Otto Lang

Procedure Guideline for Myocardial Perfusion Imaging 3.3

1Memorial Sloan Kettering Cancer Center, New York, New York; 2Saint Louis University Health Sciences Center, St. Louis, Missouri; 3Georgetown University Medical Center, Washington, DC; 4Emory University Hospital, Atlanta, Georgia; 5Allegheny University of the Health Sciences, Philadelphia, Pennsylvania; 6UCLA School of Medicine, Los Angeles, California; 7Yale University School of Medicine, New Haven, Connecticut; 8William Beaumont Hospital, Royal Oak, Michigan; 9Third Medical School, Charles University, Prague, Czech Republic; and 10Mount Sinai School of Medicine, New York University, New York

Predictors of Improvement of Unrepaired Moderate Ischemic Mitral Regurgitation in Patients Undergoing Elective Isolated Coronary Artery Bypass Graft Surgery

Background— The persistence of moderate ischemic mitral regurgitation (IMR) after isolated coronary artery bypass graft surgery is an important independent predictor of long-term mortality. The aim of the present study was to identify predictors of postoperative improvement in moderate IMR in patients with ischemic heart disease undergoing elective isolated coronary artery bypass graft surgery. Methods and Results— The study population consisted of 135 patients with ischemic heart disease (age, 65±9 years; 81% male) and moderate IMR undergoing isolated coronary artery bypass graft surgery. Fourteen patients died before the 12-month follow-up echocardiography and were excluded. At the 12-month follow-up, 57 patients showed no or mild IMR (improvement group), whereas 64 patients failed to improve (failure group). Before coronary artery bypass graft surgery, the improvement group had significantly more viable myocardium and less dyssynchrony between papillary muscles than the failure group (P<0.001). All other preoperative parameters were similar in both groups. Large extent (≥5 segments) of viable myocardium (odds ratio, 1.45; 95% confidence interval, 1.22 to 1.89; P<0.001) and absence (<60 ms) of dyssynchrony (odds ratio, 1.49; 95% confidence interval, 1.29 to 1.72; P<0.001) were independently associated with improvement in IMR. The majority (93%) of patients with viable myocardium and an absence of dyssynchrony showed an improvement in IMR. In contrast, only 34% and 18% of patients with dyssynchrony and nonviable myocardium, respectively, showed an improvement in IMR, whereas 32% and 49%, respectively, of these patients showed worsening of IMR (P<0.001). Conclusion— Reliable improvement in moderate IMR by isolated coronary artery bypass graft surgery was observed only in patients with concomitant presence of viable myocardium and absence of dyssynchrony between papillary muscles.

Early Tissue Distribution of Bone Marrow Mononuclear Cells After Transcoronary Transplantation in a Patient With Acute Myocardial Infarction

A 57-year-old man with no history of coronary artery disease was admitted for acute anterior ST-segment–elevation myocardial infarction caused by an occlusion of the proximal left anterior descending (LAD) coronary artery. The culprit artery was recanalized with direct stenting with an optimal result. Left ventricular ejection fraction was 40% with anteroapicoseptal akinesia. A positron-emission tomography study demonstrated reduced perfusion and borderline fluorine-18-fluorodeoxyglucose uptake in apical segments and adjacent anterior and septal wall, suggesting reduced viability in the distal LAD territory. Nine days after infarction, the patient underwent autologous bone marrow stem cell transplantation as a part of a research protocol. Bone marrow blood was aspirated under local anesthesia from both iliac crests. A total of 27.4×108 of …

One Day Kinetics of Myocardial Engraftment After Intracoronary Injection of Bone Marrow Mononuclear Cells in Patients with Acute and Chronic Myocardial Infarction.

Objective: To investigate the kinetics of myocardial engraftment of bone marrow-derived mononuclear cells (BMNCs) after intracoronary injection using 99mTc-d,l-hexamethylpropylene amine oxime (99mTc-HMPAO) nuclear imaging in patients with acute and chronic anterior myocardial infarction. Design: Nuclear imaging-derived tracking of BMNCs at 2 and 20 h after injection in the left anterior descending (LAD) coronary artery. Setting: Academical cardiocentre. Patients: Five patients with acute (mean (SD) age 58 (11) years; ejection fraction range 33–45%) and five patients with chronic (mean (SD) age 50 (6) years; ejection fraction range 28–34%) anterior myocardial infarction. Interventions: A total of 24.2×108–57.0×108 BMNCs (20% labelled with 700–1000 MBq 99mTc-HMPAO) were injected in the LAD coronary artery. Results: At 2 h after BMNC injection, myocardial activity was observed in all patients with acute (range 1.31–5.10%) and in all but one patient with chronic infarction (range 1.10–3.0%). At 20 h, myocardial engraftment was noted only in three patients with acute myocardial infarction, whereas no myocardial activity was noted in any patient with chronic infarction. Conclusions: Engraftment of BMNCs shows dynamic changes within the first 20 h after intracoronary injection. Persistent myocardial engraftment was noted only in a subset of patients with acute myocardial infarction.

