Original Article
Prediction of appropriate ICD therapy in patients with ischemic heart failure

https://doi.org/10.1007/s12350-020-02321-yGet rights and content

Abstract

Background

Previous studies show inconsistent results on the role of innervation imaging (with I-123-mIBG) and perfusion imaging in predicting appropriate ICD therapy (aICDth). These studies included patients with both dilated and ischemic cardiomyopathy. This study compared the ability of 123I-mIBG imaging along with perfusion imaging (using thallium-199) to predict aICDth in patients with ischemic heart failure (IHF) in relation to indication for ICD implantation (primary vs. secondary prevention of sudden cardiac death (SCD)).

Methods

mIBG/thallium SPECT imaging were performed before ICD implantation in 80 patients with IHF: 49 candidates for primary and 31 for secondary SCD prevention.

Results

During a mean follow-up of 18 months, the imaging results could not predict patients with appropriate ICD therapy among patients with ICD implants for primary SCD prevention.

While in the secondary SCD prevention group, those who received a ICDth had significantly larger summed scores of regional perfusion and innervation impairment, but not higher heart-to-mediastinal mIBG ratio. The best results to predict aICDth were using mIBG summed score (cut-off point > 34%, sensitivity 72%, specificity 100%, AUC 0.909, P < 0.0001).

Conclusion

The prognostic value of innervation and perfusion imaging in patients with IHF differ based on indication for ICD implantation (primary vs. secondary prevention of SCD).

Introduction

Cardiovascular diseases are the leading cause of morbidity and mortality worldwide. Moreover, 25% of cardiovascular deaths happen suddenly. In particular, patients with prior myocardial infarction (MI) have an increased risk of sudden cardiac death (SCD).1,2

Currently, the use of an implantable cardioverter-defibrillator (ICD) is the main tool for SCD prevention.3 According to modern guidelines, the implantation of ICD for primary SCD prevention is recommended in patients with left ventricular ejection fraction (LVEF) of 35% or less that is due to ischemic heart disease who are at least 40 days post MI and at least 90 days of postrevascularization, with NYHA class II or III of heart failure (HF) despite guideline-directed management and therapy, and with expected meaningful survival of greater than 1 year.3,4 For NYHA class IV it is recommended only for candidates for cardiac transplantation or a left ventricular assist device.3,4 However, in few trials it was shown that only about 25% of these patients received appropriate ICD therapy (ICDth), and therefore there is a need to improve selection criteria for primary SCD prevention.5, 6, 7

It is known that HF is associated with activation of the sympathetic cardiac system, which is involved in mechanisms of cardiac arrhythmias development. Cardiac sympathetic activity can be non-invasively assessed with meta-iodobenzylguanidine (123I-mIBG) using both planar and SPECT techniques.8 To date, there are many studies, showing the possibility of 123I-mIBG scintigraphy to predict SCD in HF patients.8, 9, 10, 11, 12, 13 It has been demonstrated that late heart-to-mediastinum (H/M) ratio < 1.6 can serve as a predictor of adverse arrhythmological events (AEs) in cohorts of patients with ischemic or non-ischemic cause of HF.10 It has also been shown that scores of regional innervation/perfusion impairment predispose to ventricular arrhythmias and can serve as predictors of ICD discharges.14 However, the majority of 123I-mIBG studies have been performed using heterogeneous samples, which included patients with dilated and non-ischemic cardiomyopathy or candidates for primary and secondary SCD prevention.10,12,13 Meanwhile, this could affect the results of 123I-mIBG scintigraphy for the differentiation of high-risk patients.15,16 We hypothesized that scintigraphic predictors of ICDth are different in relation to indication for ICD implantation (primary or secondary SCD prevention).

In our study, we chose to focus only on patients with ischemic HF (IHF) for several reasons. Firstly, the ischemic heart disease is the most common cause for HF worldwide.17 Secondly, an association between regional innervation/perfusion abnormalities, innervation/perfusion mismatch, hibernation areas, and susceptibility to arrhythmias was demonstrated particularly in patients with ischemic heart disease.8,14, 15, 16,18

The goal of our study was to compare the ability of 123I-mIBG imaging along with perfusion imaging (using thallium-199) to predict appropriate ICD therapy in patients with ischemic heart failure in relation to indication for ICD implantation (primary vs. secondary prevention of SCD).

Section snippets

Patients

From November 2016 to October 2018 94 patients with prior MI referred for ICD implantation at the Department of Surgical Treatment of Complicated Cardiac Arrhythmias and Pacing, Cardiology Research Institute Tomsk NRMC were considered for inclusion in the study. Among them 4 patients refused to participate, 10 patients met the exclusion criteria. The prospective research included remained 80 (the average age of 63.7 ± 9.7 years) patients with indications for ICD implantation for primary or

123I-mIBG Images Acquisition and Analysis

All patients underwent thyroid block by taking a 5% Lugol’s solution for 3 days (5 drops of Lugol’s solution 3 times a day) before administration of 111-370 MBq 123I-mIBG. Myocardial scintigraphy was acquired in supine position, with a dual-head gamma-camera Forte (Philips Healthcare, Amsterdam, the Netherlands) equipped with low-energy general-purpose collimators at fifteen (i.e., early) and 240 (i.e., late) minutes after tracer injection. Planar anterior thoracic images were acquired for 10

199Tl SPECT Acquisition and Analysis

To detect areas of stable perfusion impairment and areas of viable myocardium at 48 h after 123I-mIBG imaging in all patients, we performed cardiac 199Tl (Tomsk Polytechnic University, TPU) SPECT. Thallium-199 (72.5 keV) is low-energy cyclotron-produced radionuclide, with 7.4 hours of half-life.24,25 Its kinetics and images are indistinguishable from 201Tl, allowing the performance of high-quality stress, rest, and redistribution protocols for myocardium perfusion scintigraphy.26,27 Since 199Tl

Patient’s Characteristics

Group 1 enrolled 49 candidates for ICD implantation for primary SCD prevention, Group 2 to 31 candidates for secondary SCD prevention. Baseline characteristics, 123I-mIBG and 199Tl imaging results of the enrolled patients are presented in Table 1. An intermediate decrease in the H/M for 123I-mIBG was defined as 1.40-1.89, based on the previous reports.29

Except LVEF, all clinical and scintigraphic parameters in both groups did not differ significantly. In Group 1, LVEF was significantly lower

Discussion

In the present study was shown that prognostic values of 123I-mIBG and 199Tl scintigraphy differ between candidates for primary and secondary SCD prevention.

Last years, the value of 123I-mIBG scintigraphy for predicting SCD in patients with HF has been actively investigated.8,12,13 The majority of these studies were performed mainly on heterogeneous patients sampling, which could affect the results.

In the study of Boogers et al. a heterogeneous cohort of patients with predominance of ischemic

New Knowledge Gained

The prognostic value of innervation and perfusion imaging in patients with IHF differ based on indication for ICD implantation (primary vs. secondary prevention of SCD).

Conclusion

The prognostic value of innervation and perfusion imaging in patients with IHF differ based on indication for ICD implantation (primary vs. secondary prevention of SCD). Both 123I-mIBG and 199Tl SPECT could not predict appropriate ICDth in patients after MI who were candidates for primary SCD prevention in the current study. In the same time, the good relationship between size of denervated and/or hypoperfused myocardium and appropriate ICDth was shown in candidates for secondary SCD

Disclosure

S.I. Sazonova, T.A. Atabekov, R.E. Batalov, A.I. Mishkina, J.V. Varlamova, K.V. Zavadovsky, and S.V. Popov declares that they have no conflict of interest.

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