John C. Lasher

Comparative effects of volume loading, dobutamine, and nitroprusside in patients with predominant right ventricular infarction.

To assess the value of volume loading and to determine the relative efficacy of dobutamine compared with nitroprusside therapy in acute right ventricular infarction (RVMI), 13 patients with clinical, hemodynamic, and radionuclide angiographic evidence of RVMI were evaluated. In 10 patients who had an initial pulmonary arterial wedge pressure less than 18 mm Hg, volume loading did not improve cardiac index (1.9 +/- 0.5 [SD] to 2.1 +/- 0.4 liters/min/m2), despite significant increases in mean right atrial pressure (11 +/- 2 to 15 +/- 2 mm Hg, p less than .001) and pulmonary arterial wedge pressure (10 +/- 4 to 15 +/- 2 mm Hg, p less than .001). Nine patients received dobutamine or nitroprusside in random order, while hemodynamic measurements and radionuclide angiograms were obtained simultaneously. Compared with nitroprusside, dobutamine produced a statistically significant increase in cardiac index (2.0 +/- 0.4 to 2.7 +/- 0.5 vs 2.1 +/- 0.4 to 2.3 +/- 0.5 liters/min/m2, p less than .001), stroke volume index (29 +/- 6 to 36 +/- 8 vs 29 +/- 6 to 30 +/- 6 ml/m2, p = .02), and right ventricular ejection fraction (30 +/- 8% to 42 +/- 7% vs 34 +/- 8% to 37 +/- 4%, p less than .01) by two-way analysis of variance. We conclude that volume loading does not improve cardiac index in patients with acute RVMI despite a rise in cardiac filling pressures and that infusion of dobutamine, after appropriate volume loading, produces a significant improvement in cardiac index and right ventricular ejection fraction over those after infusion of nitroprusside.

Hemodynamically important right ventricular infarction: follow-up evaluation of right ventricular systolic function at rest and during exercise with radionuclide ventriculography and respiratory gas exchange.

The prognosis and recovery of right ventricular systolic function in patients with hemodynamically documented right ventricular myocardial infarction (RVMI) is unclear. Therefore 27 patients who met hemodynamic criteria for RVMI were followed for at least 1 year. Four patients died within 1 year and 23 survived. Postmortem examination performed in three of the four patients showed extensive infarction of the right and left ventricles. Survivors underwent early and late follow-up resting radionuclide ventriculograms and late exercise studies. During long-term follow-up (1 to 4 years) resting radionuclide ventriculography demonstrated a significant improvement in right ventricular ejection fraction (30 +/- 7% to 43 +/- 8%; p less than .001) and right ventricular wall motion index (2.2 +/- 0.4 to 1.5 +/- 0.5; p less than .001) in 18 patients who survived longer than 1 year. Fourteen of these patients underwent upright bicycle exercise while off beta-blocking drugs and peak radionuclide ejection fraction was acquired after anaerobic threshold was achieved. Right ventricular ejection fraction increased significantly from 41 +/- 10% to 47 +/- 12% (p less than .001), as did the left ventricular ejection fraction (55 +/- 15% to 60 +/- 12%; p less than .05). The direction and magnitude of change of the right ventricular ejection fraction correlated significantly with the left ventricular ejection fraction (r = .82, p less than .02). Deviations from this correlation occurred in patients who had a decreased forced expiratory volume in 1 sec and an abnormal ventilatory reserve during exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship of various measures of end-systole to left ventricular maximum time-varying elastance in man.

