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Rest reverse redistribution in acute reperfused myocardial infarction: Significance of post-injection Tl-SPECT images
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Abstracts M o n d a y m o r n i n g , A p r i l 19, 1 9 9 9
4.29 M O N D A Y A M A P R I L 19
Journal of Nuclear Cardiology January/February 1999, Part 2
4.31 Non Invasive Assessment of The Outcome of Acute PTCA using Radionuclide Imaging
Waheed Radwan; Alia Abd EI-Fanah; Mohamed Ashraf Tamer; Ahmed Abd EI-Aal; Helmy EI-Ghawaby; Ayman EI-Naggar; Ahmed Abd EI-Aziz; Sherif Mokhtar, MD
Objective: To validate the use of single photon emission computed tomography perfusion imaging in early assessment of the success of primary and rescue PTCA. We studied 15 patients (pts), all are males, with acute MI with a mean age of 464-12 years, admitted to Critical Care Department within 6 hours of the onset of chest pain. (MI was anterior in 13, inferior in 1, and lateral in one pt). Following admission, all pts were subjected to clinical evaluation, 12-lead ECG, serial serum CPK, CK-MGB and co-agulation profile, then I5 mci of Technitium sestamibi was given 1.V. and the first set of SPECT images was acquired to assess the segments of myocardium at risk (MAR) before moving to the catheter laboratory. Coronary angiography was done aiming at identification of the infarct-related artery, and visualization of intracoronary thrombus, with anatomically suitable lesions, PTCA and stenting were done, and within 24 hours, a second set of SPECT images was acquired to estimate the infarct size (IS) and the extent of myocardial salvage. In addition, a second look by coronary angiography was done to assess patency, degree of residual stenosis and possible complications. TIMI flow was assessed before and after PTCA. MAR and IS were quantified by application of 13 segments scoring system and the extent of myocardial salvage was estimated by the score difference between the 2 sets of images. Salvage index (SI) was calculated as score difference/MAR. Successful reperfusion was considered with SI exceeding 30%. In our pts, the mean value of MAR was 394-8 (range, 25 to 53), IS: 124-7 (range, 2 to 28), Sl: 694-16 (range of SI: 33-95%). T1M1flow before PTCA was 0 in 14 pts, and 1 in one pt. Post PTCA, TIMI flow became 3 in 12 (80% ofpts), 2 in 2 pts (13% of pts), 1 in one pt (6%) and this pt had thelowest Slby scintigraphy (33%). The acute success rate was 94%, & mean residual stenosis was 12% (range 0 to 20). Hospital mortality rate was 6%, and complications occurred in 3 pts. Conclusion: Non invasive scintigraphic assessment correlates with arteriographic evidence of patency of infarct related artery.
Role Of Acute Perfusion Imaging In Assessment Of Success Of Reperfusion By Throublolytic Therapy Alia Abd EI-Fattah, MD Critical Care Medicine Department, Cairo University, Egypt Objective: To validate the use of perfusion imaging in assessment of reperfusion and patency of infarct related artery in the evolving phase of acute MI to guide the management strategy. We studied 3 8 p t s admitted to critical care department within 6 hours of onset of chest pain of first attack of acute MI. Mean age was 464-11 y (30 males). MI was anterior in 29, inferior in 7, and lateral in 2 pts. All pts were subjected to full clinical examination, 12-lead EKG, serial cardiac enzymes CPK, CK-MB and coagulation profile, then injection of 15 mCi Tc-sestamibi I.V. before any therapeutic intervention. Then 1,500,000 IU of streptokinase was given over one hour. Acquiring the 1st set of SPECT images (which reflects the myocardium at risk (MAR) was delayed untill the pt is hemodynamically stable but within 3 hours from admission, then immediately, a second bolus of Tc-sestamibi (25-30 mCi LV.) was given and acquizition of 2na set of SPECT images to estimate the final infarct size (IS) was done. MAR and IS were quantified by application of 13 segments scoring system (3-0) in I st and 2nd sets of images. Myocardial salvage was estimatedas, salvage index (SI) = score difference/MAR. SI > 30% was an indication for successful thrombolysis. All pts were subjected to coronary angiography within one week to correlate scintigraphic evidence of successful reperfusion to angiographic evidence of patent infarct related artery. Paitnets were divided into two groups: (GrI) pts with SI > 30% i.e. successful reperfusoin) (30 pts), GrlI: Pts with SI < 30% failed reperfusion) (8 pts) who were moved to the cath lab. and then subjected to rescue PTCA. In Gr 1: Mean MAR was 31.54-10.9, initial final scores, infarct size (IS) and SI were: 26.54-4.2, 33.77:53.2, 13.64-7.8 and 59.574-17.56. Timiflow was 2.3 in 28 pts and 0 in 2 pts. In Grll: Mean MAR was 38.54-8 initial, final scores, IS, SI were: 23.8±3.1, 26.54-3.4, 31.64-8.5, 17.54-13.8. Timiflow was 0 in all pts. Conclusion: Early assessment of infarct related artery status in the acute phase of MI could be achieved non invasively by acute perfusions imaging with a sensitivity of 93% and sepcificity 100%. Selection of pts for rescue PTCA can be guided by successive acute perfusion imaging.
