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The International Journal of Cardiovascular Imaging
 
Int J Cardiovasc Imaging. 2010 December; 26(8): 893–896.
Published online 2010 June 8. doi:  10.1007/s10554-010-9650-z
PMCID: PMC2991157

Gated myocardial SPECT imaging; true additional value in AMI?

Over the years, myocardial perfusion imaging has shown to be a very accurate approach in establishing the diagnosis myocardial ischemia and infarction [115]. It also allows identifying the site, size and the severity of perfusion defects in patients with acute chest pain. It is well known that perfusion abnormalities may persist for several hours after the acute event together with wall motion and wall thickening abnormalities very likely due to myocardial stunning. Analysis by gated SPECT imaging may detect these high risk patients who might otherwise be seen as low risk patients due to normal perfusion. This is particularly important in patients with inferolateral ischemia as perfusion artifacts are common in the inferolateral myocardial region [1631]. Concentration and proximity of subdiaphragmatic radioactivity relative to myocardium comprise a major factor in the nature and severity of inferior wall artifacts. If the subdiaphragmatic radioisotope concentration is equivalent to that in the myocardium, complex, potentially uninterpretable hot and cold inferior wall artifacts are produced. Gating offers considerable additional value to SPECT myocardial perfusion imaging in characterizing fixed defects thereby potentially improving test specificity. Since perfusion, function and wall motion/thickening can be assessed simultaneously, gated SPECT imaging follows the concept of a one-stop shop such as propagated by MRI studies [15, 3245]. This holds in particular for regions with diminished radioisotope uptake. In case of preserved wall motion and/or thickening in region with a perfusion defect there might be still remaining viability influencing the appropriate management strategy [4650]. On the other hand, it might be very interesting to study wall motion/thickening in areas with apparent normal myocardial perfusion in the acute phase of myocardial ischemia.

In the current issue of the International Journal of Cardiovascular Imaging, Neill et al. [51] used gated SPECT imaging at rest to compared semi-quantitative visual scores of perfusion, motion and thickening with an automated hypoperfusion index in patients with suspected acute inferolateral perfusion defects. In the absence of perfusion defects motion and thickening abnormalities were assessed. The authors studied 68 patients (of whom 56 with acute myocardial infarction) with chest pain at rest with either ST depression ≥0.1 mV in ≥1 of leads I, aVL, V1-V6 on 12-lead ECG or ST elevation ≥0.05 mV in ≥1 posterior lead on the body surface map. A rest gated SPECT image was performed within 24 h of the origin of chest symptoms. The ECG gated images were obtained 45–60 min after intravenous administration of 350–400 MBq of Tc99–sestamibi. The myocardial images were semi-quantitatively evaluated for perfusion, motion and thickening. The scores were compared to the automated global hypoperfusion index. This index is equivalent to the product of the surface of the hypoperfused area and the mean severity of the hypoperfused area, and expressed as a percentage of the left ventricular mass. A hypoperfusion index >5 was considered abnormal. It was shown by the authors that the summed perfusion score correlated well with the hypoperfusion index. Summed thickening score correlated well with the hypoperfusion index and the agreement between the scorers was good. Of the 1,156 evaluated segments, 21% of normally perfused segments had a motion abnormality and 19% of normally perfused segments had a thickening abnormality. It was concluded that, using gated SPECT imaging, assessment of wall motion and thickening in addition to perfusion in acute myocardial ischemia improves the diagnostic accuracy for acute myocardial infarction in particular in patients with inferolateral wall ischemia.