The SNM Practice Guideline for Somatostatin Receptor Scintigraphy 2.0

VOICE Credit: This activity has been approved for 1.0 VOICE (Category A) credit. For CE credit, participants can access this activity on page 325 or on the SNM Web site (http://www.snm.org/ce_online) through December 31, 2013. You must answer 80% or the questions correctly to receive 1.0 CEH (Continuing Education Hour) credit.

Increased prognostic value of combined myocardial perfusion SPECT imaging and the quantification of lung Tl-201 uptake.

Purpose The authors wanted to identify those patients assessed by exercise SPECT in whom the quantification of lung Tl-201 uptake helps to evaluate disease prognosis. Methods One hundred forty-nine patients (114 men, 35 women; 74 after myocardial infarction [MI]; mean age, 54 ± 9 years) underwent exercise Tl-201 SPECT. The SPECT patterns were divided into normal (n = 45), fixed defects (n = 29), and inducible ischemia (n = 75). Anterior planar imaging was performed before SPECT acquisition to calculate the lung-to-heart ratio (L:H). Results During an average follow-up of 20 ± 9 months, eight patients had died of cardiac causes and 13 patients experienced nonfatal MIs. Among the 45 patients with normal perfusion, no cardiac event was observed and the L:H ratio was not helpful for risk stratification. In 29 patients with fixed defects, four cardiac deaths occurred (all in patients with L:H ratios >0.5; annual event rate, 21.1% for L:H ratios >0.5 compared with 0% for L:H ratios <0.5; chi-square = 4.07, P < 0.05). Among the 75 patients with ischemia, 4 died and 13 had nonfatal MIs (annual event rate, 15.4% for L:H ratios >0.5 compared with 13% for L:H ratios <0.5; P = NS). Conclusions These findings suggest a benign prognosis in patients with normal SPECT (regardless of the L:H ratio). Conversely, all patients with ischemia are at high risk for future cardiac events. Quantification of the Tl-201 lung uptake seems to be valuable in evaluations of disease prognosis, especially in patients with fixed defects.

Activity and practice of nuclear cardiology in the Czech Republic, 2001

Radionuclide myocardial perfusion imaging (MPI) has been on the rise in Europe and the USA. Details on nuclear cardiology in the Czech Republic are not available as yet, as it is impossible to obtain comprehensive data from official registers owing to different methods of reporting and data evaluation. A questionnaire concerning nuclear cardiology activity and practice in 2001 was sent to all nuclear medicine departments in the Czech Republic. All 48 departments completed the questionnaire. In 2001, 50 planar and 54 tomographic (SPET) scintillation cameras were used. The average age of the SPET cameras was 5 years (13% of SPET cameras were >8 years old). Out of the 48 centres, 39 (81%) provided a nuclear cardiology service; the total number of cardiological studies was 15,740 in 2001 (1.5 studies/1,000 population/year). The most frequently employed method was MPI (81.7%), the frequency of which had increased by 10% compared with 2000; 26 of the 39 (67%) departments reported that MPI activity was increasing. Nevertheless, the Czech Republic nuclear cardiology activity remained below the European average (2.2/1,000 population in 1994) and, particularly, below activity in the USA (15/1,000 in 1997). The activity was rather unevenly spread. Whereas two centres with >1,000 studies/year accounted for 20% of the total MPI studies, 16 of 39 (41%) departments exhibited low activity (<200 studies/year) and accounted for only 15% of the total MPI studies. The use of SPET increased from 91% in 2000 to 94% in 2001 (only three institutes performed planar examinations). The most widely used tracer was 99m Tc-MIBI (60% of total MPI), followed by 201Tl (21%) and 99m Tc-tetrofosmin (19%). ECG-gated SPET was employed by 20/39 (51%) centres, of which 11 (28%) performed it as a standard examination; 39% of the total MPI studies included this technique. Thirteen percent (5/39) of the departments used attenuation correction, and 69% (27/39) of the departments used a prone projection. Equilibrium radionuclide ventriculography, with 2,317 examinations (14.7%), ranked second among all nuclear cardiology methods, followed by first-pass angiocardiography (406 studies, 2.6%) and 18F-FDG (163 studies, 1%).

