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Year : 2010  |  Volume : 25  |  Issue : 3  |  Page : 103-108 Table of Contents   

Nuclear cardiology

Date of Web Publication25-Nov-2010

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How to cite this article:
. Nuclear cardiology. Indian J Nucl Med 2010;25:103-8

How to cite this URL:
. Nuclear cardiology. Indian J Nucl Med [serial online] 2010 [cited 2022 Jan 27];25:103-8. Available from:


Variability of F18-FDG uptake in myocardium

Khan Anna Ara, Sarika, Bhattacharya A, Singh B, Mittal BR

Department of Nuclear Medicine, PGIMER, Chandigarh-160012, India

Aims and Objectives: The goal of this work was to: 1) Analyze myocardial uptake in routine oncological PET scanning via visual assessment. 2) Correlate F-18 FDG myocardial SUV values to blood glycemic levels (BGL). Background: F-18 FDG gets trapped in cancer cells due to their increased glycolytic activity and thus reveals the presence of tumor when other conventional modalities cannot detect any evident lesions. Oncological studies are performed in fasting conditions to minimize the competition between normal glucose and F-18 FDG glucose uptake. For high quality images normal organs should not interfere with the interpretation of images however myocardium represents a prominent F-18 FDG uptake. Materials and Methods: The study population included 83 oncological patients referred for PET scan (40M: 43F; Mean age = 53.74+_12.33 yrs, range = 24- 81 years). Patients with any myocardial abnormality and liver lesions were excluded from the study. All patients were checked for BGL prior to FDG injection. Emission scans were acquired on PET CT (GE Advance Discovery STE) scanner 45-60minutes post injection. The images were retrospectively analyzed and categorized into Uniform High, Uniform Low and Patchy myocardial uptake patterns. Further SUV values were determined on entire left ventricular myocardial region and liver on transaxial slices.The statistical technique of correlation was applied for the following distribution of data to determine the relation between BGL and uptake in entire Left Ventricular region of the myocardium. Results: There were 48.19% (40/83), 19.27% (16/83), 32.5% (27/83) patients in "Uniform Low", "Uniform High" and "Patchy" groups respectively. A scattered plot obtained between Glucose and Ratio (between entire left ventricle SUV and Liver SUV) indicates lack of correlation; r= -0.159 patients range of glucose level average blood glucose average entire lv-suv uniform low 40 63mg% - 217mg% 99.89(+ OR-) 26.76 2.38 (±) 2.2 uniform high 16 75mg%- 143mg% 95.72 (±) 19.82 5.15(+or-)2 patchy uptake 27 54mg% - 133mg% 90.13 (±) 16.55 3.3 (±) 3.17 Correlation coefficient between blood glucose levels and average of entire left ventricle SUV value showed a value of -0.066 indicative of almost negligible correlation between the two variables. A significant number of patients (48.19%) showed uniform low myocardial uptake in routine oncological PET studies. Conclusion: Higher BGL would indicate higher availability of glucose for utilization and possible increased myocardial uptake but the study suggests variable results. On data analysis it is observed that patient with highest BGL had a uniform low myocardial uptake, and the patient with lowest BGL showed patchy myocardial uptake. Other patients with glycemic levels in the normal range showed uniform low, uniform high as well as patchy uptake patterns thus indicating that a low blood glucose level does not indicate diminished heart uptake. Although the blood glucose levels did not present a vast variation amongst the three categories still the F-18 FDG uptake pattern differed (though the category of patients with uniform low uptake had greater mean glucose level than the other 2 categories). Hence blood glucose level does not determine the type of myocardial uptake.