Analysis of gated SPECT images for wall motion and thickening abnormalities adds important diagnostic and prognostic information to the assessment of myocardial perfusion. Using gated SPECT imaging, myocardial areas may be identified by the presence of wall motion or thickening abnormalities in the presence of normal perfusion. Wall motion and thickening defects are often present in a segment with abnormal perfusion and are useful for discerning real perfusion defects from artifacts. Occurrence of attenuation artifacts during non-gated SPECT perfusion imaging has been considered an important limitation of the technique [5255]. Apical thinning due to the overlying diaphragm and the occurrence of anteroseptal defects as a result of breast attenuation are very common causes for unwanted perfusion deficits, leading to image misinterpretation and potentially a wrong diagnosis. In radionuclide myocardial perfusion SPECT imaging, successful attenuation correction programs have been developed in order to discriminate between true and false perfusion defects [5658]. Nowadays, gated SPECT fulfills a pivotal role in discriminating true perfusion defects from artifacts. On the other hand, wall motion and/or thickening disturbances in normally perfused areas may unravel pathophysiological states such as myocardial stunning. Such a gated approach should be routinely used in evaluating myocardial SPECT images and this is validly underscored by the study of Neill et al. [51].

Open Access

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Footnotes

Editorial comment to the article of Neill et al. (doi: 10.1007/s10554-010-9641-0).

