Detection of pericardial effusion during Tc-99m sestamibi cardiac imaging

NUCLEAR CARDIOLOGY BULLET Detection of pericardial effusion during Tc-99m sestamibi cardiac imaging Amar D. Patel, MD, Wael S. Abo-Auda, MD, Himanshu Gupta, MD, and Ami E. Iskandrian, MD, FACC, FAHA Case history. A 52-year-old man with chronic renal insufficiency, insulin-dependent diabetes mellitus, and hypertension was referred for preoperative evaluation for kidney-pancreas transplantation. His most recent creatinine level was 10.0, and he was scheduled to start hemodialysis. He complained of nausea, vomiting, lower-extremity edema, and dyspnea on exertion. Physical examination findings were unremarkable except for a trace pedal edema. Clinical dilemma. The history and physical examination may not reveal myocardial ischemia. As a result, diabetic patients undergo stress myocardial perfusion imaging before transplant surgery. Imaging and intervention. The patient underwent adenosine technetium 99m sestamibi single photon emission computed tomography (SPECT) perfusion imaging. Raw planar projection rest images demonstrated a large photopenic “halo” of diminished tracer concentration surrounding the heart (Figure 1). The SPECT perfusion images revealed defects suggestive of 3-vessel ischemia (Figure 2). The gated SPECT images demonstrated a left ventricular ejection fraction of 26% in the poststress images and 38% at rest, consistent with resting left ventricular dysfunction and poststress stunning. The dynamic cine display of the 3-dimensional gated images showed a rocking motion of the heart, with a maximum swing of 22° along the long axis of the left ventricle (Figure 3). A subsequent 2-dimensional echocardiogram revealed a large pericardial effusion with a maximum depth of 50 mm. Because of extensive myocardial ischemia by SPECT imaging, diagnostic cardiac catheterization was performed. Hemodynamic assessment did not suggest tamponade physiology, and coronary angiography revealed severe 3-vessel coronary artery disease. From the Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Ala. Reprint requests: Ami E. Iskandrian, MD, Distinguished Professor of Medicine and Radiology, 318 LHRB, 1900 University Blvd, Birmingham, AL 35294-0006; [email protected]. J Nucl Cardiol 2003;10:102-4. Copyright © 2003 by the American Society of Nuclear Cardiology. 1071-3581/2003/$30.00 ⫹ 0 doi:10.1067/mnc.2003.31

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Coronary artery bypass grafting surgery was performed with 1100 mL of clear pericardial fluid drained during the procedure. The patient’s postoperative course was unremarkable, with a follow-up resting Tc-99m sestamibi study that did not reveal evidence of a pericardial effusion or a rocking motion of the heart (Figures 1 and 3). Discussion. Diagnosis of a pericardial effusion with the use of radionuclide perfusion techniques is uncommon.1-3 However, detection of a pericardial effusion from gated equilibrium radionuclide angiography with Tc-99m pertechnate has been reported and, in fact, was one of the earliest uses of nuclear imaging in cardiac diseases before echocardiography.4 SPECT evidence of a pericardial effusion is suggested by a photopenic halo around the heart. The halo is produced by a lack of tracer uptake in the pericardial fluid. Furthermore, the rocking motion of the heart, as assessed by gated SPECT images, is suggestive of a rather large pericardial effusion. Although echocardiography remains the standard diagnostic imaging method for detection of pericardial effusion, knowledge of the radionuclide findings of pericardial effusion is important in order to establish the diagnosis and initiate appropriate workup. Acknowledgment The authors have indicated they have no financial conflicts of interest.

References 1. Herzog E, Krasnow N, DePuey G. Diagnosis of pericardial effusion and its effects on ventricular function using gated Tc-99m sestamibi perfusion SPECT. Clin Nucl Med 1998;23:361-4. 2. Fojaja MRG, Klain M, Cardei S, Gisonni P, Cuocolo A. Detection of pericardial effusion during Tc-99m MIBI parathyroid imaging in a patient with chronic renal failure. Clin Nucl Med 1996;21:496-7. 3. Cesani F, Tee H, Esquivel-Avila J, Villanueva-Meyer J. Pericardial effusion in primary hypothyroidism Tc-99m sestamibi imaging. Clin Nucl Med 1995;20:457-8. 4. Iskandrian AE, Verani MS, editors. Nuclear cardiac imaging: principles and applications. 2nd ed. Philadelphia: FA Davis; 1996.

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Patel et al Detection of pericardial effusion

Figure 1. Raw planar projection rest images showing large photopenic “halo” around heart preoperatively (left), suggestive of pericardial effusion, and its resolution postoperatively (right). AP, Anteroposterior views; LAO, left anterior oblique views.

Figure 2. Adenosine Tc-99m sestamibi perfusion SPECT perfusion images. Note the perfusion defect pattern suggestive of 3-vessel disease.

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Figure 3. Three-dimensional gated rest images of left ventricle showing rocking motion of heart before cardiac surgery (top). Note how the left ventricular end-systolic silhouette (shaded region) is displaced outside the end-diastolic silhouette (grid region). This abnormality is corrected after surgical intervention (bottom). The left ventricular ejection fraction was 38% before surgery and 28% after surgery. SEP, Septum; LAT, lateral; ANT, anterior; INF, inferior.