Korean J Radiol.  2014 Apr;15(2):277-285. 10.3348/kjr.2014.15.2.277.

Impaired Coronary Flow Reserve Is the Most Important Marker of Viable Myocardium in the Myocardial Segment-Based Analysis of Dual-Isotope Gated Myocardial Perfusion Single-Photon Emission Computed Tomography

• Lee WW
• So Y
• Kim KB
• Lee DS

• KMID: 1705584
• DOI: http://doi.org/10.3348/kjr.2014.15.2.277

Abstract

OBJECTIVE
The aim of this study was to investigate the most robust predictor of myocardial viability among stress/rest reversibility (coronary flow reserve [CFR] impairment), 201Tl perfusion status at rest, 201Tl 24 hours redistribution and systolic wall thickening of 99mTc-methoxyisobutylisonitrile using a dual isotope gated myocardial perfusion single-photon emission computed tomography (SPECT) in patients with coronary artery disease (CAD) who were re-vascularized with a coronary artery bypass graft (CABG) surgery.
MATERIALS AND METHODS
A total of 39 patients with CAD was enrolled (34 men and 5 women), aged between 36 and 72 years (mean 58 +/- 8 standard in years) who underwent both pre- and 3 months post-CABG myocardial SPECT. We analyzed 17 myocardial segments per patient. Perfusion status and wall motion were semi-quantitatively evaluated using a 4-point grading system. Viable myocardium was defined as dysfunctional myocardium which showed wall motion improvement after CABG.
RESULTS
The left ventricular ejection fraction (LVEF) significantly increased from 37.8 +/- 9.0% to 45.5 +/- 12.3% (p < 0.001) in 22 patients who had a pre-CABG LVEF lower than 50%. Among 590 myocardial segments in the re-vascularized area, 115 showed abnormal wall motion before CABG and 73.9% (85 of 115) had wall motion improvement after CABG. In the univariate analysis (n = 115 segments), stress/rest reversibility (p < 0.001) and 201Tl rest perfusion status (p = 0.024) were significant predictors of wall motion improvement. However, in multiple logistic regression analysis, stress/rest reversibility alone was a significant predictor for post-CABG wall motion improvement (p < 0.001).
CONCLUSION
Stress/rest reversibility (impaired CFR) during dual-isotope gated myocardial perfusion SPECT was the single most important predictor of wall motion improvement after CABG.

Keyword

Myocardium; Tissue viability; Ischemia; Coronary artery bypass grafting; Single-photon emission-computed tomography

MeSH Terms

Adult
Aged
Analysis of Variance
Cardiac-Gated Single-Photon Emission Computer-Assisted Tomography/*methods
Coronary Artery Bypass
Coronary Artery Disease/physiopathology/*radionuclide imaging/surgery
Coronary Circulation/*physiology
Coronary Disease/radionuclide imaging/surgery
Female
Humans
Male
Middle Aged
Myocardial Contraction/physiology
Myocardium
Nitriles/diagnostic use
Stroke Volume/physiology
Technetium/diagnostic use
Ventricular Function, Left/physiology
Nitriles
Technetium

Figure

• 

  Fig. 1 Dual-isotope gated myocardial single-photon emission computed tomography protocol. 201Tl was first injected and rest image was acquired. Pharmacologic stress using dipyridamole (0.56 mg/kg over 4 minutes) was performed. 99mTc-MIBI was injected 3 minutes after completion of dipyridamole infusion. Electrocardiography-gated stress image was obtained 1 hour later. 201Tl 24 hours redistribution study was performed in case of rest perfusion defects. 99mTc-MIBI = 99mTc-methoxyisobutylisonitrile

• 

  Fig. 2 Viable myocardium according to viability markers of dual-isotope gated myocardial single-photon emission computed tomography. A. Stress/rest reversibility. B. 201Tl rest perfusion status. C. 201Tl 24 hours redistribution. D. 99mTc-methoxyisobutylisonitrile systolic wall thickening. All myocardial segments indicated by white arrows presented wall motion abnormality before revascularization and improved wall motion after revascularization. Arrows indicate the myocardial segments of interest regarding the myocardial viability.

• 

  Fig. 3 LVEF change after CABG. Gated LVEF increased significantly (p < 0.001) after CABG (45.5 ± 12.3%) in 22 patients with pre-CABG LVEFs lower than 50% (37.8 ± 9.0%). CABG = coronary artery bypass graft, LVEF = left ventricular ejection fraction

• 

  Fig. 4 Diagnostic performances of individual viability markers for wall motion improvement. Ac = accuracy, NPV = negative predictive value, PPV = positive predictive value, Sn = sensitivity, Sp = specificity, 99mTc-MIBI = 99mTc-methoxyisobutylisonitrile

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