References

1. Bavelaar-Croon CD, Pauwels EK, Wall EE. Gated single-photon emission computed tomographic myocardial imaging: a new tool in clinical cardiology. Am Heart J. 2001;141:383–390. doi: 10.1067/mhj.2001.112780. [PubMed] [Cross Ref]
2. Bax JJ, Lamb H, Dibbets P, Pelikan H, et al. Comparison of gated single-photon emission computed tomography with magnetic resonance imaging for evaluation of left ventricular function in ischemic cardiomyopathy. Am J Cardiol. 2000;86:1299–1305. doi: 10.1016/S0002-9149(00)01231-5. [PubMed] [Cross Ref]
3. Chamuleau SA, Eck-Smit BL, Meuwissen M, et al. Long-term prognostic value of CFVR and FFR versus perfusion scintigraphy in patients with multivessel disease. Neth Heart J. 2007;15:369–374. doi: 10.1007/BF03086017. [PMC free article] [PubMed] [Cross Ref]
4. Tio RA, Slart RH, Boer RA, et al. Reduced regional myocardial perfusion reserve is associated with impaired contractile performance in idiopathic dilated cardiomyopathy. Neth Heart J. 2009;17:470–474. doi: 10.1007/BF03086306. [PMC free article] [PubMed] [Cross Ref]
5. Knaapen P, Haan S, Hoekstra OS, et al. Cardiac PET-CT: advanced hybrid imaging for the detection of coronary artery disease. Neth Heart J. 2010;18:90–98. [PMC free article] [PubMed]
6. Wall EE, Heidendal GA, Hollander W, Westera G, Roos JP. I-123 labeled hexadecenoic acid in comparison with thallium-201 for myocardial imaging in coronary heart disease. A preliminary study. Eur J Nucl Med. 1980;5:401–405. doi: 10.1007/BF00261781. [PubMed] [Cross Ref]
7. Molhoek SG, Bax JJ, Bleeker GB, et al. Comparison of response to cardiac resynchronization therapy in patients with sinus rhythm versus chronic atrial fibrillation. Am J Cardiol. 2004;94:1506–1509. doi: 10.1016/j.amjcard.2004.08.028. [PubMed] [Cross Ref]
8. Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction; joint ESC/ACCF/AHA/WHF task force for the redefinition of myocardial infarction. Eur Heart J. 2007;28:2525–2538. doi: 10.1093/eurheartj/ehm355. [PubMed] [Cross Ref]
9. Lennep JE, Westerveld HT, Lennep HW, Zwinderman AH, Erkelens DW, Wall EE. Apolipoprotein concentrations during treatment and recurrent coronary artery disease events. Arterioscler Thromb Vasc Biol. 2000;20:2408–2413. [PubMed]
10. Bavelaar-Croon CD, Kayser HW, Wall EE, et al. Left ventricular function: correlation of quantitative gated SPECT and MR imaging over a wide range of values. Radiology. 2000;217:572–575. [PubMed]
11. Wall EE, Dijkman PR, Roos A, et al. Diagnostic significance of gadolinium-DTPA (diethylene-triamine penta-acetic acid) enhanced magnetic resonance imaging in thrombolytic treatment for acute myocardial infarction: its potential in assessing reperfusion. Br Heart J. 1990;63:12–17. doi: 10.1136/hrt.63.1.12. [PMC free article] [PubMed] [Cross Ref]
12. Dijkman PR, Wall EE, Roos A, et al. Acute, subacute, and chronic myocardial infarction: quantitative analysis of gadolinium-enhanced MR images. Radiology. 1991;180:147–151. [PubMed]
13. Braun S, Wall EE, Emanuelsson S, Kobrin I. Effects of a new calcium antagonist, mibefradil (Ro 40–5967), on silent ischemia in patients with stable chronic angina pectoris: a multicenter placebo-controlled study. The mibefradil international study group. J Am Coll Cardiol. 1996;27:317–322. doi: 10.1016/0735-1097(95)00472-6. [PubMed] [Cross Ref]
14. ten Kate GJ, Wuestink AC, Feyter PJ. Coronary artery anomalies detected by MSCT-angiography in the adult. Neth Heart J. 2008;16:369–375. doi: 10.1007/BF03086181. [PMC free article] [PubMed] [Cross Ref]
15. Bakx AL, Wall EE, Braun S, Emanuelsson H, Bruschke AV, Kobrin I. Effects of the new calcium antagonist mibefradil (Ro 40–5967) on exercise duration in patients with chronic stable angina pectoris: a multicenter, placebo-controlled study. Ro 40–5967 International Study Group. Am Heart J. 1995;130:748–757. doi: 10.1016/0002-8703(95)90073-X. [PubMed] [Cross Ref]
