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Percutaneous myocardial laser revascularisation-scintigraphic and echocardiographic assessment of the results
Journal of Nuclear Cardiology Volume 12, Number 2
Abstracts Monday, May 9, 2005
S31
5.45
5.47
Initial experience in Mexico of 18-FDG PET compared with thallium SPECT in the assessment of myocardial viability. E. Erick Alexanderson1, A. Meave2, A. Ricalde.2 1Instituto Nacional de Cardiologia/ UNAM, Nuclear Cardiology and PET-Cyclotron, Mexico City, Mexico, 2UNAM, PET-Cyclotron Unit, Mexico City, Mexico
Myocardial perfusion Tc99m MIBI SPECT and multislice computed tomography (MSCT) in the assessment of the results of chronic total coronary occlusion (CTO) angioplasty. M. Magdalena Kostkiewicz1, P. Wilkolek2, M. Pasowicz2, P. Klimeczek3, P. Pieniazek2, T. Przewlocki2, M. Pieculewicz2, W. Tracz.2 1Institute of Cardiology, Dept. of Nuclear Medicine, Krakow, Poland, 2Institute of Cardiology, Dept of Cardiovascular Diseases, Krakow, Poland, 3Of Heart and Lung Institute, Centre for Diagnosis, Krakow, Poland
In patients with myocardial infarction and left ventricular dysfunction, the evidence of myocardial viability is primordial. There are some methods to detect the presence of myocardial viability, 201-thallium reinjection SPECT protocol represents the most common radioisotopic technique to evaluate it. Positron emission tomography (PET) using FDG is considered the gold standard. Objective: The aim of this study was to compare globally and by segments the value of both techniques in the detection of viable myocardium. Methods: Twenty-six consecutive patients with previous myocardial infarction and left ventricular dysfunction were studied. All of them underwent into a SPECT perfusion scan and a FDG PET study to asses myocardial viability. Each study was performed in less than one week between the other. For the analysis, the myocardium was divided into 17 segments. A visual semi-quantitative analysis was carried out according to the following score indicating radiotracer uptake: O⫽normal to 4⫽absent. Myocardial viability was defined as the presence of normal, mildly or moderately reduced radiotracer uptake. The scores obtained by PET were compared to those obtained in SPECT. A T Student and Chi square tests were used for the quantitative and qualitative variables respectively, statistical analysis was performed using the SPSS v. 10 program. Results: 442 segments were analyzed. PET detected viability in 134 segments that had been defined as non-viable by SPECT. No differences in the analysis by vascular territories were found. Thirty percent of the segments that were defined as non viable by SPECT were viable by PET, meanwhile only 1% of the segments detected viable by SPECT were considered non viable with PET. (Table 1) Conclusions: FDG PET study represents a better technique to detect myocardial viability, compared to thallium reinjection SPECT protocol. By this study we have demonstrated that 3 of each 10 studies may be diagnosed as non viable where viability is present.
Restenosis assessment in patients after CTO recanalization is often difficult due to frequent, well developed collateral circulation and scar in the area of myocardial infarction. The aim of the is to evaluate the role of MIBI SPECT and MSCT in assessment of restenosis after successfully recanalized and stented CTO. 44 patients underwent successful PCI and stent implantation of CTO 29 (72.5%) patients had myocardial infarction in the occluded artery area. In 16 (40%) patients-left anterior descending (LAD), 8 (20%)-circumflex (Cx) and 16 (40%)-right coronary artery (RCA) were recanalized. MIBI SPECT revealed reversible perfusion defect in all patients before recanalization. MIBI SPECT and MSCT of coronary arteries at 6 and 12 months were done. Patients free from symptoms and with negative results of exercise test, MIBI SPECT and MSCT were assumed non-restenotic. Results of SPECT and MSCT were compared to angiographic ones Results: Mean follow-up time was 19⫾9.9 (3-42) months. Restenosis was detected in 16 patients, but in 2-neither scintigraphy, nor MSCT was performed. Positive MIBI SPECT was observed in 11 (78.6%), and MSCT in 9 (64.3%). In 2 (14.2%) Sensitivity, positive and negative predictive values were 78.6%, 78.6% and 62.5%MIBI SPECT, respectively, whereas MSCT showed sensitivity of 64.3%, positive predictive value of 81.8% and negative predictive value of 50.0%. Conclusions: Restenosis rate accounted for 40%. Both MIBI SPECT and MSCT facilitated detection of restenosis, although SPECT showed higher sensitivity and negative predictive value, as compared to MSCT.