Keywords: Myocardium, FDG uptake, glycemic levels


Role of cardiac FDG PET-CT in inflammatory cardiomyopathy

Mansoor M, Kalyani R, Gauri D, Rao Jyotsna E, Kavitha N, Atul V

Department of NM, Apollo Gleneagles PET-CT Centre Hyderabad, India

Aim: Role of cardiac FDG PET-CT in the diagnosis and monitoring treatment response of inflammatory cardiomyopathy. Materials and Methods: This is a retrospective analysis of 72 patients (over a period of 3 years) referred for cardiac PET-CT with dilated cardiomyopathy (DCM) or idiopathic ventricular tachycardia (VT), to rule out inflammatory cardiomyopathy. FDG cardiac PET was done with patients following very high fat low carbohydrate protein preferred diet (VHFLCPPD) protocol one day prior to scan. Myocardial perfusion scan with 99mTc-tetrofosmin or 13N-NH3 was done prior to FDG PET. All patients underwent breathhold CECT, chest PET-CT and cardiac PET-CT 45 min post FDG injection. Scans were reported jointly by a radiologist and nuclear medicine physician. Clinical/pathological follow-up was obtained where possible. Results: 50(69.4%) patients had positive myocardial FDG uptake with matched perfusion defect on NH3/Tc scan in the absence of CAD. 30(42%) patients had associated metabolically active lymphadenopathy and organ lesions. 4 patients had metabolically active lymphnodes with no myocardial inflammation. 18 patients had no abnormality detected on the scan. Patients with positive lymphnodes underwent biopsy and proven to have granulomatous disease either sarcoidosis and with TB or TB alone. 15 patients had post treatment scan which showed complete metabolic response in 7, partial response in 6 and stable disease in 2. Conclusion: Evaluating patients with DCM or idiopathic VT secondary to inflammatory myocarditis is challenging. Cardiac PET scan with VHFLCPPD protocol is the most sensitive modality available for assessment of disease activity in inflammatory cardiomyopathy and monitoring the treatment response especially in patients with ICD.

Keywords: FDG PET-CT, inflammatory cardiomyopathy, disease activity


Assessment of left ventricular diastolic dysfunction using gated spect and its comparison with tissue doppler echocardiography

Jain Nikunj, Sunil HV, Govindrajan M, Nair G, Selvakumar J

Department of Nuclear Medicine and PET-CT, Narayana Hrudalaya Institute of Medical Sciences, Bengaluru

Introduction: Diastolic dysfunction alone or in association with systolic dysfunction has been recognised as the cause of cardiac dyspnea and less commonly congestive heart failure (CHF). Diastolic function is most commonly assessed by echocardiography. Cardiac magnetic resonance (CMR) and nuclear imaging techniques such as equilibrium radionuclide angiography (ERNA) and Gated SPECT MPI can also provide information about diastolic function. Aim: To compare the diastolic parameters obtained on Gated SPECT MPI with the findings of Tissue Doppler Echocardiography. Materials and Methods: In this prospective study, 24 subjects (age between 35 and 65, 20 males and 4Females) underwent both Tissue Doppler echocardiography and 16 frame gated SPECT (MPI) on the same day. For each patient, diastolic parameters (PFR and TPFR on 16 frame Gated SPECT, using QGS/QPS software and E/A, E/e', IVRT & DT on Tissue Doppler echocardiography) at rest were computed. On the basis of these parameters patients were divided into two categories, one with diastolic dysfunction and the other with no diastolic dysfunction separately by both the modalities. Results: 12 subjects had diastolic dysfunction on both the modalities. 10 subjects had no diastolic dysfunction on both the modalities. 22 patients out of 24 subjects (91.6%) showed concordant results. 2 patients had discordant results. Conclusion: Due to high concordance with 2D TDI as shown in this study, Gated SPECT appears to be a reliable modality for the evaluation of diastolic dysfunction. Diastolic parameters can be included in the standard reporting format of the myocardial perfusion scan.

Keywords: Diastolic dysfunction, 16 frame gated SPECT, tissue Doppler imaging


Calculation of lung to heart ratio from exercise 99m Tc-Tetrofosmin myocardial perfusion imaging

