Original Article
Could myocardial viability be related to left ventricular dyssynchrony? Simultaneous evaluation by gated SPECT-MPI

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Abstract

Background

Left ventricular contraction dyssynchrony (LVCD) has been related to induced ischemia and transmural scar but the interplay of myocardial viability and dyssynchrony is unknown. The aim of the present study was to establish the role of dyssynchrony in the context of a viability study performed with nitrate augmentation gated single photon emission computed tomography (GSPECT) myocardial perfusion imaging (MPI).

Methods

Fifty-four consecutive patients with ischemic dilated cardiomyopathy (IDC) and depressed left ventricular ejection fraction (LVEF) were included. They underwent a two-day rest/nitroglycerine (NTG) study GSPECT MPI to determine the myocardial viability. Patients with a nitrate-induced uptake increase of > 10% vs baseline, in at least, two consecutive dysfunctional segments were considered viable as well as those who showed no improvement in the uptake but the uptake was > 50% on post NTG study. Patients with no nitrate-induced uptake increase of > 10% and the uptake of < 50% were considered non-viable. Perfusion, function and LVCD were compared in 25 viable patients vs 29 non-viable patients at baseline and after NTG administration.

Results

After NTG administration, in the viable group, the LVEF increased (36.44 ± 6.64% vs 39.84 ± 6.39%) and the end-systolic volume decreased significantly (119.28 ± 31.77 mL vs 109.08 ± 33.17 mL) (P < 0.01). These patients also experienced a significant reduction in the LVCD variables: phase standard deviation was reduced in the post NTG study (57.77° ± 19.47° vs 52.02° ± 17.09°) as well as the phase histogram bandwidth (190.20° ± 78.83° vs 178.0° ± 76.14°) (P < 0.05). Functional and LVCD variables remained similar in the non-viable patients (P > 0.05).

Conclusion

In patients with IDC and depressed LVEF, the myocardial viability detected by rest/ NTG GSPECT MPI, might determine LVCD improvement.

Introduction

Positron emission tomography (PET) flow/metabolic mismatch is considered the nuclear medicine gold standard for the assessment of myocardial viability. Baseline/nitrate technetium 99m (Tc-99m) tetrofosmin gated single photon emission computerized tomography (GSPECT) myocardial perfusion imaging (MPI) may provide equivalent clinical information.1, 2, 3, 4 In comparison with PET, SPECT imaging is probably less accurate. However, this disadvantage is partly, if not entirely, overcome by the wider availability and lower costs of SPECT imaging.5

In addition, GSPECT MPI is useful for the analysis of left ventricular (LV) function and synchronism with high repeatability and reproducibility.6, 7, 8, 9, 10, 11 Phase analysis has been developed and validated to measure LV synchrony by GSPECT MPI.9, 10, 11, 12, 13 This technique also offers the possibility of determining myocardial viability, ventricular function and LV synchrony in the same study.

The severity of cardiac dyssynchrony appears as a negative marker in the evolution of patients with dilated cardiomyopathy.14, 15, 16, 17 Also, many studies have shown that regional dyssynchrony, viability and regional scar are important for optimizing LV lead placement, and they are important factors related to cardiac resynchronization therapy response.18, 19, 20, 21, 22, 23

Considering that LV contraction dyssynchrony (LVCD) has been shown to be related to induced ischemia24, 25, 26, 27, 28 and regional scar29,30, we hypothesized that myocardial viability could be related to LVCD. The aim of the present study was to establish the role of dyssynchrony in the context of a viability study performed with nitrate augmentation GSPECT MPI.

Section snippets

Ethics Statement

Informed consent was obtained from each patient. This study complies with the Declaration of Helsinki. The protocol was approved by the institution´s ethical committee.

Patient Selection

Fifty-four consecutive patients were enrolled as the study group. They were suffering from ischemic dilated cardiomyopathy (ICD) demonstrated by invasive coronary angiography (a severe proximal stenosis > 70% in at least one main coronary artery), depressed LV ejection fraction (LVEF) (less than 40%) and they were referred for

Patient Characteristics

Both groups were similar regarding demographic characteristics, coronary risk factors, previous myocardial infarction (93%), myocardial infarction localization (63% anterior), symptoms (40% typical angina). All patients showed a significant coronary artery stenosis in at least one main coronary artery. No differences were found in the coronary artery disease extension and location between groups (P > 0.05). The three-vessel disease and the left descending coronary artery enrolment were the most

Discussion

Nitrate-augmented MPI has demonstrated improvement in the detection of myocardial viability,1, 2, 3, 4,32, 33, 34, 35, 36, 37, 38, 39, 40 in LV function1,41, 42, 43, 44, 45, 46 and an accurate prediction of recovery of LV function after revascularization in patients with severe coronary artery disease and LV dysfunction.4,7,44,45

On the other hand, stress-rest GSPECT MPI has revealed a controversial relationship between induced ischemia and LVCD: Some recent studies have demonstrated LVCD

New Knowledge Gained

To our knowledge, this is the first time that the relationship between myocardial viability and LVCD has been studied. With the NTG administration just prior to GSPECT acquisition, we were able to recognize those viable segments with dyssynchrony improvement.

Conclusions

In patients with IDC and depressed LVEF, the myocardial viability detected by rest/NTG GSPECT MPI might determine LVCD improvement. This analysis could be helpful in predicting functional recovery after cardiac revascularization. However, this hypothesis warrants further study.

