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Dual-Isotope Myocardial Perfusion Spect with Rest Thallium-201 and Stress Tc-99m Sestamibi
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NUCLEAR CARDIOLOGY
DUAL-ISOTOPE MYOCARDIAL PERFUSION SPECT WITH REST THALLIUM-201 AND STRESS Tc-99m SESTAMIBI Daniel S. Berman, MD, Hosen Kiat, MD, Kenneth Van Train, BS, John D. Friedman, MD, Fan Ping Wang, MD, and Guido Germano, PhD
The commercial availability of technetium99m (Tc-99m)-labeled myocardial perfusion agents has added choices in the noninvasive clinical assessment of coronary artery disease. Several studies have suggested that rest/ stress technetium-99m sestamibi single-photon emission computerized tomography (SPECT) has similar sensitivity and specificity to thallium-201 (Tl-201) SPECT for the detection of coronary artery disease. 6• 7• 11 Preferential use of Tc-99m sestamibi has been advocated principally due to improved image quality, which results from the combined physical and biologic characteristics of this agent. 3• 4 Rest/ stress Tc-99m sestamibi studies, however, which require two injections using either same-day or two-day protocols, have drawbacks. Two-day protocols are not ideal for patients because of the requirement for two visits to the imaging laboratory. Sameday rest/stress protocols are more convenient but involve the superimposition of a resting perfusion pattern on a stress SPECT pattern, thereby potentially reducing defect contrast. Also, same-day rest/ stress studies lack ideal
efficiency because a 1-hour delay is needed after rest injection before imaging to allow for hepatobiliary clearance. With respect to the assessment of myocardial viability, rest/ stress sestamibi imaging has theoretical constraints in separating hibernating myocardium from infarction that do not apply to Tl-201 due to the redistribution properties of Tl-201 and the option of obtaining redistribution images. Given these limitations of standard sestamibi protocols, our group decided to investigate another approach for Tc-99m sestamibi SPECT- dual-isotope rest-stress myocardial perfusion SPECT, which takes advantage of the Anger camera's ability to collect data in different energy windows. For the dual-isotope approach, separate radiopharmaceuticals are employed for the rest injection and the stress injection.
PROTOCOLS The two fundamental types of procedures are simultaneous5· 10 or separate acquisition dual-isotope SPECT.2 With either approach, because two radiopharmaceuticals are util-
From the Division of Nuclear Medicine, Department of Imaging (DSB, HK, JDF), and the Division of Cardiology, Department of Medicine (HK, FPW, JDF), Department of Medical Physics (KVT, GG), and Department of Nuclear Cardiology (DSB), Cedars-Sinai Medical Center; and the University of California School of Medicine (HK, JDF, GG, DSB), Los Angeles, California
CARDIOLOGY CLINICS VOLUME 12 •NUMBER 2 •MAY 1994
261
270
BERMAN et al
Tc-99m sestamibi SPECT when combined assessment of stress myocardial perfusion and myocardial viability is desired.
