Original Article
Myocardial perfusion imaging analysis in patients with regurgitant valvular heart disease

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Abstract

Background/Aim

We noticed that there was decreased correlation of the findings from myocardial perfusion imaging (MPI) and cardiac catheterization (CATH) in patients with mitral regurgitation (MR) and aortic regurgitation (AR) compared to patients without valve disease.

Methods

Through a systematic review of MPI records at the Harry S. Truman Memorial Veterans’ Hospital between 1998 and 2008, we identified 58 patients with at least moderate MR or AR by echocardiogram who underwent cardiac catheterization within 6 months of the MPI study. A control group was formulated with 60 patients who did not have significant MR or AR on echocardiogram and who had both MPI and CATH. Correlation between MPI and CATH was graded as complete, partial, or absent.

Results

Correlation between MPI and CATH was lower in the valve disease patients (study group) when compared to controls. Correlation was complete in 76% of study patients and 90% of controls, partial in 15% of study patients and 5% of controls, and absent in 9% of study patients and 5% of controls. Differences between the groups were significant (P < .05).

Conclusions

Patients with regurgitant valvular heart disease may have myocardial perfusion abnormalities that are not associated with angiographic critical coronary stenosis.

Introduction

Myocardial perfusion imaging (MPI) is frequently performed to diagnose new coronary artery disease (CAD) and to risk stratify patients with known CAD. MPI has been shown to have a reasonable sensitivity of 87%-89% and specificity 73%-75% for detection of CAD with either exercise or vasodilator stress. Myocardial perfusion imaging abnormalities are known to be present in patients without critical coronary stenosis but associated with other myocardial diseases and left ventricle dysfunction. In patients with significant mitral or aortic regurgitation (MR, AR), there are significant hemodynamic changes that result in left ventricular volume overload, eccentric cardiac hypertrophy with increased left ventricular chamber volumes with eventual progression to left ventricular dysfunction and failure.1,2 The literature regarding the diagnostic accuracy of MPI in patients with moderate to severe MR or AR is sparse.3

Section snippets

Study Design

Systematic review of the findings from patients that have MPI and CATH is performed as part of the clinical quality review program. During the time between January 1998 and January 2008 approximately 1,500 patient records were reviewed at the Harry S. Truman Memorial Veterans’ Hospital. Fifty-eight patients were identified from this group who also had echocardiography that demonstrated moderate to severe mitral valve or aortic valve regurgitation. Data from the medical record of these patients

Results

We identified 58 patients with at least moderate MR or AR by echocardiogram who underwent cardiac catheterization within 6 months of the MPI study (study group). The control group was formulated with 60 patients who did not have significant MR or AR on echocardiogram and who had both MPI and CATH, Table 1. Study group patients had the following types of valvular regurgitation: 42 had moderate MR, 2 had moderate-severe MR, 4 had severe MR, 5 had moderate AR, and 5 had moderate MR and moderate

Discussion

In this retrospective study of male veterans with mitral and aortic regurgitation there was decreased positive predictive value of MPI in identifying CAD when compared to patients without valvular heart disease (76% vs 90%). The ability of MPI in identifying critical CAD in the control group was similar to previous published studies.3 There was also a significant decrease in the left ventricle ejection fraction in the patients with regurgitant valve disease. In the study group, MR was most

Limitations

Our small retrospective study is comprised predominantly of older men. In women and younger men the findings of MPI may be different. Our study subjects had a reduced EF when compared to controls and may have had a higher proportion of primary myocardial pathologies that were the cause of the MPI abnormalities. Comparison of the left ventricle volumes in the two groups was not performed. We have not performed longitudinal follow-up to ascertain the clinical impact of the MPI abnormalities.

Conclusions

In men with moderate regurgitant valvular disease and cardiomyopathy, the specificity of MPI is decreased when compared to patients without valvular heart disease. Gated SPECT is reliable in determining systolic function in this population. Prior to cardiac valve surgery, current practice of definitive evaluation by coronary angiography appears justified.

References (20)

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This report was supported with resources and the use of facilities at the Harry S. Truman Memorial Veterans’ Hospital.

VISN 15 Veterans Administration Research award to A. Chockalingam.

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