascularizados fue de 5,9/100 pacientes/año y en los que continuaron con TM 12,9/100 pacientes/año. En los pacientes sin criterios de viabilidad revascularizados la mortalidad cardíaca fue de 6,2/100 pacientes/año y en los que recibieron TM 1,9/100 pacientes/año. En los pacientes con criterios de viabilidad el NNT fue de 4 y en los pacientes sin viabilidad miocárdica fue de 24.
El NNT mediante RC para obtener 1 supervivencia en los pacientes con criterios gammagráficos de viabilidad fue 6 veces menor con respecto a los pacientes sin criterios de viabilidad, con un menor coste y mortalidad.
To evaluate the number of patients needed to treat (NNT) to assess the magnitude of benefit of coronary revascularisation (CR) in patients with ischaemic cardiomyopathy (IC) in relation to the presence or absence of myocardial viability in myocardial perfusion gated-SPECT (single photon emission computed tomography) images.
We studied 198 consecutive patients with IC using rest gated-SPECT with technetium-based agents. The cardiac mortality was analysed in four groups: viable with CR (n = 50), viable with medical treatment (MT) (n = 90), non-viable with CR (n = 18), and non-viable with medical treatment (n = 40).
During 2.3 ± 1.2 years of follow-up, the cardiac mortality rate in patients with scintigraphic viability criteria undergoing revascularisation was 5.9/100 patients/year and 12.9/100 patients/year in those who received medical treatment. In patients without viability who underwent revascularisation, the cardiac mortality rate was 6.2/100 patients/year and in those who received MT it was 1.9/100 patients/year. In patients with myocardial viability the NNT was 4, while in patients without myocardial viability, the NNT was 24.
In patients with scintigraphic viability criteria, the NNT to obtain one survival with CR was 6 times lower with respect to patients without viability, with lower cost and mortality.
Chronic Ischemic Left Ventricular Dysfunction. From Pathophysiology to Imaging and its Integration Into Clinical Practice
2008, JACC: Cardiovascular Imaging
Citation Excerpt :
Infarct mass correlated well between the 2 modalities (r = 0.81, p < 0.0001), but LGE more frequently identified subendocardial scarring than PET did, again reflecting its superior spatial resolution. In fact, when the transmural extent of scarring is <37%, PET defines the segment as viable due to the presence of sufficient signal from remaining viable mid-wall and subepicardium (40). When a scar is >37% transmural, PET defines the segment as nonviable.
Chronic ischemic left ventricular dysfunction is present in a number of clinical syndromes in which myocardial revascularization results in an improvement of left ventricular function, patients' functional class, and their survival. Early diagnosis of and treatment of viability is essential. Coronary arteriography is of limited value in diagnosis of viability. Noninvasive testing is essential for diagnosis, which can be matched to the pathophysiologic changes that occur in hibernating myocardium. However, no single test has a perfect, or near perfect, sensitivity and specificity, and thus, a combination of tests are usually needed. Algorithms are developed to integrate these tests in clinical decision making.
MRI of myocardial ischemia: Indications and protocols
2007, Feuillets de Radiologie
Les maladies cardiovasculaires représentent la première cause de décès dans les pays industrialisés. L’IRM cardiaque est capable d’étudier la cinétique de contraction myocardique globale ou segmentaire, d’apprécier la viabilité myocardique après injection de gadolinium et de rechercher des zones d’ischémies myocardiques en utilisant des agents pharmacologiques. L’infarctus récent se présente sous la forme d’une zone myocardique dysfonctionnelle associée à une prise de contraste myocardique d’extension transmurale variable dont l’importance est inversement corrélée aux chances de récupération de la zone nécrosée. Des dégâts microvasculaires (no-reflow) de pronostic péjoratif peuvent être authentifiés dans les semaines suivant la réouverture de l’artère. Plus tardivement, l’étude du remodelage ventriculaire et de ses complications comme un anévrysme ventriculaire sont possibles en IRM. La détection d’une ischémie myocardique est le plus souvent effectuée en couplant une séquence dynamique de perfusion à l’injection d’un agent vasodilatateur (adénosine ou dypiridamole). Elle traduit une chute de la réserve coronaire dans le territoire ischémique. Une étude de la réserve contractile segmentaire est possible en associant une perfusion de dobutamine à dose croissante à la réalisation de séquences dynamiques sur le myocarde. L’apparition ou l’amélioration de l’activité contractile d’un segment est prédictive de sa récupération après revascularisation. L’IRM est enfin un outil efficace dans la recherche des diagnostics différentiels comme les myocardites ou les maladies systémiques.
Ischemic heart disease is the primary cause of mortality in industrialized countries. Cardiac MRI can analyze global and regional myocardial function, can demonstrate the presence of underlying myocardial infarction and can demonstrate the presence of myocardial ischemia via the infusion of vasodilatator drugs. Myocardial infarction MRI features associate wall-motion abnormalities and myocardial late enhancement whose extension is predictive of functional recovery after revascularization. Microcirculatory damage (no-reflow) may be also detected on first-pass images and 10 minutes after injection. Their presence is correlated with the appearance of negative events in the following months. MRI study of ventricular remodeling and its complications such as ventricular wall aneurysm is also reliable. Identification of and ischemic cardiac area requires a first-pass perfusion MR sequence and vasodilatator drugs infusion such as adenosine or dypiridamole. The principle of vasodilatator stress is based on a reduction of coronary blood flow in the ischemic area during maximal vasodilatation, and not at rest, because of a flow competition with non ischemic areas. Assessment of myocardial viability may be also performed using low-dose dobutamine infusion and cine MR sequences. Improvement of contraction of a dysfunctional segment on cine MR during low-dose infusion dobutamine is predictive of a functional recovery after revascularization. Lastly, MRI can evidence differential diagnosis such as myocarditis or systemic diseases.
Viability Imaging
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: This work was supported by Grant 2001.158 from the Netherlands Heart Foundation, The Hague, The Netherlands. Dr. Kühl was supported in part by grants from the Faculty of Medicine of the Rheinisch-Westfälische Technische Hochschule, Aachen and by the Grimmke-Stiftung, Düsseldorf, Germany.

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Coronary artery diseaseRelation of End-Diastolic Wall Thickness and the Residual Rim of Viable Myocardium by Magnetic Resonance Imaging to Myocardial Viability Assessed by Fluorine-18 Deoxyglucose Positron Emission Tomography

Section snippets

Patients

Magnetic resonance imaging

Results

Discussion

Lancet

J Am Coll Cardiol

Lancet

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Chronic myocardial infarctionassessment of morphology, function, and perfusion by gradient echo magnetic resonance imaging and 99mTc-methoxyisobutyl-isonitrile SPECT

Am Heart J

Coronary artery disease
Relation of End-Diastolic Wall Thickness and the Residual Rim of Viable Myocardium by Magnetic Resonance Imaging to Myocardial Viability Assessed by Fluorine-18 Deoxyglucose Positron Emission Tomography