References 1. Areeda J, Van Train K, Kiat H, et al: Quantitative assessment of reversibility for rest Tl-201-stress Tc99m sestamibi separate acquisition dual-isotope myocardial perfusion SPECT: Develoment and prospective validation. J Nucl Med 34:64P, 1993 2. Berman D, Kiat H, Friedman JD, et al: Separate acquisition rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion SPECT: A clinical validation study. J Am Coll Cardiol 22:1455-1464, 1993 3. Berman DS, Kiat H, Maddahi J: The new 99m-Tc myocardial perfusion imaging agents: 99m-Tc sestamibi and 99m-Tc teboroxime. Circulation 84:17-21, 1991 4. Berman DS, Kiat H, Van Train K, et al: Tc-99m sestamibi imaging in the assessment of chronic coronary artery disease. Semin Nucl Med 21:190-212, 1991 5. Friedman J, Van Train K, Kiat H, et al: Simultaneous dual-isotope rest/stress myocardial perfusion scintigraphy: A feasibility study. J Am Coll Cardiol 17:390A, 1991 6. Iskandrian AS, Heo J, Kong B, et al: Use of technetium-99m isonitrile (RP-30A) in assessing left ventricular perfusion and function at rest and during exercise in coronary artery disease, and comparison with coronary arteriography and exercise thallium201 SPECT imaging. Am J Cardiol 64:270-275, 1989 7. Kahn J, McGhie I, Akers M, et al: Quantitative rotational tomography with Tl-201 and Tc-99m 2-methoxy-isobutyl-isonitrile: A direct comparison in normal individuals and patients with coronary artery disease. Circulation 79:1282-1293, 1989 8. Kiat H, Areeda J, Van Train K, et al: Quantitative assessment of stress defect extent and reversibility on rest Tl-201/stress Tc-99m sestamibi dual-isotope myocardial perfusion SPECT: A prospective validation [abstract]. Circulation 88:I-440, 1993 9. Kiat H, Biasio Y, Wong FP, et al: Frequency of reversible resting hypoperfusion in patients undergoing rest Tl-201/stress Tc-sestamibi separate acquisition dual-isotope myocardial perfusion SPECT. J Am Coll Cardiol 21:222A, 1993
10. Kiat H, Friedman JD, German G, et al: Comparative feasibility of separate or simultaneous rest thallium201-stress technetium-99m sestamibi dual isotope myocardial perfusion SPECT. J Nucl Med, April 1994, in press 11. Kiat H, Van Train K, Maddahi J, et al: Development and prospective application of quantitative 2-day stress-rest Tc-99m methoxy isobutyl isonitrile SPECT for the diagnosis of coronary artery disease. Am Heart J 120:1255-1266, 1990 12. Maddahi J, Rodrigues E, Berman DS: Assessment of myocardial perfusion by single-photon agents. In Pohost GM, O'Rourke RA (eds): Principles and Practices of Cardiovascular Imaging. Boston, Little, Brown, 1991, pp 179-219 12a. Marzullo P, Parodi 0, Reisenhofer B, et al: Value of rest thallium-201-technetium-99m sestamibi scans and dobutamine echocardiography for detecting myocardial viability. Am J Cardiol 71:166-172, 1993 13. Matzer L, Kiat H, Friedman J, et al: Separate acquisition dual-isotope myocardial perfusion SPECT using pharmacologic stress. J Am Coll Cardiol 19:127A, 1992 14. Rozanski A, Berman DS: The efficacy of cardiovascular nuclear medicine exercise studies. Semin Nucl Med 17:104-120, 1987 15. Rozanski A, Diamond GA, Berman DS, et al: The declining specificity of exercise radionuclide ventriculography. N Engl J Med 309:518-522, 1983 16. Smith WH, Watson DD: Technical aspects of myocardial planar imaging with technetium-99m sestamibi. Am J Cardiol 66:16E-22E, 1990 17. Taillefer R, Primeau M, Costi P, et al: Technetium99m sestamibi myocardial perfusion imaging in detection of coronary artery disease: Comparison between initial (1-hour) and delayed (3-hour) postexercise images. J Nucl Med 32:1961- 1965, 1991 18. Van Train K, Areeda J, Garcia E, et al: Quantitation