Nisha Bhatia, Sarika, Singh B, Mittal BR

Department of Nuclear Medicine, PGIMER, Chandigarh-160012, India

Background: In Myocardial Perfusion Scintigraphic (MPS) studies, increased lung uptake of 201 Thallium or 99mTc-MIBI is a reliable marker of multi-vessel disease in patients with coronary artery disease (CAD). The aim of the present study was to investigate whether the lung-to-heart uptake ratio (LHR) with 99mTc Tetrofosmin provides some valuable information to detect patients with multi-vessel CAD. Method: Fifty three patients underwent exercise 99mTc-tetrofosmin MPS. The patients were divided in two groups; Group A patients have left ventricular ejection fraction more than 50% while Group B patients have left ventricular ejection fraction less than 50%. The LHR was calculated by delineating two regions of interest (ROI) each on early (10min post injection) and delayed (40min post injection) anterior planar images. One ROI was placed over the left mid-lung and second over the left ventricle myocardium. The ratio of average counts of both the ROI was further subjected to the statistical analysis. Results: On early images, mean average LHR was 0.343 ± 0.064 and 0.482 ± 0.166 in Group A (45 patients, 19 females, 26 Male, mean age 51.33±11.95 yrs, LVEF ≥ 50%) and Group B (8 patients, 1 females, 7 Male, mean age 57.75 ± 10.09 yrs, LVEF< 50%) respectively. On delayed images, average LHR was 0.321 ± 0.057 and 0.427 ± 0.119 respectively. A statistically significant correlation was found between the LHR and LVEF during exercise and rest among the total 53 patients. Conclusions: The present study suggests that Lung-to-heart uptake ratio measured by exercise MPS with 99mTc-Tetrofosmin provides clinically useful information to detect multi-vessel disease in patients with CAD.

Keywords: Technetium-99m-Tetrofosmin, myocardial perfusion imaging, gated single-photon emission computed tomography


Study of diastolic function in patient with normal myocardial perfusion using dedicated solid state detector cardiac camera

Gemawat Shilpa

Jaslok Hospital and Research Centre, Mumbai, India

Aim: Study of diastolic function in patient with normal myocardial perfusion using dedicated solid state detector cardiac camera Materials and Methods: A total of 29 patients (13 male, 16 females) with suspected / known coronary artery diseases who had normal stress-rest myocardial perfusion using 99m Tc - Tetrofosmin and dedicated solid state detector cardiac camera were included in the study Diastolic function was analyzed after 16 frame gated SPECT acquisition and processed using supplied software. Results: Abnormal diastolic function was present in 27 out of 29 patients. 21 patient were symptomatic of which 10 patients had only shortness of breath on exertion, 4 patients had chest pain on exertion and 7 patients had both shortness of breath and chest pain. Conclusion: 1. In patients with normal myocardial perfusion, diastolic dysfunction is present in significant number of patients. 2. Probability of diastolic dysfunction is more in patients with shortness of breath on exertion. 3. Diastolic function is an important parameter to consider while reporting myocardial perfusion imaging. 4. Close follow up of patients with diastolic dysfunction and normal myocardial perfusion imaging should be the area of future study to elucidate its prognostic significance.

Keywords: Solid state detector cardiac camera, diastolic dysfunction, myocardial perfusion imaging, Time to peak filling (TTPF)


Dilated cardiomyopathy - Approach made simplified with myocardial perfusion scintigraphy and cardiac viability studies

Shwetal Pawar, Maitra R, Tilve GH

Department of Nuclear Medicine, KEM Hospital and Seth G S Medical College, Mumbai, India

Aim and Objective: To differentiate the ischemic vs nonischemic dilated cardiomyopathy and to assess myocardial viability in the ischemic cardiomyopathy. Materials and Methods: 34 patients (24 males and 10 females) with dilated cardiomyopathy diagnosed on echocardiography with reduced left ventricular ejection fraction and global hypokinesia were included between the period of Jan 2009 and July 2010. All the patients underwent rest myocardial perfusion scintigraphy first; 45 minutes after intravenous injection of 7 mCi of Tc-99m MIBI. The stress myocardial perfusion imaging (after physical stress or gm/kg/min; 6 min infusion) wasmpharmacological stress with adenosine; 140 performed in the patients with normal perfusion at rest. The F-18 FDG (5 mCi) cardiac viability studies were performed in patient with abnormal rest myocardial perfusion. The images were acquired on GE Infinia systems and processed on Emory toolbox (ECT) to study the ischemia and viability. Results: The mean left ventricular ejection fraction was found to be 27.38% at rest. The stress and rest perfusion scintigraphy was carried out in 20/34(58%) patients in whom 9(45%) patients underwent pharmacological stress with Inj adenosine and 11(55%) patients underwent physical stress. The stress induced ischemia was diagnosed in 12(60%) patients and infarct in 2(10%) patients with mixed ischemia and infarct pattern in 2(10%) patients. The nonischemic cause was diagnosed in 4 patients. The cardiac viability study was carried out in 14/34 (42%) patients with 6(42%) viable, 5(35%) nonviable and 3(21%) mixed viable and nonviable patterns were identified. Conclusion: The myocardial perfusion scintigraphy was the simplified approach for differentiating ischemic verses nonischemic dilated cardiomyopathy with addition of cardiac viability study (18 FDG) made it one stop shop for the complete work-up of patients for further management.