This investigation was designed to calculate left ventricular maximum time-varying elastance (Emax), to define the relationship between Emax and pressure-volume (P-V) relations at other, more easily defined measured of end-systole, and to determine whether these measures of left ventricular contractile function can be normalized in man. Accordingly, we studied 10 subjects with simultaneous high-fidelity micromanometer left ventricular and ascending aortic pressure recordings and biplane contrast cineangiograms at control conditions and during infusion of methoxamine and nitroprusside. Emax was defined as the maximum slope of the linear relation of isochronal, instantaneous P-V data points obtained from each of the three loading conditions. Left ventricular end-systole was also defined for each loading condition as: the time of the maximum P-V ratio (maxPV), minimum ventricular volume (minPV), (-)dP/dtmin [(-)dP/dtPV], and zero systolic flow approximated by the central aortic dicrotic notch (AodiPV). The mean heart rates and LV (+)dP/dtmax were insignificantly altered during the three loading conditions. Isochronal Emax ranged from 3.38 to 6.73 mm Hg/ml (mean 5.48 +/- 1.23 [SD] mm Hg/ml) and the volume-axis intercepts at zero pressure ranged from -2 to 51 ml (mean 18 +/- 16 ml). The isochronal slope calculations were reproducible (r = .97 to .99). The end-systolic P-V slope values for the maxPV, minPV, (-)dP/dtPV, and AodiPV relations correlated with isochronal Emax (r = .90, .88, .69, and .74, respectively). The average slope values for these end-systolic P-V relations, however, underestimated the mean Emax (p less than .01 to p less than .001). The mean extrapolated volume-axis intercepts for these end-systolic P-V relations also underestimated that for Emax. Finally, the isochronal Emax and other end-systolic P-V relation slope values demonstrated inverse linear relationships with left ventricular mass (r = -.68 to -.91, p less than .05 to p less than .001). Only the Emax volume-axis intercepts showed a linear relationship with left ventricular end-diastolic volume (r = .75). Thus we conclude that the time-varying elastic properties of the left ventricle can be calculated in man, that commonly used end-systolic P-V relations significantly underestimate isochronal Emax, and that normalization of isochronal Emax and other end-systolic P-V relation slope values might be performed in man with left ventricular mass; no obvious relationship between volume-axis intercepts and measures of left ventricular or body size was apparent.

Validation of attenuation-corrected equilibrium radionuclide angiographic determinations of right ventricular volume: comparison with cast-validated biplane cineventriculography.

To determine the accuracy of attenuation-corrected equilibrium radionuclide angiographic determinations of right ventricular volumes, we initially studied 14 postmortem human right ventricular casts by water displacement and biplane cineventriculography. Biplane cineventriculographic right ventricular cast volumes, calculated by a modification of Simpsons rule algorithm, correlated well with right ventricular cast volumes measured by water displacement (r = .97, y = 8 + 0.88x, SEE = 6 ml). Moreover, the mean volumes obtained by both methods were no different (73 +/- 28 vs 73 +/- 25 ml). Subsequently, we studied 16 patients by both biplane cineventriculography and equilibrium radionuclide angiography. The uncorrected radionuclide right ventricular volumes were calculated by normalizing background corrected end-diastolic and end-systolic counts from hand-drawn regions of interest obtained by phase analysis for cardiac cycles processed, frame rate, and blood sample counts. Attenuation correction was performed by a simple geometric method. The attenuation-corrected radionuclide right ventricular end-diastolic volumes correlated with the cineventriculographic end-diastolic volumes (r = .91, y = 3 + 0.92x, SEE = 27 ml). Similarly, the attenuation-corrected radionuclide right ventricular end-systolic volumes correlated with the cineventriculographic end-systolic volumes (r = .93, y = - 1 + 0.91x, SEE = 16 ml). Also, the mean attenuation-corrected radionuclide end-diastolic and end-systolic volumes were no different than the average cineventriculographic end-diastolic and end-systolic volumes (160 +/- 61 and 83 +/- 44 vs 170 +/- 61 and 86 +/- 43 ml, respectively). Comparison of the uncorrected and attenuation-corrected radionuclide right ventricular volumes demonstrated narrower 95% confidence intervals for the attentuation-corrected right ventricular volume determinations over a wide range of cineventriculographic volumes. Thus we conclude that: (1) attenuation-corrected radionuclide right ventricular end-diastolic and end-systolic volumes compare closely with those obtained by a cast-validated biplane cineventriculographic method and (2) attenuation-corrected radionuclide right ventricular volumes correspond more closely to determinations of biplane cineventriculographic right ventricular volumes and are thus likely to be more accurate than uncorrected radionuclide right ventricular volumes.