PET vs SPECT in Myocardial Viability
SPECT
Viable Non Viable
PET Viable
Non Viable
252 (57%) 135 (30%)
5 (1.13%) 50 (11.3%)
5.46
5.48
Cardiac denervation early after transmyocardial CO2-laser revascularisation in I-123-MIBG planar and SPECT studies. A. Anna Teresinska1, M. Sliwinski2, S. Konieczna1, M. Szymanska2, P. Hendzel2, Z. Juraszynski2, A. Debski3, B. Szumilak.1 1National Institute of Cardiology, Nuclear Medicine, Warsaw, Poland, 2National Institute of Cardiology, Ist Clinic of Cardiosurgery, Warsaw, Poland, 3National Institute of Cardiology, Ist Clinic of Coronary Artery Disease, Warsaw, Poland
Percutaneous myocardial laser revascularisation-scintigraphic and echocardiographic assessment of the results. M. Magdalena Kostkiewicz1, W. Szot2, J. Trebacz3, K. Zmudka3, P. Podolec4, W. Tracz.4 1Institute of Cardiology, Dept. of Nuclear Medicine, Krakow, Poland, 2Of Heart and Lung Institute, Centre for Diagnosis, Krakow, Poland, 3Dept of hemodynamics and angiography, Krakow, Poland, 4Institute of Cardiology, Dept of Cardiovascular Diseases, Krakow, Poland
Aim: to study the range of changes caused by transmyocardial CO2-laser revascularisation [TMLR] in cardiac adrenergic nervous system [SYSTadren]. Material and methods: fourty-seven pts were studied for neuronal activity and integrity with I-123-MIBG planar and SPECT imaging before [MIBG-0] and 7-21 days after cardiac surgery [MIBG-early]. Sole laser revascularisation was performed in 23 pts and laser revascularisation concurrent with 1 bypass was performed in 24 pts. The group characteristics: 37 M (79%); age: 43-76 (av.63)y; LVEF 30-70 (av.53)%; III/IV CCS class. During the surgery, 15-32 (av.23) channels were generated in myocardium. Registration of I-123-MIBG planar images was started 3.5 hrs and of SPECT images was started 4 hrs after injection of the radiopharmaceutical. In planar studies, global activity of SYSTadren was measured by heart/mediastinum index [H/M]. In SPECT studies, regional MIBG uptake was assessed in 17 segments [seg] of the LV; 4-grade intensity scale was applied (0⫽normal uptake, 3⫽severe defect). Summarized MIBG uptake deficiency in SPECT was expressed by summary defect score [SDS]. Results: in total, in MIBG-early, uptake was deteriorated in 42% of seg (95% confidence interval CI⫽38-46%) and was improved only in 10% (CI⫽8-12%). In septal segments non-revascularised by CABG (nor by laser), uptake was deteriorated in 23% of seg (CI⫽16-32%) and was improved in 13% (CI⫽8-21%, NS). In lased segments, uptake was deteriorated in 48% of seg (CI⫽43-53%) and was improved only in 8% (CI⫽6-11%). In bypassed segments (which were also lased, in a part), uptake was deteriorated in 38% of seg (CI⫽30-48%) and was improved in 13% (CI⫽7-20%). In the group of lased pts, SDS has deteriorated from 23⫾6 to 29⫾5 (p⬍0,001) and H/M has decreased from 2.01 to 1.68 (p⬍0.0001). In the group of lased-and-bypassed pts, SDS has deteriorated from 20⫾6 to 25⫾7 (p⬍0.006) and H/M has decreased from 1.77 to 1.61 (p⬍0.003). Significant clinical improvement was observed in evaluated pts. Conclusion: early after TMLR, the integrity and activity of SYSTadren is deteriorated, what can be a mechanism resposible for clinical improvement observed early (⬍ 3 weeks) after TMLR.