4.30
4.32
REST REVERSE REDISTRIBUTION IN ACUTE REPERFUSED MYOCARDIAL INFARCTION : SIGNIFICANCE OF POST-INJECTION TL-SPECT IMAGES. M. Faraggi, D. Kadla-Cohen, R. Lebtahi, N. Delahaye, L. Sarda, R. G6nin, N. Gazzar, PG Steg, D. Le Guludec, Bichat Hospital, Pads, France.
IDENTIFICATION OF MYOCARDIAL ISCHEMIA IN AREAS .OF NORMAL PERFUSION BY REST-DUAL ISOTOPE SPECT WITH F18 DEOXYGLUCOSE AND TC99M SESTAMIBI IN PATIENTS WITH UNSTABLE ANGINA A.Hashimoto, A.Fischman, M.Moroi, G.Zervos, H.Gold, T.Yasuda. Massachusetts General Hospital, Boston, USA.
Rest TI reverse redistribution (RR) was studied 8 days after acute reperfused myocardial infarction in 33 TIMI-3 patients. Post-injection and redistribution images on day 8 (D8) were compared to those obtained on day 42 (D42), to acute microvascular perfusion assessed by intra-coronary myocardial contrast echocardiography (MCE) in the acute phase (16 segment, 3 grade perfusion score) and to late functional recovery on D42 assessed by 2D echocardiography. TI defect size was expressed in % of the whole myocardium after a bull's eye polar map. A marked significant RR was found on day 8 (absolute change: 7.5+7.9% of the 10 min=post-injection defect size, p<5.10-6) and significantly decreased on day 42 to 2.7+6.8%, (p=0.004 between day 8 and 42). The 10 min-post injection defect size best predicted the final infarct size on day 42 evaluated with thallium on D42 and 2D echocardiography (both r=0.8,p<10 3) and was closely related to microvascular perfusion : patients with adequate reperfusion had smaller post-injection defect on day 8 (21.1+14.6%) and a larger reverse redistribution (10.2:1:6.1%) than patients with no reflow (35.3+13% and 3.2:1:9.2%, respectively, p<0.04 for both). Conclusion: The early post-injection scans on day 8 were the relevant images for assessing myocardial salvage and predicting wall motion recovery.
A myocardial region supplied by a significantly stenosed coronary artery often demonstrates normal rest perfusion, e v e n in p a t i e n t s (pts) w i t h u n s t a b l e a n g i n a ( U A ) . It h a s b e e n unknown whether the areas of normal perfusion with recent repetitive ischemia show focal myocardial FDG uptake. We i n v e s t i g a t e d t h e d i a g n o s t i c v a l u e o f F D G u p t a k e in a r e a s o f normal rest-MIBI perfusion for identifying significant d o r o n a r y s t e n o s i s ( > 5 0 % ) in U A p t s . 8 5 U A p t s ( 6 4 + 1 1 years, 58M/27F) with coronary lesions (mean stenosis 85 +17%) underwent rest-dual isotope SPECT with FDG and MIBI under fasting condition. The left ventricle was divided i n t o 7 s e g m e n t s . F o c a l F D G u p t a k e w a s d e m o n s t r a t e d in 1 8 0 o f 4 7 3 s e g m e n t s in a r e a s o f n o r m a l M I B I p e r f u s i o n ( > 8 0 % o f n o r m a l ) , in 4 9 o f 5 2 s e g m e n t s in a r e a s o f r e d u c e d M I B I p e r f u s i o n ( 5 0 - 8 0 % o f n o r m a l ) , a n d in 3 5 o f 7 0 s e g m e n t s i n areas of MIBI perfusion defects (<50% of normal). Out of t h e s e 1 8 0 s e g m e n t s s h o w i n g e n h a n c e d F D G u p t a k e in a r e a s of normal MIBI perfusion, 128 (71%) were associated with significant coronary lesions, and the remaining 52 (29%) had normal coronary a r t e r i e s . In U A pts, s e n s i t i v i t y a n d specificity of FDG MIBI SPECT for detecting coronary s t e n o s i s in a r e a s o f n o r m a l p e r f u s i o n at r e s t w e r e 8 7 % (128/147) and 84%-(274/326). Our results support a unique c l i n i c a l u s e f u l n e s s o f r e s t - F D G M I B I S P E C T in U A p t s .