Human breast tumor imaging using 111In labeled monoclonal antibody: athymic mouse model

The monoclonal antibody (MoAb) 323/A3, an IgG1, was raised against the human breast tumor cell line MCF-7 and recognized a 43 Kd membrane associated glycoprotein. Histochemical studies with the antibody detected 75% of metastatic lymph nodes, 59% of primary breast tumors, and showed some staining in 20% of benign breast lesions. For radionuclide imaging, the MoAb 323/A3 was labeled with both 125I and 111In, via covalently coupled diethylenetriaminepentaacetic acid (DTPA) by the mixed anhydride method. The antibody activity of the DTPA modified 323/A3 was assessed by an immunoassay using viable and fixed MCF-7 target cells. Male athymic nude mice bearing BT-20 human mammary tumors were injected with dual 125I/111In labeled DTPA 323/A3 via the tail veins. The animals were imaged with a gamma camera equipped with a pinhole collimator at 1–3 h, 1, 2, 3, 4 and 5 days after the tracer administration. On day 5 or 6, the animals were killed, and the biodistribution of the radiotracers was determined for the blood, thyroid, heart, lungs, liver, spleen, kidneys, gastrointestinal tract and tumor. Target to blood ratio at 6 days for the 111In tracer was 24:1 in the group with a mean tumor weight of 0.492 g, and 13:1 in another group with a mean tumor weight of 0.1906 g (day 5). However, the 125I activity showed only 3.6:1 and 5.4:1 target to blood ratios in the corresponding groups. The larger tumors localized less 111In tracer (27.13%±7.57% injected dose/g, Mean±SD) than the smaller tumors (52.75%±22.25% ID/g). Analysis of the gamma images showed that the maximum tracer concentration occurred in the tumors at about 2 to 3 days after intravenous tracer administration. The excellent tumor resolution observed with BT-20 tumors may be due to increased 43 Kd glycoprotein antigen density in this tumor cell line.

Rapid objective measurement of gamma camera resolution using statistical moments

An easy and rapid method for the measurement of the intrinsic spatial resolution of a gamma camera was developed. The measurement is based on the first and second statistical moments of regions of interest (ROIs) applied to bar phantom images. This leads to an estimate of the modulation transfer function (MTF) and the full-width-at-half-maximum (FWHM) of a line spread function (LSF). Bar phantom images were acquired using four large field-of-view (LFOV) gamma cameras (Scintronix, Picker, Searle, Siemens). The following factors important for routine measurements of gamma camera resolution with this method were tested: ROI placement and shape, phantom orientation, spatial sampling, and procedural consistency. A 0.2% coefficient of variation (CV) between repeat measurements of MTF was observed for a circular ROI. The CVs of less than 2% were observed for measured MTF values for bar orientations ranging from -10 degrees to +10 degrees with respect to the x and y axes of the camera acquisition matrix. A 256 x 256 matrix (1.6 mm pixel spacing) was judged sufficient for routine measurements, giving an estimate of the FWHM to within 0.1 mm of manufacturer-specified values (3% difference). Under simulated clinical conditions, the variation in measurements attributable to procedural effects yielded a CV of less than 2% in newer generation cameras. The moments method for determining MTF correlated well with a peak-valley method, with an average difference of 0.03 across the range of spatial frequencies tested (0.11-0.17 line pairs/mm, corresponding to 4.5-3.0 mm bars). When compared with the NEMA method for measuring intrinsic spatial resolution, the moments method was found to be within 4% of the expected FWHM.