Background: Percutaneous myocardial laser revascularisation (PMR) is a novel therapeutic technique aimed at delivering oxygenated blood via a series of channels made by percutaneous approach to the ischemic regions of the heart. In patients with the end stage coronary artery disease PMR is associated with a reduction in symptoms, improved exercise tolerance and enhanced quality of life. The study aimed to assess perfusion in the PMR patients in the long-term follow-up, with a view to establishing possible correlation with their clinical improvement. Material and methods: 24 patients aged 46-74 years, mean 62 years, with chronic coronary artery disease were enrolled into the study. All of them were referred to the PMR procedure based on the standard criteria. At baseline (one week prior to the procedure), after 3 and 15 months after PMR all patients underwent myocardial gated perfusion scintigraphy (GSPECT), and echocardiography with dobutamine stress test. The collected data were analyzed using the ANOVA and Pearson’s correlation test. Results: In the long term follow-up in the entire group a deterioration, or no changes in perfusion in the areas reperfused by PMLR, were observed, although without any statistical significance. Due to the progression of chronic CAD in the long term follow-up we observed deteriorated perfusion in the other, non-reperfused areas, mainly in LAD region. EF measured by GSPECT decreased during the follow-up (48.89⫾14.58 at baseline vs. 43.7⫾26.94 at 3 months, and vs. 42.97⫾23.28 at 15 months), although it lacked statistical significance. In stress echocardiography mean WMSI decreased significantly from 1.71⫾0.24 before PMLR down to 1.55⫾0.21 at the early and long-term follow-up. At long-term follow-up mean echocardiographically estimated EF was 52.7⫾8.3% and not significantly different from baseline. This changes were accompanied by significant increase of mean CCS score from 2.54⫾0.78 before the procedure to 3.52⫾0.51 (P⬍0.0001) 1 month after, and subsequently by a decrease of 2.78⫾0.65 in the long-term follow-up. Conclusions: Since our study failed to demonstrate any improvement whatsoever in perfusion, nor in ventricular function after laser revascularization, it may be reasonably assumed that the clinical benefits of PMR were in fact largely due to the placebo effect of the procedure itself. Admittedly, a relatively small group of patients was assessed and therefore larger trials are still required to establish the practical value of this technique.
M O N D M A O Y N D M A A Y Y M 9 A Y 9
Abstracts Monday, May 9, 2005
S31
5.45
5.47
Initial experience in Mexico of 18-FDG PET compared with thallium SPECT in the assessment of myocardial viability. E. Erick Alexanderson1, A. Meave2, A. Ricalde.2 1Instituto Nacional de Cardiologia/ UNAM, Nuclear Cardiology and PET-Cyclotron, Mexico City, Mexico, 2UNAM, PET-Cyclotron Unit, Mexico City, Mexico
Myocardial perfusion Tc99m MIBI SPECT and multislice computed tomography (MSCT) in the assessment of the results of chronic total coronary occlusion (CTO) angioplasty. M. Magdalena Kostkiewicz1, P. Wilkolek2, M. Pasowicz2, P. Klimeczek3, P. Pieniazek2, T. Przewlocki2, M. Pieculewicz2, W. Tracz.2 1Institute of Cardiology, Dept. of Nuclear Medicine, Krakow, Poland, 2Institute of Cardiology, Dept of Cardiovascular Diseases, Krakow, Poland, 3Of Heart and Lung Institute, Centre for Diagnosis, Krakow, Poland
In patients with myocardial infarction and left ventricular dysfunction, the evidence of myocardial viability is primordial. There are some methods to detect the presence of myocardial viability, 201-thallium reinjection SPECT protocol represents the most common radioisotopic technique to evaluate it. Positron emission tomography (PET) using FDG is considered the gold standard. Objective: The aim of this study was to compare globally and by segments the value of both techniques in the detection of viable myocardium. Methods: Twenty-six consecutive patients with previous myocardial infarction and left ventricular dysfunction were studied. All of them underwent into a SPECT perfusion scan and a FDG PET study to asses myocardial viability. Each study was performed in less than one week between the other. For the analysis, the myocardium was divided into 17 segments. A visual semi-quantitative analysis was carried out according to the following score indicating radiotracer uptake: O⫽normal to 4⫽absent. Myocardial viability was defined as the presence of normal, mildly or moderately reduced radiotracer uptake. The scores obtained by PET were compared to those obtained in SPECT. A T Student and Chi square tests were used for the quantitative and qualitative variables respectively, statistical analysis was performed using the SPSS v. 10 program. Results: 442 segments were analyzed. PET detected viability in 134 segments that had been defined as non-viable by SPECT. No differences in the analysis by vascular territories were found. Thirty percent of the segments that were defined as non viable by SPECT were viable by PET, meanwhile only 1% of the segments detected viable by SPECT were considered non viable with PET. (Table 1) Conclusions: FDG PET study represents a better technique to detect myocardial viability, compared to thallium reinjection SPECT protocol. By this study we have demonstrated that 3 of each 10 studies may be diagnosed as non viable where viability is present.