16. Kurvers MJ, Braam RL, Verzijlbergen JF, Heestermans AA, Ten Berg JM. Myocardial salvage in STEMI patients treated with primary coronary angioplasty as demonstrated by myocardial SPECT. Neth Heart J. 2007;15:422–423. doi: 10.1007/BF03086044. [PMC free article] [PubMed] [Cross Ref]
17. Jongbloed MR, Lamb HJ, Bax JJ, et al. Noninvasive visualization of the cardiac venous system using multislice computed tomography. J Am Coll Cardiol. 2005;45:749–753. doi: 10.1016/j.jacc.2004.11.035. [PubMed] [Cross Ref]
18. Nooijer R, Verkleij CJ, der Thüsen JH, et al. Lesional overexpression of matrix metalloproteinase-9 promotes intraplaque hemorrhage in advanced lesions but not at earlier stages of atherogenesis. Arterioscler Thromb Vasc Biol. 2006;26:340–346. doi: 10.1161/01.ATV.0000197795.56960.64. [PubMed] [Cross Ref]
19. Hoogendoorn LI, Pattynama PM, Buis B, Geest RJ, Wall EE, Roos A. Noninvasive evaluation of aortocoronary bypass grafts with magnetic resonance flow mapping. Am J Cardiol. 1995;75:845–848. doi: 10.1016/S0002-9149(99)80429-9. [PubMed] [Cross Ref]
20. Laarse A, Kerkhof PL, Vermeer F, et al. Relation between infarct size and left ventricular performance assessed in patients with first acute myocardial infarction randomized to intracoronary thrombolytic therapy or to conventional treatment. Am J Cardiol. 1988;61:1–7. doi: 10.1016/0002-9149(88)91294-5. [PubMed] [Cross Ref]
21. Wall EE, Hollander W, Heidendal GA, Westera G, Majid PA, Roos JP. Dynamic myocardial scintigraphy with 123I-labeled free fatty acids in patients with myocardial infarction. Eur J Nucl Med. 1981;6:383–389. [PubMed]
22. Vliegen HW, Doornbos J, Roos A, Jukema JW, Bekedam MA, Wall EE. Value of fast gradient echo magnetic resonance angiography as an adjunct to coronary arteriography in detecting and confirming the course of clinically significant coronary artery anomalies. Am J Cardiol. 1997;79:773–776. doi: 10.1016/S0002-9149(96)00866-1. [PubMed] [Cross Ref]
23. Hoeven BL, Pires NM, Warda HM, et al. Drug-eluting stents: results, promises and problems. Int J Cardiol. 2005;99:9–17. doi: 10.1016/j.ijcard.2004.01.021. [PubMed] [Cross Ref]
24. Ertaş G, Beusekom HM, Giessen WJ. Late stent thrombosis, endothelialisation and drug-eluting stents. Neth Heart J. 2009;17:177–180. doi: 10.1007/BF03086242. [PMC free article] [PubMed] [Cross Ref]
25. Pluim BM, Lamb HJ, Kayser HW, et al. Functional and metabolic evaluation of the athlete’s heart by magnetic resonance imaging and dobutamine stress magnetic resonance spectroscopy. Circulation. 1998;97:666–672. [PubMed]
26. Scholte AJ, Schuijf JD, Kharagjitsingh AV, et al. Different manifestations of coronary artery disease by stress SPECT myocardial perfusion imaging, coronary calcium scoring, and multislice CT coronary angiography in asymptomatic patients with type 2 diabetes mellitus. J Nucl Cardiol. 2008;15:503–509. doi: 10.1016/j.nuclcard.2008.02.015. [PubMed] [Cross Ref]
27. Torn M, Bollen WL, Meer FJ, Wall EE, Rosendaal FR. Risks of oral anticoagulant therapy with increasing age. Arch Intern Med. 2005;165:1527–1532. doi: 10.1001/archinte.165.13.1527. [PubMed] [Cross Ref]
28. Ypenburg C, Schalij MJ, Bleeker GB, et al. Impact of viability and scar tissue on response to cardiac resynchronization therapy in ischaemic heart failure patients. Eur Heart J. 2007;28:33–41. doi: 10.1093/eurheartj/ehl379. [PubMed] [Cross Ref]
29. Ypenburg C, Roes SD, Bleeker GB, et al. Effect of total scar burden on contrast-enhanced magnetic resonance imaging on response to cardiac resynchronization therapy. Am J Cardiol. 2007;99:657–660. doi: 10.1016/j.amjcard.2006.09.115. [PubMed] [Cross Ref]