Activity of nuclear cardiology in the Czech Republic between 2000 and 2005

Dear Sir, During the past 10 years, few data have been published on the activity of nuclear cardiology in Europe [1–5]. Recently, the European Council of Nuclear Cardiology organised a survey on myocardial perfusion imaging (MPI) in Europe (http://www.ecnc-nuclearcardiology.org). We read with great interest the paper of Marcassa et al. [6] about the regulatory background of nuclear cardiology in Europe. We would like to comment on the situation in the Czech Republic. On behalf of the Working Group of Nuclear Cardiology of the Czech Society of Cardiology, a questionnaire was sent to all nuclear medicine departments in February 2006 to ascertain whether the activity had increased since the first survey in 2001 [5] and since the second survey in 2003 [7]. The questionnaire surveyed the quality of the equipment, current clinical practice and the number of studies (stress/rest MPI = one study). Out of the 46 centres in the Czech Republic, 40 (87%) reported providing a nuclear cardiology service. There were 75 SPECT cameras in 2005 in comparison with 66 in 2003 and 54 in 2001. However, the average age of the SPECT cameras was 6 years (49% of the SPECT cameras were older than 8 years). The total number of cardiac studies in 2005 was 18,728 (i.e. 1.9 studies/1,000 population). MPI studies accounted for 94.9% of total nuclear cardiology. As a previous survey showed, the rate of use of MPI increased annually by 10%, 13% and 21%, respectively, in 2001–2003 [7]. However, there was no increase in 2004 and only a 2% increase in 2005 (Table 1). There was a reduction in the use of other methods (equilibrium and first-pass angiocardiography) from 2001 to 2005 (Table 2). Although PET capacity in the Czech Republic has recently increased (with four new PET scanners since 2001), the total number of cardiac FDG studies in 2005 increased only slightly (Table 2); 217 cardiac FDG studies represent 2% of the total number of FDG PET procedures performed in the Czech Republic in 2005 (12,089 studies). There is no doubt that the number of MPI studies in Europe is very low relative to the number of studies predicted from epidemiological data, particularly when comparison is made with the USA. Our previous survey documented a rapid increase in the use of MPI in the Czech Republic in 2001–2003 [5]. The stagnation in the expansion of use of MPI in past 2 years may be due to the negative influence of the issues described by Marcassa et al. (e.g. there is a limited nuclear medicine capacity, cardiologists are not allowed to handle radionuclides, etc.) [6]. Eur J Nucl Med Mol Imaging (2007) 34:959–960 DOI 10.1007/s00259-007-0398-1

EFFECT OF SPINAL CORD STIMULATION ON CARDIAC SYMPATHETIC NERVE ACTIVITY IN PATIENTS WITH HEART FAILURE

We aimed at testing the hypothesis that spinal cord stimulation (SCS) reduces cardiac sympathetic nerve activity in patients with heart failure (HF). Patients with HF (NYHA -class III, EF ≤35%, QRS < 120 ms) were randomly assigned to SCS ON for 6 weeks followed by a 6-week OFF period, or vice

Pulse wave as an alternate signal for data synchronization during gated myocardial perfusion SPECT imaging.

Purpose: Proper identification of the cardiac cycle is essential for gated SPECT myocardial perfusion imaging. We have developed an alternate method of ECG for gating, that is, using the peripheral pulse wave (PW) as the triggering signal for gated SPECT acquisition. The aim of this study is to compare the use of this method of gating with the standard ECG trigger. Methods: We tested the PW triggering by comparing it with the ECG trigger. We evaluated 33 patients (25 males, 8 females), average age of 61 years (39–80) referred for stress myocardial perfusion imaging. Data from all patients were acquired twice and were processed by CEqual and QGS software. We compared the left ventricular ejection fraction (LVEF), end-diastolic and end-systolic volumes (EDV, ESV). Paired t test and Pearson correlation coefficient were used for comparison. Results: The mean LVEF, EDV, and ESV calculated with the ECG trigger were 0.52, 120, and 64, respectively, those with the pulse-wave trigger were 0.48, 126, and 71, respectively. Mean paired difference for LVEF was −0.034 (P < 0.001), for EDV 5.9 (P = 0.012), and for ESV 7.9 (P < 0.001). Pearson correlation coefficient for LVEF was 0.955, for EDV 0.987, and for ESV 0.991 (P < 0.001 for all correlations). Conclusion: Triggering of gated-data acquisition by the PW is feasible. Quantitative parameters of cardiac function correlate highly with those obtained from the ECG trigger and the absolute differences are not clinically significant across a wide range of values.