Myocardial Viability in Patients With Chronic Coronary Artery Disease: Comparison of 99mTc‐Sestamibi With Thallium Reinjection and [18F]Fluorodeoxyglucose

Background99mTc-sestamibi and thallium imaging have similar accuracy when used for diagnostic purposes, but whether sestamibi provides accurate information regarding myocardial viability in patients with chronic coronary artery disease has not been established. Since there is minimal redistribution of sestamibi over time, it may overestimate nonviable myocardium in patients with left ventricular dysfunction, in whom blood flow may be reduced at rest. Methods and ResultsWe studied 54 patients with chronic coronary artery disease with a mean ejection fraction of 34±14%. Patients underwent stress/redistribution/reinjection thallium tomography and, within a mean of 5 days, same-day rest/stress sestamibi imaging using the same exercise protocol and with patients achieving the same exercise duration. Of the 111 reversible thallium defects on either the redistribution or reinjection study, 40 (36%) were determined to be irreversible on the rest/stress sestamibi study, whereas only 3 of 63 irreversible thallium defects despite reinjection (5%) were classified to be reversible by sestamibi imaging. The concordance regarding reversibility of myocardial defects between thallium stress/redistribution/reinjection and same day rest/ stress sestamibi studies was 75%. A subgroup of 25 patients also underwent positron emission tomography (PET) studies with 15O-labeled water and [18F]fluorodeoxyglucose (FDG) at rest after an oral glucose load. As in the overall group of 54 patients, there was concordance between thallium and sestamibi imaging regarding defect reversibility in 51 of 73 regions (70%). In the remaining 22 discordant regions (30%), 18 (82%) appeared irreversible by sestamibi imaging but were reversible by thallium imaging. Myocardial viability was confirmed in 17 of 18 regions, as evidenced by normal FDG uptake (10 regions) or FDG/blood flow mismatch (7 regions) on PET. These regions were present in 16 of the 25 patients studied (64%). We then explored methods to improve the sestamibi results. First, when the 18 discordant regions with irreversible sestamibi defects were further analyzed according to the severity of defects, 14 (78%) demonstrated only mild-tomoderate reduction in sestamibi activity (51% to 85% of normal activity), suggestive of predominantly viable myocardium, and the overall concordance between thallium and sestamibi studies increased to 93%. Second, when an additional 4-hour redistribution image was acquired in 18 patients after the injection of sestamibi at rest, 6 of 16 discordant irreversible regions (38%) on the rest/stress sestamibi study became reversible, thereby increasing the concordance between thallium and sestamibi studies to 82%. ConclusionsThese data indicate that same-day rest/stress sestamibi imaging will incorrectly identify 36% of myocardial regions as being irreversibly impaired and nonviable compared with both thallium redistribution/reinjection and PET. However, the identification of reversible and viable myocardium can be greatly enhanced with sestamibi if an additional redistribution image is acquired after the rest sestamibi injection or if the severity of reduction in sestamibi activity within irreversible defects is considered.

[1]  S L Bacharach,et al.  Concordance and discordance between stress-redistribution-reinjection and rest-redistribution thallium imaging for assessing viable myocardium. Comparison with metabolic activity by positron emission tomography. , 1993, Circulation.

[2]  E. Picano,et al.  Value of rest thallium-201/technetium-99m sestamibi scans and dobutamine echocardiography for detecting myocardial viability. , 1993, The American journal of cardiology.

[3]  R. Bonow Identification of viable myocardium in patients with coronary artery disease and left ventricular dysfunction , 1993 .

[4]  J A Frank,et al.  Regional Left Ventricular Wall Thickening: Relation to Regional Uptake of 18Fluorodeoxyglucose and 201TI in Patients With Chronic Coronary Artery Disease and Left Ventricular Dysfunction , 1992, Circulation.

[5]  V. Dilsizian,et al.  Metabolic evidence of viable myocardium in regions with reduced wall thickness and absent wall thickening in patients with chronic ischemic left ventricular dysfunction. , 1992, Journal of the American College of Cardiology.