30. Roos A, Matheijssen NA, Doornbos J, et al. Myocardial infarct size after reperfusion therapy: assessment with Gd-DTPA-enhanced MR imaging. Radiology. 1990;176:517–521. [PubMed]
31. Roos A, Matheijssen NA, Doornbos J, Dijkman PR, Rugge PR, Wall EE. Myocardial infarct sizing and assessment of reperfusion by magnetic resonance imaging: a review. Int J Card Imaging. 1991;7:133–138. doi: 10.1007/BF01798054. [PubMed] [Cross Ref]
32. Rugge FP, Wall EE, Dijkman PR, Louwerenburg HW, Roos A, Bruschke AV. Usefulness of ultrafast magnetic resonance imaging in healed myocardial infarction. Am J Cardiol. 1992;70:1233–1237. doi: 10.1016/0002-9149(92)90754-M. [PubMed] [Cross Ref]
33. Holman ER, Jonbergen HP, Dijkman PR, Laarse A, Roos A, Wall EE. Comparison of magnetic resonance imaging studies with enzymatic indexes of myocardial necrosis for quantification of myocardial infarct size. Am J Cardiol. 1993;71:1036–1040. doi: 10.1016/0002-9149(93)90569-X. [PubMed] [Cross Ref]
34. Bleeker GB, Schalij MJ, Boersma E, et al. Relative merits of M-mode echocardiography and tissue Doppler imaging for prediction of response to cardiac resynchronization therapy in patients with heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol. 2007;99:68–74. doi: 10.1016/j.amjcard.2006.07.068. [PubMed] [Cross Ref]
35. Ypenburg C, Sieders A, Bleeker GB, et al. Myocardial contractile reserve predicts improvement in left ventricular function after cardiac resynchronization therapy. Am Heart J. 2007;154:1160–1165. doi: 10.1016/j.ahj.2007.07.035. [PubMed] [Cross Ref]
36. Ypenburg C, Wall EE, Schalij MJ, Bax JJ. Imaging in cardiac resynchronisation therapy. Neth Heart J. 2008;16:S36–S40. doi: 10.1007/BF03086204. [PMC free article] [PubMed] [Cross Ref]
37. Geest RJ, Niezen RA, Wall EE, Roos A, Reiber JH. Automated measurement of volume flow in the ascending aorta using MR velocity maps: evaluation of inter- and intraobserver variability in healthy volunteers. J Comput Assist Tomogr. 1998;22:904–911. doi: 10.1097/00004728-199811000-00013. [PubMed] [Cross Ref]
38. Tops LF, Schalij MJ, Holman ER, Erven L, Wall EE, Bax JJ. Right ventricular pacing can induce ventricular dyssynchrony in patients with atrial fibrillation after atrioventricular node ablation. J Am Coll Cardiol. 2006;48:1642–1648. doi: 10.1016/j.jacc.2006.05.072. [PubMed] [Cross Ref]
39. Bleeker GB, Holman ER, Steendijk P, et al. Cardiac resynchronization therapy in patients with a narrow QRS complex. J Am Coll Cardiol. 2006;48:2243–2250. doi: 10.1016/j.jacc.2006.07.067. [PubMed] [Cross Ref]
40. Bleeker GB, Bax JJ, Fung JW, et al. Clinical versus echocardiographic parameters to assess response to cardiac resynchronization therapy. Am J Cardiol. 2006;97:260–263. doi: 10.1016/j.amjcard.2005.08.030. [PubMed] [Cross Ref]
41. Rugge FP, Boreel JJ, Wall EE, et al. Cardiac first-pass and myocardial perfusion in normal subjects assessed by sub-second Gd-DTPA enhanced MR imaging. J Comput Assist Tomogr. 1991;15:959–965. doi: 10.1097/00004728-199111000-00010. [PubMed] [Cross Ref]
42. van der Wall EE, Vliegen HW, de Roos A, Bruschke AV. Magnetic resonance imaging in coronary artery disease. Circulation. 1995;92:2723–2739. [PubMed]
43. Oemrawsingh PV, Mintz GS, Schalij MJ, Zwinderman AH, Jukema JW, Wall EE. Intravascular ultrasound guidance improves angiographic and clinical outcome of stent implantation for long coronary artery stenoses: final results of a randomized comparison with angiographic guidance (TULIP Study) Circulation. 2003;107:62–67. doi: 10.1161/01.CIR.0000043240.87526.3F. [PubMed] [Cross Ref]
