Circulation, Vol 89, 578-587, Copyright © 1994 by American Heart Association
V Dilsizian, JA Arrighi, JG Diodati, AA Quyyumi, K Alavi, SL Bacharach, JA Marin- Neto, PT Katsiyiannis and RO Bonow
BACKGROUND: 99mTc-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 RESULTS: We 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-to-moderate 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%. CONCLUSIONS: These 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.
ARTICLES
Myocardial viability in patients with chronic coronary artery disease. Comparison of 99mTc-sestamibi with thallium reinjection and [18F]fluorodeoxyglucose [published erratum appears in Circulation 1995 Jun 15;91(12):3026]
Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892.
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