Keywords: Viability, FDG Cardiac PET, ischaemic cardiomyopathy


Myocardial perfusion scan: The third umpire

Mitra Sujata, Muthu GS

Department of Nuclear Medicine and RIA, Tata Main Hospital Jamshedpur-831001, India

A Myocardial Perfusion Scan (MPS) is an established non-invasive procedure that provides information on primary diagnosis and prognosis in patients with stable pain chest. In between June 2007-March 2009, the basis of referral for Coronary Angiography (CAG) in 76% of 58 patients referred for a coronary angiography (CAG) at Tata Main Hospital was the MPS report and intervention was done in 80% of these cases. The concern was that 24% CAG was not done based on MPS findings and 52% of such patients did not benefit from the CAG referral. Purpose of study was to optimize the selection of patients for revascularization and medical therapy through better utilization of MPS. A cross functional team of Cardiologists and NM physician determined the root cause for the referral not based on MPS. These were (a). false- positive MPS in patients with low clinical probability (b). absence of quantified MPS report which did not help to establish extent of disease. (c). false negative MPS reports in which disease was missed due to lack of co-relation with other test modality. Corrective action was addressed through developing a protocol that combined clinical assessment, TMT and MPS reports to refer patients for CAG. The MPS reporting was changed to include quantitative measures of extent, severity score and LV functional parameters. To identify low reversibility, Nitrate enhanced delay images were done. 71patients during the period 2009-2010 were assessed on this protocol before being subjected to CAG. 71 patients were referred based on the new protocol and 86% of these patients underwent intervention. The% accuracy of MPS improved from 84% to 89%. Application of pre test clinical probability helped to rule out patients with low risk of CAD, thus reducing the incidence of false positive MPS. Quantifying the MPS report and correlation with symptoms and addition of another stress test resolved the issue of equivocal MPS reports.

Keywords: Myocardial perfusion scan, patient selection, therapy


Comparison of equilibrium gated radionuclide ventriculography and 2D-tissue doppler imaging for detection of intraventricular dyssynchrony

Vijayraghavan RL, Harish B, Ravikishore AG, Sunil HV, Nair Gopinathan, Selvakumar J

Department of Nuclear Medicine, Narayana Hrudayalaya Institute of Medical Sciences, Bengaluru, India

Background: Cardiac resynchronization therapy has been proved to be beneficial in end-stage heart failure patients with significant intraventricular dyssynchrony. Various techniques available for detection of intraventricular dyssynchrony include echocardiography, magnetic resonance imaging and radionuclide ventriculography. Aim: To compare the findings of 2D-Tissue Doppler Imaging and Equilibrium gated radionuclide Ventriculography in evaluation of intraventricular dyssynchrony. Materials and Methods: 24 end-stage heart failure patients were evaluated for intraventricular dyssynchrony. Resting ERNV was performed on all patients according to ASNC guidelines. Phase image was analyzed on XT-ERNA software; mean phase angle and the standard deviation of phase spread were computed. Intraventricular dyssynchrony was defined as a phase standard deviation of >50º. On the same day, 2D-TDI was also performed. A septum to posterior wall motion delay of >140ms and delay in lateral wall contraction of >70ms were considered significant for intraventricular dyssynchrony on 2D-TDI. Linear regression was performed to correlate the values of intraventricular dyssynchrony between the modalities and to study the relation between LV ejection fraction and dyssynchrony. Results: Intraventricular dyssynchrony was more often detected on ERNV phase analysis than 2D-TDI (41.6% versus 25%). The results between the two modalities were concordant in 83.3% (20/24 cases, r=0.51) of cases. LV ejection fraction and intraventricular dyssynchrony showed negative correlation on ERNV (r= -0.647), indicating an improvement in synchrony with rise in ejection fraction. Conclusion: The results of ERNV for detection of intraventricular dyssynchrony were comparable with 2D-TDI. In our study, phase analysis on ERNV detected intraventricular dyssynchrony with a greater sensitivity than 2D-Tissue Doppler Imaging. Hence it is imperative that we consider nuclear phase analysis on ERNV as a novel alternative for evaluation of cardiac dyssynchrony. These findings need further validation with a higher sample size.