of same-day Tc-99m sestamibi myocardial SPECT: Multicenter trial validation [abstract]. J Nucl Med 33:876, 1992 19. Van Train K, Areeda J, Garcia E, et al: Quantitative same-day rest-stress Tc-99m sestamibi SPECT: Definition and validation of normal limits and criteria for abnormality. J Nucl Med 34:1494-1502, 1993 20. Van Train K, Maddahi J, Berman DS, et al: Quantitative analysis of tomographic stress thallium-201 myocardial scintigrams: A multicenter trial. J Nucl Med 31:1168-1179, 1990 21. Watson DD, Smith WH, Glover DK, et al: Dualisotope SPECT imaging of Tc-99m sestamibi and Tl201: Comparing myocardial defect magnitudes. Circulation 84:II-314, 1991
Address Reprint Requests to Daniel S. Berman, MD Co-Chairman, Department of Imaging Cedars-Sinai Medical Center 8700 Beverly Blvd. Los Angeles, CA 90048
NUCLEAR CARDIOLOGY
DUAL-ISOTOPE MYOCARDIAL PERFUSION SPECT WITH REST THALLIUM-201 AND STRESS Tc-99m SESTAMIBI Daniel S. Berman, MD, Hosen Kiat, MD, Kenneth Van Train, BS, John D. Friedman, MD, Fan Ping Wang, MD, and Guido Germano, PhD
The commercial availability of technetium99m (Tc-99m)-labeled myocardial perfusion agents has added choices in the noninvasive clinical assessment of coronary artery disease. Several studies have suggested that rest/ stress technetium-99m sestamibi single-photon emission computerized tomography (SPECT) has similar sensitivity and specificity to thallium-201 (Tl-201) SPECT for the detection of coronary artery disease. 6• 7• 11 Preferential use of Tc-99m sestamibi has been advocated principally due to improved image quality, which results from the combined physical and biologic characteristics of this agent. 3• 4 Rest/ stress Tc-99m sestamibi studies, however, which require two injections using either same-day or two-day protocols, have drawbacks. Two-day protocols are not ideal for patients because of the requirement for two visits to the imaging laboratory. Sameday rest/stress protocols are more convenient but involve the superimposition of a resting perfusion pattern on a stress SPECT pattern, thereby potentially reducing defect contrast. Also, same-day rest/ stress studies lack ideal
efficiency because a 1-hour delay is needed after rest injection before imaging to allow for hepatobiliary clearance. With respect to the assessment of myocardial viability, rest/ stress sestamibi imaging has theoretical constraints in separating hibernating myocardium from infarction that do not apply to Tl-201 due to the redistribution properties of Tl-201 and the option of obtaining redistribution images. Given these limitations of standard sestamibi protocols, our group decided to investigate another approach for Tc-99m sestamibi SPECT- dual-isotope rest-stress myocardial perfusion SPECT, which takes advantage of the Anger camera's ability to collect data in different energy windows. For the dual-isotope approach, separate radiopharmaceuticals are employed for the rest injection and the stress injection.
PROTOCOLS The two fundamental types of procedures are simultaneous5· 10 or separate acquisition dual-isotope SPECT.2 With either approach, because two radiopharmaceuticals are util-
From the Division of Nuclear Medicine, Department of Imaging (DSB, HK, JDF), and the Division of Cardiology, Department of Medicine (HK, FPW, JDF), Department of Medical Physics (KVT, GG), and Department of Nuclear Cardiology (DSB), Cedars-Sinai Medical Center; and the University of California School of Medicine (HK, JDF, GG, DSB), Los Angeles, California
CARDIOLOGY CLINICS VOLUME 12 •NUMBER 2 •MAY 1994
261
270
BERMAN et al
Tc-99m sestamibi SPECT when combined assessment of stress myocardial perfusion and myocardial viability is desired.