Abstracts M o n d a y m o r n i n g , A p r i l 19, 1 9 9 9
4.29 M O N D A Y A M A P R I L 19
Journal of Nuclear Cardiology January/February 1999, Part 2
4.31 Non Invasive Assessment of The Outcome of Acute PTCA using Radionuclide Imaging
Waheed Radwan; Alia Abd EI-Fanah; Mohamed Ashraf Tamer; Ahmed Abd EI-Aal; Helmy EI-Ghawaby; Ayman EI-Naggar; Ahmed Abd EI-Aziz; Sherif Mokhtar, MD
Objective: To validate the use of single photon emission computed tomography perfusion imaging in early assessment of the success of primary and rescue PTCA. We studied 15 patients (pts), all are males, with acute MI with a mean age of 464-12 years, admitted to Critical Care Department within 6 hours of the onset of chest pain. (MI was anterior in 13, inferior in 1, and lateral in one pt). Following admission, all pts were subjected to clinical evaluation, 12-lead ECG, serial serum CPK, CK-MGB and co-agulation profile, then I5 mci of Technitium sestamibi was given 1.V. and the first set of SPECT images was acquired to assess the segments of myocardium at risk (MAR) before moving to the catheter laboratory. Coronary angiography was done aiming at identification of the infarct-related artery, and visualization of intracoronary thrombus, with anatomically suitable lesions, PTCA and stenting were done, and within 24 hours, a second set of SPECT images was acquired to estimate the infarct size (IS) and the extent of myocardial salvage. In addition, a second look by coronary angiography was done to assess patency, degree of residual stenosis and possible complications. TIMI flow was assessed before and after PTCA. MAR and IS were quantified by application of 13 segments scoring system and the extent of myocardial salvage was estimated by the score difference between the 2 sets of images. Salvage index (SI) was calculated as score difference/MAR. Successful reperfusion was considered with SI exceeding 30%. In our pts, the mean value of MAR was 394-8 (range, 25 to 53), IS: 124-7 (range, 2 to 28), Sl: 694-16 (range of SI: 33-95%). T1M1flow before PTCA was 0 in 14 pts, and 1 in one pt. Post PTCA, TIMI flow became 3 in 12 (80% ofpts), 2 in 2 pts (13% of pts), 1 in one pt (6%) and this pt had thelowest Slby scintigraphy (33%). The acute success rate was 94%, & mean residual stenosis was 12% (range 0 to 20). Hospital mortality rate was 6%, and complications occurred in 3 pts. Conclusion: Non invasive scintigraphic assessment correlates with arteriographic evidence of patency of infarct related artery.
Role Of Acute Perfusion Imaging In Assessment Of Success Of Reperfusion By Throublolytic Therapy Alia Abd EI-Fattah, MD Critical Care Medicine Department, Cairo University, Egypt Objective: To validate the use of perfusion imaging in assessment of reperfusion and patency of infarct related artery in the evolving phase of acute MI to guide the management strategy. We studied 3 8 p t s admitted to critical care department within 6 hours of onset of chest pain of first attack of acute MI. Mean age was 464-11 y (30 males). MI was anterior in 29, inferior in 7, and lateral in 2 pts. All pts were subjected to full clinical examination, 12-lead EKG, serial cardiac enzymes CPK, CK-MB and coagulation profile, then injection of 15 mCi Tc-sestamibi I.V. before any therapeutic intervention. Then 1,500,000 IU of streptokinase was given over one hour. Acquiring the 1st set of SPECT images (which reflects the myocardium at risk (MAR) was delayed untill the pt is hemodynamically stable but within 3 hours from admission, then immediately, a second bolus of Tc-sestamibi (25-30 mCi LV.) was given and acquizition of 2na set of SPECT images to estimate the final infarct size (IS) was done. MAR and IS were quantified by application of 13 segments scoring system (3-0) in I st and 2nd sets of images. Myocardial salvage was estimatedas, salvage index (SI) = score difference/MAR. SI > 30% was an indication for successful thrombolysis. All pts were subjected to coronary angiography within one week to correlate scintigraphic evidence of successful reperfusion to angiographic evidence of patent infarct related artery. Paitnets were divided into two groups: (GrI) pts with SI > 30% i.e. successful reperfusoin) (30 pts), GrlI: Pts with SI < 30% failed reperfusion) (8 pts) who were moved to the cath lab. and then subjected to rescue PTCA. In Gr 1: Mean MAR was 31.54-10.9, initial final scores, infarct size (IS) and SI were: 26.54-4.2, 33.77:53.2, 13.64-7.8 and 59.574-17.56. Timiflow was 2.3 in 28 pts and 0 in 2 pts. In Grll: Mean MAR was 38.54-8 initial, final scores, IS, SI were: 23.8±3.1, 26.54-3.4, 31.64-8.5, 17.54-13.8. Timiflow was 0 in all pts. Conclusion: Early assessment of infarct related artery status in the acute phase of MI could be achieved non invasively by acute perfusions imaging with a sensitivity of 93% and sepcificity 100%. Selection of pts for rescue PTCA can be guided by successive acute perfusion imaging.