Keywords: American Society of Nuclear Cardiology (ASNC), equilibrium gated radionuclide ventriculography (ERNV), tissue doppler imaging (TDI), intraventricular dyssynchrony


Evaluation of full time and half time acquired cardiac perfusion images and its correlation with coronary angiography

Madhusudhanan P, Kapoor A, Arya A, Ora M, Kheruka S, Dube V, Uttam Kumar, Verma RS, Singh RD, Gambhir S

Department of Nuclear Medicine and Cardiology, SGPGIMS, Lucknow-226014, India

Background: The myocardial perfusion study takes a longer time to complete. A reduction in acquisition time would mean reduced patient motion related artifacts, improvement in camera efficiency and reduction in cost. Iterative reconstruction algorithms produce more accurate images with fewer artifacts. Materials and Methods: Seventy three patients undergoing myocardial perfusion imaging were selected for additional half time acquisition. Patients with suspected or known coronary artery disease who have undergone coronary angiography recently were preferably included. Images were analysed in 4 groups - full time FBP, half time FBP, half time OSEM and half time OSEM. Three independent observers blinded to the clinical data and the acquisition protocol analysed images for change in image quality between these groups. Semiquantitative parameters of summed stress score, summed rest score, summed difference score and left ventricular ejection fraction were also compared using appropriate statistical methods. Results: No difference was noted in SSS, SRS, SDS and LVEF calculated for full time and half time. However, significant difference was found between SSS, SRS and SDS calculated for FBP and OSEM processed half time studies and no significant difference for LVEF calculated for these two groups. Significant change in image quality was noted by 2 observers only in 1.4% and 2.7% of cases. A true positivity rate of 88% was seen in comparison with coronary angiography. Conclusion: Gated myocardial perfusion SPECT images acquired in half the routine scan time provides equal diagnostic information compared to a conventional full time study, regardless of the processing protocol.

Keywords: Cardiac perfusion, full time, half time, coronary angiography


Observation on FDG myocardial uptake in patients of lymphoma undergoing treatment with Adriamycin: Can (F-18)FDG-PET be an early marker of chemotherapeutic cardiotoxicity?

Borde Chaitanya R, Kand P, Basu S, Asopa R

Radiation Medicine Centre, Bhabha Atomic Research Centre, Parel, Mumbai 400012, Indai

Background: Adriamycin is a commonly used chemotherapeutic agent in patients with cancer, having cardiotoxicity as its main side effect. This effect is through generation of free radicals and mitochondrial damage. Adriamycin produces hypoxia and decreases synthesis of ATP molecules by aerobic oxidation. To meet this energy synthesis- demand deficit, glycolysis is favored. Hence such 'injured' myocardial cells switch over to glucose as their main source of energy. Neuregulins are a family of growth factors which exert cytoprotection in Adriamycin treated myocytes. Increased glycolysis is one of the downregulatory signal in this pathway. (F-18)FDG is concentrated in the myocardial cells via Glut receptors and acts as a marker of glucose metabolism. Based on the above facts, we decided to study the effects of adriamycin on glucose metabolism in myocardium in vivo, with the help of F18- FDG PET. Aim: To observe (F-18)FDG myocardial uptake in patients of lymphoma undergoing treatment with Adriamycin. Materials and Methods: A retrospective analysis was done from the data of (F-18)FDG PET scan of lymphoma patients who have completed anthracyclin chemotherapy and underwent the said scan for their routine evaluation. The cardiac processing was done separately and a polar map (Bulls eye) generated from the SA slices of the myocardial tracer activity of these patients. Mean SUV value was calculated for the above-mentioned map. This mean SUV calculated in both pre- and post-chemotherapy scans was compared and analysed. Results: 18 patients (16M and 2F with mean age: 32.66±14.81 years) of lymphoma who underwent pre- and post-doxorubicin therapy formed part of the study. The mean dose of doxorubicin received was 227.77±116.59 mg/M 2 of BSA. Three different groups were identified among these cases, 1) Group A showing increase in cardiac FDG uptake in post doxorubicin PET scan. Mean dose of doxorubicin received was 256.25 mg/m 2 of BSA. 2) Group B showing fall in myocardial FDG uptake in post doxorubicin PET scan as compared to pre therapy scan. Mean dose of doxorubicin received was 137.5 mg/m2 of BSA. 3) Group C, did not show significant FDG uptake in pre as well as post doxorubicin PET scans. Mean dose of doxorubicin received was 250 mg/m2 of body surface area (BSA). Preliminary results did not show any correlation between the dose of doxorubicin administered and myocardial (F-18)FDG concentration. Conclusion: The lymphoma patients treated with doxorubicin demonstrated variable dose dependent effects of glucose utilization in the myocardium using FDG-PET. However, prospective study with larger number of patients and patients receiving higher dose of doxorubicin could be worthwhile in ascertaining the metabolic changes associated with the drug and its effect on substrate metabolism of the heart.

