Circulation, Vol 88, 1736-1745, Copyright © 1993 by American Heart Association
JA Marin-Neto, V Dilsizian, JA Arrighi, NM Freedman, P Perrone-Filardi, SL Bacharach and RO Bonow
BACKGROUND. The clinical significance and pathophysiological mechanisms of
reverse redistribution on stress-redistribution thallium-201 myocardial
scintigraphy in patients with chronic coronary artery disease are unclear.
Recent studies have shown that thallium-201 reinjection is a useful
technique for the detection of myocardial viability in chronic coronary
artery disease. In this investigation we determined whether thallium
reinjection distinguishes viable from nonviable myocardium in regions with
reverse redistribution. METHODS AND RESULTS. We studied 39 patients with
chronic stable coronary artery disease (age, 60 +/- 10 years), all of whom
demonstrated reverse redistribution on standard exercise-redistribution
thallium single- photon emission computed tomography (SPECT). Reverse
redistribution was defined as > or = 10% decrease in relative
thallium-201 activity between stress and redistribution images and included
either the worsening of a perfusion defect apparent on post-stress images
or the appearance of a new defect on the redistribution images. Thallium
reinjection was performed immediately after the 3- to 4-hour redistribution
study. Of 39 regions with reverse redistribution, 32 (82%) showed enhanced
thallium-201 activity (> or = 10% increase) after reinjection. In the
other 7 regions (18%), the scintigraphic defect persisted after
reinjection. Abnormal Q waves were present in only 8 of 32 (25%) regions
with enhanced thallium-201 uptake after reinjection compared with 5 of 7
(71%) regions not responding to reinjection (P < .05). Akinetic or
dyskinetic wall motion was present in 3 of 32 (9%) regions showing enhanced
uptake after reinjection, in contrast with 5 of 7 (71%) regions not
responding to reinjection (P < .01). Critically stenosed or totally
occluded coronary arteries supplied 24 of 29 (83%) regions with enhanced
thallium-201 uptake after reinjection but only 2 of 7 (28%) regions not
showing a positive response to reinjection (P < .05). Collateral
circulation was detected in 23 of 29 (79%) regions with a positive thallium
reinjection effect but in only 1 of the other 7 regions (P < .01).
Sixteen of the 39 patients also underwent positron emission tomography
using 18F-fluorodeoxyglucose (FDG) to assess glucose utilization and
H2(15)O to assess regional blood flow. The 14 regions with reverse
redistribution that responded to reinjection with enhanced thallium uptake
all showed either normal patterns of FDG uptake and flow or an ischemic
pattern with increased FDG uptake relative to flow. Reduced FDG uptake and
reduced flow values were seen in the two regions not responding to thallium
reinjection. CONCLUSIONS. These observations indicate that reverse
redistribution in chronic coronary artery disease usually reflects viable
myocardium, critically dependent upon collateral circulation.
ARTICLES
Thallium reinjection demonstrates viable myocardium in regions with reverse redistribution
Cardiology Branch, National Heart, Lung, and Blood Institute, Bethesda, Md.
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