[6]  V. Dilsizian,et al.  Thallium-201 and technetium-99m-sestamibi for assessing viable myocardium. , 1992, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[7]  M. Chiariello,et al.  Identification of viable myocardium in patients with chronic coronary artery disease: comparison of thallium-201 scintigraphy with reinjection and technetium-99m-methoxyisobutyl isonitrile. , 1992, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[8]  V. Dilsizian,et al.  Differential Uptake and Apparent 201TI Washout After Thallium Reinjection: Options Regarding Early Redistribution Imaging Before Reinjection or Late Redistribution Imaging After Reinjection , 1992, Circulation.

[9]  V. Dilsizian,et al.  Regional thallium uptake in irreversible defects. Magnitude of change in thallium activity after reinjection distinguishes viable from nonviable myocardium. , 1992, Circulation.

[10]  A. Bol,et al.  Regional Oxidative Metabolism in Patients After Recovery From Reperfused Anterior Myocardial Infarction: Relation to Regional Blood Flow and Glucose Uptake , 1992, Circulation.

[11]  J. Mattera,et al.  Thallium-201 for assessment of myocardial viability: quantitative comparison of 24-hour redistribution imaging with imaging after reinjection at rest. , 1991, Journal of the American College of Cardiology.

[12]  R. Taillefer,et al.  Technetium-99m-sestamibi myocardial perfusion imaging in detection of coronary artery disease: comparison between initial (1-hour) and delayed (3-hour) postexercise images. , 1991, Journal of Nuclear Medicine.

[13]  Y. Yonekura,et al.  Metabolic activity in the areas of new fill-in after thallium-201 reinjection: comparison with positron emission tomography using fluorine-18-deoxyglucose. , 1991, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[14]  V. Dilsizian,et al.  Thallium Reinjection After Stress‐Redistribution Imaging: Does 24‐Hour Delayed Imaging After Reinjection Enhance Detection of Viable Myocardium? , 1991, Circulation.

[15]  B. Gersh,et al.  Primary angioplasty in myocardial infarction: assessment of improved myocardial perfusion with technetium-99m isonitrile. , 1991, Journal of the American College of Cardiology.

[16]  P. McLaughlin,et al.  Are the kinetics of technetium-99m methoxyisobutyl isonitrile affected by cell metabolism and viability? , 1990, Circulation.

[17]  J. Kronauge,et al.  Uptake and retention of hexakis (2-methoxyisobutyl isonitrile) technetium(I) in cultured chick myocardial cells. Mitochondrial and plasma membrane potential dependence. , 1990, Circulation.

[18]  R. Taillefer Technetium-99m sestamibi myocardial imaging: same-day rest-stress studies and dipyridamole. , 1990, The American journal of cardiology.

[19]  Y. Yonekura,et al.  Significance of fill-in after thallium-201 reinjection following delayed imaging: comparison with regional wall motion and angiographic findings. , 1990, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[20]  D D Watson,et al.  Quantification of area at risk during coronary occlusion and degree of myocardial salvage after reperfusion with technetium-99m methoxyisobutyl isonitrile. , 1990, Circulation.

[21]  Y. Yonekura,et al.  Value of thallium-201 reinjection after delayed SPECT imaging for predicting reversible ischemia after coronary artery bypass grafting. , 1990, The American journal of cardiology.

[22]  V. Dilsizian,et al.  Enhanced detection of ischemic but viable myocardium by the reinjection of thallium after stress-redistribution imaging. , 1990, The New England journal of medicine.

[23]  A. Fischman,et al.  Comparison of thallium redistribution with rest "reinjection" imaging for the detection of viable myocardium. , 1990, The American journal of cardiology.

[24]  L. Becker,et al.  Myocardial redistribution of technetium-99m-methoxyisobutyl isonitrile (SESTAMIBI). , 1990, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[25]  A. Sinusas,et al.  Technetium-99m isonitrile and Thallium-201 activity are comparable following 3 hours of low flow ischemia , 1990 .