Keywords: FDG-PET, cardiotoxicity, doxirubicin


Retrospective analysis of quantitative parameters obtained on myocardial perfusion spect imaging (ectb software) in heart failure patients and their comparison with 2D-echocardiography results

Pruthi A, Asopa R, MGR Rajan, Basu S

Radiation Medicine Centre, Bhabha Atomic Research Centre, Parel, Mumbai 400012, Indai

Objective: 1. To study the quantitative parameters obtained on Gated MPI SPECT on ECTB software in patients of fixed defects on myocardial perfusion imaging and their comparison between individuals showing evidence of hibernating myocardium and patients without any evidence of hibernating myocardium. 2. Comparative analysis of quantitative parameters such as LVEF, EDV, ESV and SV obtained in the aforementioned patients on Gated MPI SPECT (ECTB) and 2D ECHOCARDIOGRAPHY. Materials and Methods: In a retrospective analysis(from year 2008 till date), 71 left ventricular failure (LVF) patients (12 females, 59 males) who were subjected to 99Tc-Sestamibi myocardial perfusion imaging (MPI) and 18F-FDG Cardiac PET study for assessment of hibernating myocardium, were included in the study. Patients were grouped in three categories on the basis of Summed Rest score (SRS) depicting the extent of defects seen on resting myocardial perfusion SPECT analysis. In a study population matched for extent of defects, quantitative parameters such as LVEF, EDV, ESV and SV obtained from ECTB SPECT software were compared between patients showing evidence of hibernating myocardium and patients showing no evidence of hibernating myocardium. In the second part of the study, comprising of 32 LVF patients, quantitative parameters such as LVEF, EDV, ESV and SV obtained on ECTB SPECT software and 2D-Echocardigraphy were retrospectively compared. Results: STUDY I There is no significant difference in LVEF, EDV and ESV and SV measurements between those who demonstrate hibernating myocardium and those who show no evidence of hibernating myocardium across different categories of patients. The difference in the LVEF, EDV and ESV though not reaching significance on statistical analysis is quite appreciable in category "SRS 0-10" which represents early defects. This difference is not visualized in the other categories. Few trends are evident in the present study in LVEF, EDV and ESV measurements: Fall in mean LVEF with increasing SRS. Mean EDV and ESV rise with increasing SRS. STUDY 2 The study shows close correlation between the LVEF and ESV calculated on myocardial perfusion study (ECTB software) and 2 D-Echocardiography (r=0.63 and 0.52 respectively). A less close correlation exists for EDV(r=0.38) calculations. No significant correlation exists in measurement of stroke volume (SV) (r=0.03). Conclusion: The present findings are consistent with the nature of hibernating myocardium i.e. non-contractile and dysfunctional myocardium. The noticeable difference in the EDV and ESV in category "SRS 0-10" is indicative of evidence of early diastolic dysfunction in this group of patients. The trends in the LVEF, EDV and ESV are suggestive of deteriorating myocardial function with increasing extent of ischemia. The increase in left ventricular EDV and ESV with increasing ischemia is suggestive of increasing incidence of gross morphological LV cavity dilatation or "Dilated ischemic cardiomyopathy (DCMP)" in these patients. The quantitative parameters obtained on ECTB software on MPI study shows good correlation with 2D Echocardiography results