Anterior, posterior, left anterior oblique, and geometric mean views in gastric emptying studies using a glucose solution

Previous research has shown that the single anterior view of the stomach overestimates the gastric half-emptying time of a solid meal compared to the geometric mean of the anterior and posterior views. Little research has been performed comparing the various views of gastric emptying of a glucose solution. After an overnight fast, 49 nondiabetic subjects were given a 450 ml solution containing 50 g of glucose and 200 Ci of technetium-99m sulfur colloid. Sequential 1-min anterior, posterior, and left anterior oblique views were obtained every 15 min. The mean percent solution remaining in the stomach for all three views differed from the geometric mean by 1.9% or less at all time points. Average gastric half-emptying times were: geometric mean, 62.7±3.3 min; anterior, 61.9±3.2 min; posterior, 63.5±3.5 min; and left anterior oblique, 61.6±3.3 min. These half-emptying times were not statistically different. For individual patients, differences between all three views and the geometric mean were not clinically important. Approximately 95% of all patients are expected to have gastric half-emptying times measured by any of the three single views within 17 min of the gastric half-emptying time obtained using the geometric mean. The imaging of gastric emptying using glucose solutions can be performed using a convenient single view which allows continuous dynamic imaging.

Value of tomographic thallium-201 imaging in patients with chest pain following coronary artery bypass grafting

To determine whether thallium-201 washout profile analysis can detect regional myocardial ischemia caused by coronary artery bypass graft occlusion or progression of disease in nonbypassed coronary arteries, 19 consecutive patients with chest pain following bypass grafting were evaluated with coronary arteriography and thallium-201 scintigraphy. Twenty of the 55 coronary artery regions were perfused by an occluded bypass graft or a significantly stenosed (≥70% diameter narrowing) nonbypassed coronary artery, while 35 coronary regions were perfused by patent bypass grafts or insignificantly diseased coronary arteries. The tomographic thallium-201 washout profile results correlated with the bypass graft and coronary arteriographic findings (k = 0.67, P < 0.001). The sensitivity of tomographic thallium-201 washout profile abnormalities for arteriographic abnormalities was 75%, while the specificity was 86%. The authors conclude that tomographic thallium-201 washout profile analysis may be very useful in the evaluation of patients with chest pain following coronary artery bypass grafting by detecting regional myocardial ischemia caused by occlusion of specific bypass grafts or progression of disease in nonbypassed coronary arteries.

Patterns of intestinal activity with Meckel's scintigraphy

Three patterns of intestinal activity were noted in a review of 64 patients studied with Tc-99m sodium pertechnetate for suspected Meckels diverticulum: no bowel activity seen (37.5%), bowel activity visualized after stomach activity (39.1%), and diffuse bowel activity seen simultaneously with stomach activity (23.4%). The latter pattern, which is relatively common, could mask a true Meckels diverticulum and lead to either a false-negative or indeterminate diagnosis. A series of 10 dogs was also studied to evaluate the effects of fasting and feeding on the intestinal pattern. No definite relationship was observed.

Distance and depth measurements of radioactive objects utilizing rotating slant‐hole collimators

It is desirable to have an accurate method to determine the depth of various organs which are commonly imaged in nuclear medicine. The method presented here utilizes the geometrical characteristics of the rotating slant-hole collimator to calculate distances and depth. The accuracy of the calculated distance was evaluated for point sources in air separated by 11 cm. The reproducibility of the calculated distance was evaluated as a function of the extent of collimator rotation between observations for angular differences of 45 degrees, 90 degrees, 135 degrees, and 180 degrees. The theory of the method is discussed and the relative error in distance calculation analyzed mathematically as a function of (1) collimator rotation angle error, (2) collimator slant angle error, and (3) position calculation error. Our findings indicate this method to be accurate to within 2% with a reproducibility range of 3%-5% for point sources.