[26]  R. Canby,et al.  Relations of the myocardial imaging agents 99mTc-MIBI and 201T1 to myocardial blood flow in a canine model of myocardial ischemic insult. , 1990, Circulation.

[27]  V. Dilsizian,et al.  Technetium-99m isonitrile myocardial uptake at rest. I. Relation to severity of coronary artery stenosis. , 1989, Journal of the American College of Cardiology.

[28]  V. Dilsizian,et al.  Technetium-99m isonitrile myocardial uptake at rest. II. Relation to clinical markers of potential viability. , 1989, Journal of the American College of Cardiology.

[29]  A. Sinusas,et al.  Effect of ischemia and postischemic dysfunction on myocardial uptake of technetium-99m-labeled methoxyisobutyl isonitrile and thallium-201. , 1989, Journal of the American College of Cardiology.

[30]  J. Leppo,et al.  Comparison of hypoxia and ouabain effects on the myocardial uptake kinetics of technetium-99m hexakis 2-methoxyisobutyl isonitrile and thallium-201. , 1989, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[31]  P. Herrero,et al.  Quantitation of myocardial blood flow with H2 15O and positron emission tomography: assessment and error analysis of a mathematical approach. , 1989, Journal of computer assisted tomography.

[32]  M. Walsh,et al.  Noninvasive quantitation of myocardial blood flow in human subjects with oxygen-15-labeled water and positron emission tomography. , 1989, Journal of the American College of Cardiology.

[33]  J. Leppo,et al.  Comparison of the Myocardial Uptake of a Technetium-Labeled Isonitrile Analogue and Thallium , 1989, Circulation research.

[34]  S. Marsch,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 thallium-201 SPECT imaging. , 1989, The American journal of cardiology.

[35]  T. Faber,et al.  Quantitative rotational tomography with 201Tl and 99mTc 2-methoxy-isobutyl-isonitrile. A direct comparison in normal individuals and patients with coronary artery disease. , 1989, Circulation.

[36]  D. Berman,et al.  Technetium-99m hexakis 2-methoxyisobutyl isonitrile: human biodistribution, dosimetry, safety, and preliminary comparison to thallium-201 for myocardial perfusion imaging. , 1989, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[37]  D. Berman,et al.  Comparison of technetium 99m methoxy isobutyl isonitrile and thallium 201 for evaluation of coronary artery disease by planar and tomographic methods. , 1989, American heart journal.

[38]  M. Verani,et al.  Quantification of myocardial infarction during coronary occlusion and myocardial salvage after reperfusion using cardiac imaging with technetium-99m hexakis 2-methoxyisobutyl isonitrile. , 1988, Journal of the American College of Cardiology.

[39]  R. Bonow,et al.  Arterial blood concentration curves by cardiac PET without arterial sampling or image reconstruction , 1988, Proceedings. Computers in Cardiology 1988.

[40]  F Shishido,et al.  Measurement of absolute myocardial blood flow with H215O and dynamic positron-emission tomography. Strategy for quantification in relation to the partial-volume effect. , 1988, Circulation.

[41]  B. Holman,et al.  A new Tc-99m-labeled myocardial imaging agent, hexakis(t-butylisonitrile)-technetium(I) [Tc-99m TBI]: initial experience in the human. , 1984, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[42]  M E Phelps,et al.  Identification and Differentiation of Resting Myocardial Ischemia and Infarction in Man with Positron Computed Tomography, 18F‐labeled Fluorodeoxyglucose and N‐13 Ammonia , 1983, Circulation.

[43]  G S Johnston,et al.  Real-time radionuclide cineangiography in the noninvasive evaluation of global and regional left ventricular function at rest and during exercise in patients with coronary-artery disease. , 1977, The New England journal of medicine.

[44]  P. Hammond,et al.  The interrelationship between thallium and potassium in animals. , 1967, The Journal of pharmacology and experimental therapeutics.

[45]  R. Moore,et al.  The Movement of Thallium Ions in Muscle , 1960, The Journal of general physiology.