44. Portegies MC, Schmitt R, Kraaij CJ, et al. Lack of negative inotropic effects of the new calcium antagonist Ro 40–5967 in patients with stable angina pectoris. J Cardiovasc Pharmacol. 1991;18:746–751. doi: 10.1097/00005344-199111000-00013. [PubMed] [Cross Ref]
45. Tops LF, Bax JJ, Zeppenfeld K, et al. Fusion of multislice computed tomography imaging with three-dimensional electroanatomic mapping to guide radiofrequency catheter ablation procedures. Heart Rhythm. 2005;2:1076–1081. doi: 10.1016/j.hrthm.2005.07.019. [PubMed] [Cross Ref]
46. America YG, Bax JJ, Boersma E, Stokkel M, Wall EE. The additive prognostic value of perfusion and functional data assessed by quantitative gated SPECT in women. J Nucl Cardiol. 2009;16:10–19. doi: 10.1007/s12350-008-9012-6. [PubMed] [Cross Ref]
47. Wall EE, Bax JJ, Jukema JW, Schalij MJ. Gated SPECT in left bundle branch block: from improved diagnosis to improved treatment. Int J Cardiovasc Imaging. 2009;25:53–55. doi: 10.1007/s10554-008-9376-3. [PubMed] [Cross Ref]
48. Bavelaar-Croon CD, Atsma DE, Wall EE, Dibbets-Schneider P, Zwinderman AH, Pauwels EK. The additive value of gated SPET myocardial perfusion imaging in patients with known and suspected coronary artery disease. Nucl Med Commun. 2001;22:45–55. doi: 10.1097/00006231-200101000-00007. [PubMed] [Cross Ref]
49. Pitman AG, Kalff V, Every B, Risa B, Barnden LR, Kelly MJ. Contributions of subdiaphragmatic activity, attenuation, and diaphragmatic motion to inferior wall artifact in attenuation-corrected Tc-99m myocardial perfusion SPECT. J Nucl Cardiol. 2005;12:401–409. doi: 10.1016/j.nuclcard.2005.04.010. [PubMed] [Cross Ref]
50. Slart RH, Bax JJ, Veldhuisen DJ, Wall EE, Dierckx RA, Jager PL. Imaging techniques in nuclear cardiology for the assessment of myocardial viability. Int J Cardiovasc Imaging. 2006;22:63–80. doi: 10.1007/s10554-005-7514-8. [PubMed] [Cross Ref]
51. Neill J, Harbinson M, Adgey J. Myocardial wall motion and thickening assessment in early gated SPECT images of acute coronary syndrome patients likely to have inferolateral perfusion defects. Int J Cardiovasc Imaging. 2010 [PubMed]
52. Morita K, Tsukamoto E, Tamaki N. Perfusion-BMIPP mismatch: specific finding or artifact? Int J Cardiovasc Imaging. 2002;18:279–282. doi: 10.1023/A:1017416220561. [PubMed] [Cross Ref]
53. America YG, Bax JJ, Dibbets-Schneider P, Pauwels EK, Wall EE. Evaluation of the Quantitative Gated SPECT (QGS) software program in the presence of large perfusion defects. Int J Cardiovasc Imaging. 2005;21:519–529. doi: 10.1007/s10554-005-0274-7. [PubMed] [Cross Ref]
54. Purser NJ, Armstrong IS, Williams HA, Tonge CM, Lawson RS. Apical thinning: real or artefact? Nucl Med Commun. 2008;29:382–389. doi: 10.1097/MNM.0b013e3282f4a22e. [PubMed] [Cross Ref]
55. Stinis CT, Lizotte PE, Movahed MR. Impaired myocardial SPECT imaging secondary to silicon- and saline-containing breast implants. Int J Cardiovasc Imaging. 2006;22:449–455. doi: 10.1007/s10554-005-9068-1. [PubMed] [Cross Ref]
56. Verburg FA, Romijn RL, Nekolla S, Verzijlbergen JF. A phantom assessment of cold stomach-related artifacts in myocardial perfusion imaging. Nucl Med Commun. 2009;30:569–573. doi: 10.1097/MNM.0b013e32832c79ce. [PubMed] [Cross Ref]
57. Kovalski G, Keidar Z, Frenkel A, Israel O, Azhari H. Correction for respiration artefacts in myocardial perfusion SPECT is more effective when reconstructions supporting collimator detector response compensation are applied. J Nucl Cardiol. 2009;16:949–955. doi: 10.1007/s12350-009-9148-z. [PubMed] [Cross Ref]
58. Ali I, Ruddy TD, Almgrahi A, Anstett FG, Wells RG. Half-time SPECT myocardial perfusion imaging with attenuation correction. J Nucl Med. 2009;50:554–562. doi: 10.2967/jnumed.108.058362. [PubMed] [Cross Ref]

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