References 1. Areeda J, Van Train K, Kiat H, et al: Quantitative assessment of reversibility for rest Tl-201-stress Tc99m sestamibi separate acquisition dual-isotope myocardial perfusion SPECT: Develoment and prospective validation. J Nucl Med 34:64P, 1993 2. Berman D, Kiat H, Friedman JD, et al: Separate acquisition rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion SPECT: A clinical validation study. J Am Coll Cardiol 22:1455-1464, 1993 3. Berman DS, Kiat H, Maddahi J: The new 99m-Tc myocardial perfusion imaging agents: 99m-Tc sestamibi and 99m-Tc teboroxime. Circulation 84:17-21, 1991 4. Berman DS, Kiat H, Van Train K, et al: Tc-99m sestamibi imaging in the assessment of chronic coronary artery disease. Semin Nucl Med 21:190-212, 1991 5. Friedman J, Van Train K, Kiat H, et al: Simultaneous dual-isotope rest/stress myocardial perfusion scintigraphy: A feasibility study. J Am Coll Cardiol 17:390A, 1991 6. Iskandrian AS, Heo J, Kong B, et al: Use of technetium-99m isonitrile (RP-30A) in assessing left ventricular perfusion and function at rest and during exercise in coronary artery disease, and comparison with coronary arteriography and exercise thallium201 SPECT imaging. Am J Cardiol 64:270-275, 1989 7. Kahn J, McGhie I, Akers M, et al: Quantitative rotational tomography with Tl-201 and Tc-99m 2-methoxy-isobutyl-isonitrile: A direct comparison in normal individuals and patients with coronary artery disease. Circulation 79:1282-1293, 1989 8. Kiat H, Areeda J, Van Train K, et al: Quantitative assessment of stress defect extent and reversibility on rest Tl-201/stress Tc-99m sestamibi dual-isotope myocardial perfusion SPECT: A prospective validation [abstract]. Circulation 88:I-440, 1993 9. Kiat H, Biasio Y, Wong FP, et al: Frequency of reversible resting hypoperfusion in patients undergoing rest Tl-201/stress Tc-sestamibi separate acquisition dual-isotope myocardial perfusion SPECT. J Am Coll Cardiol 21:222A, 1993
10. Kiat H, Friedman JD, German G, et al: Comparative feasibility of separate or simultaneous rest thallium201-stress technetium-99m sestamibi dual isotope myocardial perfusion SPECT. J Nucl Med, April 1994, in press 11. Kiat H, Van Train K, Maddahi J, et al: Development and prospective application of quantitative 2-day stress-rest Tc-99m methoxy isobutyl isonitrile SPECT for the diagnosis of coronary artery disease. Am Heart J 120:1255-1266, 1990 12. Maddahi J, Rodrigues E, Berman DS: Assessment of myocardial perfusion by single-photon agents. In Pohost GM, O'Rourke RA (eds): Principles and Practices of Cardiovascular Imaging. Boston, Little, Brown, 1991, pp 179-219 12a. Marzullo P, Parodi 0, Reisenhofer B, et al: Value of rest thallium-201-technetium-99m sestamibi scans and dobutamine echocardiography for detecting myocardial viability. Am J Cardiol 71:166-172, 1993 13. Matzer L, Kiat H, Friedman J, et al: Separate acquisition dual-isotope myocardial perfusion SPECT using pharmacologic stress. J Am Coll Cardiol 19:127A, 1992 14. Rozanski A, Berman DS: The efficacy of cardiovascular nuclear medicine exercise studies. Semin Nucl Med 17:104-120, 1987 15. Rozanski A, Diamond GA, Berman DS, et al: The declining specificity of exercise radionuclide ventriculography. N Engl J Med 309:518-522, 1983 16. Smith WH, Watson DD: Technical aspects of myocardial planar imaging with technetium-99m sestamibi. Am J Cardiol 66:16E-22E, 1990 17. Taillefer R, Primeau M, Costi P, et al: Technetium99m sestamibi myocardial perfusion imaging in detection of coronary artery disease: Comparison between initial (1-hour) and delayed (3-hour) postexercise images. J Nucl Med 32:1961- 1965, 1991 18. Van Train K, Areeda J, Garcia E, et al: Quantitation of same-day Tc-99m sestamibi myocardial SPECT: Multicenter trial validation [abstract]. J Nucl Med 33:876, 1992 19. Van Train K, Areeda J, Garcia E, et al: Quantitative same-day rest-stress Tc-99m sestamibi SPECT: Definition and validation of normal limits and criteria for abnormality. J Nucl Med 34:1494-1502, 1993 20. Van Train K, Maddahi J, Berman DS, et al: Quantitative analysis of tomographic stress thallium-201 myocardial scintigrams: A multicenter trial. J Nucl Med 31:1168-1179, 1990 21. Watson DD, Smith WH, Glover DK, et al: Dualisotope SPECT imaging of Tc-99m sestamibi and Tl201: Comparing myocardial defect magnitudes. Circulation 84:II-314, 1991
Address Reprint Requests to Daniel S. Berman, MD Co-Chairman, Department of Imaging Cedars-Sinai Medical Center 8700 Beverly Blvd. Los Angeles, CA 90048