4.30
4.32
REST REVERSE REDISTRIBUTION IN ACUTE REPERFUSED MYOCARDIAL INFARCTION : SIGNIFICANCE OF POST-INJECTION TL-SPECT IMAGES. M. Faraggi, D. Kadla-Cohen, R. Lebtahi, N. Delahaye, L. Sarda, R. G6nin, N. Gazzar, PG Steg, D. Le Guludec, Bichat Hospital, Pads, France.
IDENTIFICATION OF MYOCARDIAL ISCHEMIA IN AREAS .OF NORMAL PERFUSION BY REST-DUAL ISOTOPE SPECT WITH F18 DEOXYGLUCOSE AND TC99M SESTAMIBI IN PATIENTS WITH UNSTABLE ANGINA A.Hashimoto, A.Fischman, M.Moroi, G.Zervos, H.Gold, T.Yasuda. Massachusetts General Hospital, Boston, USA.
Rest TI reverse redistribution (RR) was studied 8 days after acute reperfused myocardial infarction in 33 TIMI-3 patients. Post-injection and redistribution images on day 8 (D8) were compared to those obtained on day 42 (D42), to acute microvascular perfusion assessed by intra-coronary myocardial contrast echocardiography (MCE) in the acute phase (16 segment, 3 grade perfusion score) and to late functional recovery on D42 assessed by 2D echocardiography. TI defect size was expressed in % of the whole myocardium after a bull's eye polar map. A marked significant RR was found on day 8 (absolute change: 7.5+7.9% of the 10 min=post-injection defect size, p<5.10-6) and significantly decreased on day 42 to 2.7+6.8%, (p=0.004 between day 8 and 42). The 10 min-post injection defect size best predicted the final infarct size on day 42 evaluated with thallium on D42 and 2D echocardiography (both r=0.8,p<10 3) and was closely related to microvascular perfusion : patients with adequate reperfusion had smaller post-injection defect on day 8 (21.1+14.6%) and a larger reverse redistribution (10.2:1:6.1%) than patients with no reflow (35.3+13% and 3.2:1:9.2%, respectively, p<0.04 for both). Conclusion: The early post-injection scans on day 8 were the relevant images for assessing myocardial salvage and predicting wall motion recovery.
A myocardial region supplied by a significantly stenosed coronary artery often demonstrates normal rest perfusion, e v e n in p a t i e n t s (pts) w i t h u n s t a b l e a n g i n a ( U A ) . It h a s b e e n unknown whether the areas of normal perfusion with recent repetitive ischemia show focal myocardial FDG uptake. We i n v e s t i g a t e d t h e d i a g n o s t i c v a l u e o f F D G u p t a k e in a r e a s o f normal rest-MIBI perfusion for identifying significant d o r o n a r y s t e n o s i s ( > 5 0 % ) in U A p t s . 8 5 U A p t s ( 6 4 + 1 1 years, 58M/27F) with coronary lesions (mean stenosis 85 +17%) underwent rest-dual isotope SPECT with FDG and MIBI under fasting condition. The left ventricle was divided i n t o 7 s e g m e n t s . F o c a l F D G u p t a k e w a s d e m o n s t r a t e d in 1 8 0 o f 4 7 3 s e g m e n t s in a r e a s o f n o r m a l M I B I p e r f u s i o n ( > 8 0 % o f n o r m a l ) , in 4 9 o f 5 2 s e g m e n t s in a r e a s o f r e d u c e d M I B I p e r f u s i o n ( 5 0 - 8 0 % o f n o r m a l ) , a n d in 3 5 o f 7 0 s e g m e n t s i n areas of MIBI perfusion defects (<50% of normal). Out of t h e s e 1 8 0 s e g m e n t s s h o w i n g e n h a n c e d F D G u p t a k e in a r e a s of normal MIBI perfusion, 128 (71%) were associated with significant coronary lesions, and the remaining 52 (29%) had normal coronary a r t e r i e s . In U A pts, s e n s i t i v i t y a n d specificity of FDG MIBI SPECT for detecting coronary s t e n o s i s in a r e a s o f n o r m a l p e r f u s i o n at r e s t w e r e 8 7 % (128/147) and 84%-(274/326). Our results support a unique c l i n i c a l u s e f u l n e s s o f r e s t - F D G M I B I S P E C T in U A p t s .