Original ArticleSimultaneous assessment of myocardial perfusion and adrenergic innervation in patients with heart failure by low-dose dual-isotope CZT SPECT imaging
Introduction
Cardiac 123I-metaiodobenzilguanidine (MIBG) imaging has a central role in the evaluation of cardiac sympathetic activity, and impairment of innervation status has been correlated to a poor prognosis in patients with heart failure (HF).1 Semiquantitative parameters of 123I-MIBG uptake, such as the heart-to-mediastinum (H/M) ratio and washout rate (WR), indicators of autonomic dysfunction, demonstrated prognostic value in patients with HF.2 Prior studies evaluating myocardial perfusion and adrenergic innervation with two separate single-photon emission computed tomography (SPECT) acquisition procedures demonstrated that quantification of perfusion/innervation mismatch provides information about the trigger zone as a prognostic factor of ventricular arrhythmia.3
The introduction of novel dedicated SPECT cameras with semiconductor cadmium–zinc–telluride (CZT) detectors has enabled significant improvements in spatial, temporal and energy resolution in the acquisition protocols by comparison to conventional Anger cameras.4,5 Phantom and clinical studies have shown good correlation between 123I-MIBG H/M ratio and WR obtained by CZT-SPECT and Anger cameras for single tracer studies.6, 7, 8 The increased energy resolution of CZT-SPECT allows a simultaneous assessment of myocardial perfusion and sympathetic innervation in a single-session, thereby reducing imaging time. Thus, when using a low-dose of 123I-MIBG and 99mTc-labeled tracers, it is possible to considerably reduce radiation exposure.
Recently Blaire et al9 in a phantom study assessing perfusion (99mTc) and innervation (123I) using two commercially available CZT-SPECT cameras demonstrated that a simultaneous dual-isotope (SDI) acquisition is feasible and provides perfectly registered functional images with a reduced imaging time. Prior studies have demonstrated correlation between the impairment of innervation, rest perfusion and mechanical dyssynchrony or diastolic function using sequential perfusion and innervation imaging.10,11 However, no studies are available on the quantitative evaluation of perfusion and adrenergic innervation in patients with HF using a simultaneous acquisition protocol by CZT-SPECT. The aim of our study was firstly to evaluate the feasibility of a simultaneous low-dose dual-isotope 123I/99mTc-acquisition protocol using a CZT-SPECT camera. We also assessed the relationship between myocardial perfusion, adrenergic innervation and left ventricular (LV) function in patients with HF undergoing this protocol.
Section snippets
Patients
Thirty-six consecutive patients with HF referred to 123I-MIBG imaging to evaluate cardiac adrenergic innervation, underwent low-dose SDI imaging acquisition. Heart failure was defined as the presence of typical symptoms (e.g., breathlessness, ankle swelling, and fatigue) and/or evidence of structural and/or functional cardiac abnormality, with preserved (≥ 50%), mid-range (40%-49%) or reduced (< 40%) LV ejection fraction (EF).12 The exclusion criteria were atrial fibrillation, implanted
Patient characteristics
Mean regional 123I-MIBG uptake in controls and patients is reported in Table 1. In controls, tracer uptake was reduced in the inferior region compared to the other regions (P < .05). In patients, both apex and inferior walls showed a lower 123I-MIBG uptake compared to the other regions (P < .01). To rule out that the 123I-MIBG uptake reduction in the inferior region in patients may reflect normal physiology more than pathological patterns, we compared individual uptake and found that in 26
Discussion
To our knowledge this is the first study assessing the feasibility of a low-dose SDI 123I/99mTc single imaging session protocol in patients with HF using CZT-SPECT. It is already known that cardiac CZT-SPECT systems have a twofold improvement in energy resolution, allowing simultaneous dual-isotope acquisition with lower down-scatter of the two isotope photo-peaks as compared to conventional SPECT.15,16 When used in combination, the close photo-peaks of 99mTc- and 123I-isotopes require careful
New knowledge gained
Low-dose CZT-SPECT cardiac imaging may enable rapid assessment of differences in LV perfusion and innervation patterns, possibly better characterizing cardiac functional status with reduced radiation exposure and shorter examination time and an associated quality improvement over single isotope studies.
Conclusions
The extent of both myocardial innervation and perfusion defects are related to a reduction of LV systolic function, and late H/M ratio result was an independent predictor of reduced LVEF. Among parameters of cardiac innervation, WR results significantly correlated to extent of perfusion/innervation mismatch area and this could have important clinical implications.
Funding
Open access funding provided by Università degli Studi di Napoli Federico II within the CRUI–CARE Agreement.
