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Circulation, Vol 88, 509-522, Copyright © 1993 by American Heart Association
O Parodi, R De Maria, L Oltrona, R Testa, G Sambuceti, A Roghi, M Merli, L Belingheri, R Accinni and F Spinelli
BACKGROUND. The present investigation was designed to obtain an absolute
measurement of myocardial blood flow and of its transmural distribution in
ischemic heart disease and idiopathic dilated cardiomyopathy and to provide
a reference standard for cardiac imaging in nuclear cardiology. METHODS AND
RESULTS. Regional myocardial blood flow and its transmural distribution
were estimated by the reference microsphere method in eight patients with
idiopathic dilated cardiomyopathy (n = 4) or ischemic heart disease (n = 4)
during heart transplant procedure. Before aortic clamping, 99mTc-labeled
human albumin microspheres were injected into the left atrium while
arterial blood was sampled from the aorta at a constant rate. No
complications were observed during or after the procedure. From the excised
heart, myocardial slices for gamma camera imaging and well counting
analysis were obtained. Myocardial blood flow was assessed by a well
counter, correlated with the extent of fibrosis expressed as collagen per
total tissue proteins obtained from 4-hydroxyproline and glycine as
determined by high-performance liquid chromatography. Microsphere
distribution, as seen by gamma camera images in a different slice, was
correlated with the extent of fibrosis assessed by histological analysis of
the same myocardial specimen. Mean transmural myocardial blood flow was
0.49 +/- 0.17 and 0.38 +/- 0.15 mL.min-1 x g-1 in idiopathic dilated
cardiomyopathy and ischemic heart disease, respectively (P < .01).
Endocardial-to-epicardial flow ratio was lower in ischemic heart disease
than in idiopathic dilated cardiomyopathy patients (0.99 +/- 0.33 versus
1.16 +/- 0.30, P < .05). Mean myocardial fibrosis was 9 +/- 6% in
idiopathic dilated cardiomyopathy and 25 +/- 28% in ischemic heart disease.
In both groups, no correlation was found between myocardial blood flow
values and the extent of fibrosis. In ischemic heart disease, regional
myocardial blood flow was not significantly affected by the severity of
coronary stenosis (< or = 70% or > 70%) either in the endocardium
(0.44 +/- 0.24 versus 0.36 +/- 0.16 mL.min-1 x g-1, P = NS) or in the
epicardium (0.50 +/- 0.33 versus 0.38 +/- 0.33 mL.min-1 x g-1, P = NS). By
gamma camera imaging, transmural microsphere distribution appeared more
homogeneous in idiopathic dilated cardiomyopathy than in ischemic heart
disease (mean coefficient variation, 18% and 27%, respectively; P <
.02); the severity of perfusion impairment did not correlate with the
extent of fibrosis evaluated by histological criteria. CONCLUSIONS. Heart
transplant surgery offers a valuable model to assess absolute myocardial
perfusion in human heart failure. Myocardial blood flow is markedly
depressed in failing hearts of both ischemic heart disease and idiopathic
dilated cardiomyopathy patients; a different transmural myocardial blood
flow distribution is observed in ischemic heart disease than in idiopathic
dilated cardiomyopathy, with prevalent endocardial perfusion in the latter
but not the former condition. In patients with end-stage heart failure,
myocardial blood flow appears to be similarly impaired in fibrotic and
viable regions. Mechanisms other than myocardial fibrosis and coronary
lesions appear to operate in determining myocardial blood flow impairment
in heart failure.
ARTICLES
Myocardial blood flow distribution in patients with ischemic heart disease or dilated cardiomyopathy undergoing heart transplantation
CNR Clinical Physiology Institute, Section of Milan, Piazza Ospedale Maggiore, Italy.
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