Acknowledgments

To Adrienne Hunter, PhD, for her contribution to the review of the English manuscript.

Disclosures

Kenia Padrón, Amalia Peix, Lázaro Cabrera, José Garcia, Lydia Rodriguez, Regla Carrillo, Erick Mena, Yoel Fernandez declare that they have no conflict of interest.

References (51)

  • GiorgettiA et al.

    Baseline/post-nitrate Tc-99m tetrofosmin mismatch for the assessment of myocardial viability in patients with severe left ventricular dysfunction: Comparison with baseline Tc-99m tetrofosmin scintigraphy/FDG PET imaging

    J Nucl Cardiol

    (2004)
  • SchinkelAF et al.

    Single-photon emission computed tomography for assessment of myocardial viability

    Euro Intervention

    (2010)
  • HeW et al.

    Tc-99m tetrofosmin tomography after nitrate administration in patients with ischemic left ventricular dysfunction: Relation to metabolic imaging by PET

    J Nucl Cardiol

    (2003)
  • PatelRA et al.

    Prognostic role of single-photon emission computed tomography (SPECT) imaging in myocardial viability

    Curr Opin Cardiol

    (2006)
  • Sciagrà R. SPECT and PET protocols for imaging myocardial viability. Curr Cardiovasc Imaging Rep 2014. Available at:...
  • DePueyEG et al.

    Using gated technetium 99-m sestamibi SPECT to characterize fixed myocardial defects as infarct or artifact

    J Nucl Med

    (1995)
  • SciagraR et al.

    Technetium- 99m sestamibi imaging to predict left ventricular ejection fraction outcome after revascularization in patients with chronic coronary artery disease and left ventricular dysfunction: Comparison between baseline and nitrate enhanced imaging

    Eur J Nucl Med

    (2001)
  • SomsenGA et al.

    Ventricular mechanical dyssynchrony and resynchronization therapy in heart failure: A new indication for Fourier analysis of gated blood-pool radionuclide ventriculography

    Nucl Med Commun

    (2006)
  • ChenJ et al.

    Onset of left ventricular mechanical contraction as determined by phase analysis of ECG-gated myocardial perfusion SPECT imaging: Development of a diagnostic tool for assessment of cardiac mechanical dyssynchrony

    J Nucl Cardiol

    (2005)
  • HennemanMM et al.

    Phase analysis of gated myocardial perfusion single-photon emission computed tomography compared with tissue Doppler imaging for the assessment of left ventricular dyssynchrony

    J Am Coll Cardiol

    (2007)
  • HennemanM et al.

    Nuclear imaging in cardiac resynchronization therapy

    J Nucl Med

    (2007)
  • CheungA et al.

    The performance of phase analysis of gated SPECT myocardial perfusion imaging in the presence of perfusion defects: A simulation study

    J Nucl Cardiol

    (2012)
  • LinX et al.

    Repeatability of left ventricular dyssynchrony and function parameters in serial gated myocardial perfusion SPECT studies

    J Nucl Cardiol

    (2010)
  • PeixA et al.

    Stress-Rest myocardial perfusion scintigraphy and adverse cardiac events in heart failure patients

    MEDICC Review

    (2015)
  • ChalilS et al.

    Intraventricular dyssynchrony predicts mortality and morbidity after cardiac resynchronization therapy: A study using cardiovascular magnetic resonance tissue synchronization imaging

    J Am Coll Cardiol

    (2007)
  • AljaroudiWA et al.

    Relation of left-ventricular dyssynchrony by phase analysis of gated SPECT images and cardiovascular events in patients with implantable cardiac defibrillators

    J Nucl Cardiol

    (2010)
  • PazhenkottilAP et al.

    Long-term prognostic value of left ventricular dyssynchrony assessment by phase analysis from myocardial perfusion imaging

    Heart

    (2011)
  • BoogersMJ et al.

    Optimal left ventricular lead position assessed with phase analysis on gated myocardial perfusion SPECT

    Eur J Nucl Med Mol Imaging

    (2011)
  • HennemanMM et al.

    Can LV dyssynchrony as assessed with phase analysis on gated myocardial perfusion SPECT predict response to CRT?

    J Nucl Med

    (2007)
  • AugerD et al.

    Effect of cardiac resynchronization therapy in patients without left intraventricular dyssynchrony

    Eur Heart J

    (2012)
  • YpenburgC et al.

    Impact of viability and scar tissue on response to cardiac resynchronization therapy in ischemic heart failure patients

    Eur Heart J

    (2007)
  • YpenburgC et al.

    Optimal left ventricular lead position predicts reverse remodeling and survival after cardiac resynchronization therapy

    J Am Coll Cardiol

    (2008)
  • TanakaH et al.

    Dyssynchrony by speckle-tracking echocardiography and response to cardiac resynchronization therapy: Results of the Speckle Tracking and Resynchronization (STAR) study

    Eur Heart J

    (2010)
  • PeixA et al.

    Association between non-perfusion parameters and presence of ischemia in gated-SPECT myocardial perfusion imaging studies

    J Nucl Cardiol

    (2018)
  • ChenCh et al.

    Stress-induced myocardial ischemia is associated with early post-stress left ventricular mechanical dyssynchrony as assessed by phase analysis of 201Tl gated SPECT myocardial perfusion imaging

    Eur J Nucl Med Mol Imaging

    (2012)
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