Restenosis assessment in patients after CTO recanalization is often difficult due to frequent, well developed collateral circulation and scar in the area of myocardial infarction. The aim of the is to evaluate the role of MIBI SPECT and MSCT in assessment of restenosis after successfully recanalized and stented CTO. 44 patients underwent successful PCI and stent implantation of CTO 29 (72.5%) patients had myocardial infarction in the occluded artery area. In 16 (40%) patients-left anterior descending (LAD), 8 (20%)-circumflex (Cx) and 16 (40%)-right coronary artery (RCA) were recanalized. MIBI SPECT revealed reversible perfusion defect in all patients before recanalization. MIBI SPECT and MSCT of coronary arteries at 6 and 12 months were done. Patients free from symptoms and with negative results of exercise test, MIBI SPECT and MSCT were assumed non-restenotic. Results of SPECT and MSCT were compared to angiographic ones Results: Mean follow-up time was 19⫾9.9 (3-42) months. Restenosis was detected in 16 patients, but in 2-neither scintigraphy, nor MSCT was performed. Positive MIBI SPECT was observed in 11 (78.6%), and MSCT in 9 (64.3%). In 2 (14.2%) Sensitivity, positive and negative predictive values were 78.6%, 78.6% and 62.5%MIBI SPECT, respectively, whereas MSCT showed sensitivity of 64.3%, positive predictive value of 81.8% and negative predictive value of 50.0%. Conclusions: Restenosis rate accounted for 40%. Both MIBI SPECT and MSCT facilitated detection of restenosis, although SPECT showed higher sensitivity and negative predictive value, as compared to MSCT.
PET vs SPECT in Myocardial Viability
SPECT
Viable Non Viable
PET Viable
Non Viable
252 (57%) 135 (30%)
5 (1.13%) 50 (11.3%)
5.46
5.48
Cardiac denervation early after transmyocardial CO2-laser revascularisation in I-123-MIBG planar and SPECT studies. A. Anna Teresinska1, M. Sliwinski2, S. Konieczna1, M. Szymanska2, P. Hendzel2, Z. Juraszynski2, A. Debski3, B. Szumilak.1 1National Institute of Cardiology, Nuclear Medicine, Warsaw, Poland, 2National Institute of Cardiology, Ist Clinic of Cardiosurgery, Warsaw, Poland, 3National Institute of Cardiology, Ist Clinic of Coronary Artery Disease, Warsaw, Poland
Percutaneous myocardial laser revascularisation-scintigraphic and echocardiographic assessment of the results. M. Magdalena Kostkiewicz1, W. Szot2, J. Trebacz3, K. Zmudka3, P. Podolec4, W. Tracz.4 1Institute of Cardiology, Dept. of Nuclear Medicine, Krakow, Poland, 2Of Heart and Lung Institute, Centre for Diagnosis, Krakow, Poland, 3Dept of hemodynamics and angiography, Krakow, Poland, 4Institute of Cardiology, Dept of Cardiovascular Diseases, Krakow, Poland
Aim: to study the range of changes caused by transmyocardial CO2-laser revascularisation [TMLR] in cardiac adrenergic nervous system [SYSTadren]. Material and methods: fourty-seven pts were studied for neuronal activity and integrity with I-123-MIBG planar and SPECT imaging before [MIBG-0] and 7-21 days after cardiac surgery [MIBG-early]. Sole laser revascularisation was performed in 23 pts and laser revascularisation concurrent with 1 bypass was performed in 24 pts. The group characteristics: 37 M (79%); age: 43-76 (av.63)y; LVEF 30-70 (av.53)%; III/IV CCS class. During the surgery, 15-32 (av.23) channels were generated in myocardium. Registration of I-123-MIBG planar images was started 3.5 hrs and of SPECT images was started 4 hrs after injection of the radiopharmaceutical. In planar studies, global activity of SYSTadren was measured by heart/mediastinum index [H/M]. In SPECT studies, regional MIBG uptake was assessed in 17 segments [seg] of the LV; 4-grade intensity scale was applied (0⫽normal uptake, 3⫽severe defect). Summarized