Disclosures
Roberta Assante, Adriana D’Antonio, Carmela Nappi, Teresa Mannarino, Valeria Gaudieri, Emilia Zampella, Valeria Cantoni, Roberta Green, Emanuele Criscuolo, Roberto Bologna, Nicola Frega, Hein J. Verberne, Mario Petretta and Alberto Cuocolo declare that they have no financial conflicts of interest. Wanda Acampa is consultant of D-Spectrum.
References (31)
- et al.
Myocardial iodine-123 meta-iodobenzylguanidine imaging and cardiac events in heart failure. Results of the prospective ADMIRE-HF (AdreView Myocardial Imaging for Risk Evaluation in Heart Failure) study
J Am Coll Cardiol
(2010) - et al.
Cardiac sympathetic imaging with mIBG in heart failure
JACC Cardiovasc Imaging
(2010) - et al.
Diagnostic performance of myocardial perfusion imaging with conventional and CZT single-photon emission computed tomography in detecting coronary artery disease: A meta-analysis
J Nucl Cardiol
(2021) - et al.
Head-to-head comparison of diagnostic accuracy of stress-only myocardial perfusion imaging with conventional and cadmium–zinc telluride single-photon emission computed tomography in women with suspected coronary artery disease
J Nucl Cardiol
(2021) - et al.
First assessment of simultaneous dual isotope ((123)I/(99m)Tc) cardiac SPECT on two different CZT cameras: A phantom study
J Nucl Cardiol
(2018) - et al.
Relationships between left ventricular sympathetic innervation and diastolic dysfunction: The role of myocardial innervation/perfusion mismatch
J Nucl Cardiol
(2018) - et al.
Feasibility of simultaneous dual isotope acquisition for myocardial perfusion imaging with a cadmium zinc telluride camera
J Nucl Cardiol
(2020) - et al.
Myocardial iodine-labeled metaiodobenzylguanidine 123 uptake relates to age
J Nucl Cardiol
(1995) - et al.
Optimized acquisition and processing protocols for I-123 cardiac SPECT imaging
J Nucl Cardiol
(2006) - et al.
Optimization of a simultaneous dual-isotope (201)Tl/(123)I-MIBG myocardial SPECT imaging protocol with a CZT camera for trigger zone assessment after myocardial infarction for routine clinical settings: Are delayed acquisition and scatter correction necessary?
J Nucl Cardiol
(2017)
Combined assessment of left ventricular function and rest-redistribution regional myocardial thallium-201 activity for prognostic evaluation of patients with chronic coronary artery disease and left ventricular dysfunction
J Nucl Cardiol
I-123-mIBG myocardial imaging for assessment of risk for a major cardiac event in heart failure patients: Insights from a retrospective European multicenter study
Eur J Nucl Med Mol Imaging
First determination of the heart-to-mediastinum ratio using cardiac dual isotope (123I-MIBG/99mTc-tetrofosmin) CZT imaging in patients with heart failure: The ADRECARD study
Eur J Nucl Med Mol Imaging
Cross calibration of 123I-meta-iodobenzylguanidine heart-to-mediastinum ratio with D-SPECT planogram and Anger camera
Ann Nucl Med
Simultaneous dual-radionuclide myocardial perfusion imaging with a solid-state dedicated cardiac camera
Eur J Nucl Med Mol Imaging
Cited by (6)
Review of cardiovascular imaging in the Journal of Nuclear Cardiology 2022: single photon emission computed tomography
2023, Journal of Nuclear CardiologyNeuroimaging of Cardiac Sympathetic Innervation in Patients Undergoing Catheter Ablation of Ventricular Tachycardia
2022, JACC: Clinical ElectrophysiologyCardiac Perfusion and Innervation Assessment by CZT-SPECT: Have a Look to Simultaneous Dual-isotope Protocol
2023, Current Cardiovascular Imaging ReportsJ-ACCESS investigation and nuclear cardiology in Japan: implications for heart failure
2023, Annals of Nuclear Medicine<sup>123</sup>I-MIBG imaging in heart failure: impact of comorbidities on cardiac sympathetic innervation
2023, European Journal of Nuclear Medicine and Molecular Imaging
The authors of this article have provided a PowerPoint file, available for download at SpringerLink, which summarises the contents of the paper and is free for re-use at meetings and presentations. Search for the article DOI on SpringerLink.com.
The authors have also provided an audio summary of the article, which is available to download as ESM, or to listen to via the JNC/ASNC Podcast.
Copyright comment corrected publication 2022