MIBG uptake deficiency in SPECT was expressed by summary defect score [SDS]. Results: in total, in MIBG-early, uptake was deteriorated in 42% of seg (95% confidence interval CI⫽38-46%) and was improved only in 10% (CI⫽8-12%). In septal segments non-revascularised by CABG (nor by laser), uptake was deteriorated in 23% of seg (CI⫽16-32%) and was improved in 13% (CI⫽8-21%, NS). In lased segments, uptake was deteriorated in 48% of seg (CI⫽43-53%) and was improved only in 8% (CI⫽6-11%). In bypassed segments (which were also lased, in a part), uptake was deteriorated in 38% of seg (CI⫽30-48%) and was improved in 13% (CI⫽7-20%). In the group of lased pts, SDS has deteriorated from 23⫾6 to 29⫾5 (p⬍0,001) and H/M has decreased from 2.01 to 1.68 (p⬍0.0001). In the group of lased-and-bypassed pts, SDS has deteriorated from 20⫾6 to 25⫾7 (p⬍0.006) and H/M has decreased from 1.77 to 1.61 (p⬍0.003). Significant clinical improvement was observed in evaluated pts. Conclusion: early after TMLR, the integrity and activity of SYSTadren is deteriorated, what can be a mechanism resposible for clinical improvement observed early (⬍ 3 weeks) after TMLR.
Background: Percutaneous myocardial laser revascularisation (PMR) is a novel therapeutic technique aimed at delivering oxygenated blood via a series of channels made by percutaneous approach to the ischemic regions of the heart. In patients with the end stage coronary artery disease PMR is associated with a reduction in symptoms, improved exercise tolerance and enhanced quality of life. The study aimed to assess perfusion in the PMR patients in the long-term follow-up, with a view to establishing possible correlation with their clinical improvement. Material and methods: 24 patients aged 46-74 years, mean 62 years, with chronic coronary artery disease were enrolled into the study. All of them were referred to the PMR procedure based on the standard criteria. At baseline (one week prior to the procedure), after 3 and 15 months after PMR all patients underwent myocardial gated perfusion scintigraphy (GSPECT), and echocardiography with dobutamine stress test. The collected data were analyzed using the ANOVA and Pearson’s correlation test. Results: In the long term follow-up in the entire group a deterioration, or no changes in perfusion in the areas reperfused by PMLR, were observed, although without any statistical significance. Due to the progression of chronic CAD in the long term follow-up we observed deteriorated perfusion in the other, non-reperfused areas, mainly in LAD region. EF measured by GSPECT decreased during the follow-up (48.89⫾14.58 at baseline vs. 43.7⫾26.94 at 3 months, and vs. 42.97⫾23.28 at 15 months), although it lacked statistical significance. In stress echocardiography mean WMSI decreased significantly from 1.71⫾0.24 before PMLR down to 1.55⫾0.21 at the early and long-term follow-up. At long-term follow-up mean echocardiographically estimated EF was 52.7⫾8.3% and not significantly different from baseline. This changes were accompanied by significant increase of mean CCS score from 2.54⫾0.78 before the procedure to 3.52⫾0.51 (P⬍0.0001) 1 month after, and subsequently by a decrease of 2.78⫾0.65 in the long-term follow-up. Conclusions: Since our study failed to demonstrate any improvement whatsoever in perfusion, nor in ventricular function after laser revascularization, it may be reasonably assumed that the clinical benefits of PMR were in fact largely due to the placebo effect of the procedure itself. Admittedly, a relatively small group of patients was assessed and therefore larger trials are still required to establish the practical value of this technique.
M O N D M A O Y N D M A A Y Y M 9 A Y 9