Keywords: Myocardial SPECT, ECTB, Heart failure


Comparison of Emory, Cedar Sinai, 4D-MSPECT and Myometrix cardiac softwares for the assessment of left ventricular ejection fraction using Tc99m tetrofosmin gated SPECT: Validation with Equilibrium radionuclide angiocardiography - Preliminary results in Indian patient population

Ballall S, Patel C, Sharma P, Sellam K, Malhotra A, Chawla M, Narang R, Sharma G, Ramakrishnan S

Department of Cardiology and Nuclear Medicine Department, All India Institute of Medical Sciences, New Delhi, India

Aims: We compared Emory, Cedar Sinai, and 4D-MSPECT and Myometrix cardiac softwares for the assessment of Left Ventricular Ejection fraction (LVEF) using Tc99mTetrofosmin Gated SPECT (MPS) and validated the LVEF derived from these four softwares with Equilibrium radionuclide angiocardiography (ERNA) in patients with known/suspected coronary artery disease (CAD). Materials and Methods: A total of 64 patients (52M: 12F; mean age-55.52 yrs; range: 32-77 yrs) were included in the study. Thirty seven patients had known CAD and 25 patients were referred for suspected CAD. All the patients underwent equilibrium radionuclide angiocardiography (ERNA) and MPS as per the standard protocol. ERNA was processed using the vendor provided 'EF analysis' and gated MPS processed using individual cardiac softwares. Results: The mean LVEF on ERNA was 52% (median-55%; range 19-77%). The values for Emory, Cedar Sinai, 4D-MSPECT and Myometrix were 57% (median-60%; range: 13%-89%), 55% (median-58%; range: 16%-92%), 61% (median-65%; range: 22%-92%) and 54% (median-59%; range: 16%-89%) respectively. Taking a value of 50% on ERNA as cut-off, 39 patients showed normal LVEF whereas 25 had low LVEF. On correlation analysis significant positive correlation was observed between LVEF on ERNA and LVEF on myometrix (r-0.88; P<0.0001), Emory (r-0.83; P<0.0001), Cedar Sinai (r-.083; P<0.0001) and 4D-MSPECT (r-0.84; P<0.0001). Significant correlation was also seen for LVEFs among the 4 MPS softwares (r-0.9; P<0.0001). On ROC analysis using ERNA as classifying variable, the normal LVEF cut-off values for Emory, Cedar Sinai, 4D-MSPECT & Myometrix were 56%, 52%, 54%, 53% respectively. Conclusion: Good correlation was observed between Emory, Cedar Sinai, 4D-MSPECT and Myometrix cardiac softwares when compared with ERNA and also among the four softwares for assessment of LVEF. A larger number of patients are being evaluated in this on-going study to further validate the results.

Keywords: Ejection Fraction Estimation, comparison, softwares


Clinical validation of the gated blood pool SPECT QBS processing software for evaluating cardiac function in patients with dilated cardiomyopathy

Santosh S, Kashyap Raghav K, Bhattacharya A, Mittal BR

Department of Nuclear Medicine, PGIMER, Chandigarh-160012, India

The study was carried out to evaluate the commercially available automated GBPS processing software for LVEF and RVEF measurement in patients with cardiomyopathy. Patients (total=41; 24 males; mean age-44 ± 14 years) referred to our department for assessment of cardiac function in patients having dilated cardiomyopathy were prospectively included in the study. In patients with DCM, First pass radionuclide ventriculography (FP-RNV) and planar multi-gated radionuclide angiography (MUGA) were performed at rest after in-vivo labeling of RBCs. LVEF was also calculated by Echo in these patients. LVEF and RVEF were calculated by MUGA and FP-RNV respectively. Immediately after obtaining the planar views, GBPS was performed with GE Infinia Hawkeye4 camera, detectors in L-mode configuration, with step and shoot mode acquisition - 60 steps over 180º, 20 s per step, 16 frames per cardiac cycle, 64 Χ 64 matrix. GBPS was processed using the fully automated QBS algorithm and LVEF, RVEF were calculated. Spearman's coeffcient (r) of correlation was calculated for the different sets of values. The level of statistical significance was set at < 5%. Bland-Altman plots were inspected to visually assess the association between measurements from different methods. Results: Head on comparison of the mean values for patients: PLANAR QBPS ECHO LVEF (%) 31 ± 11 VS 34 ± 12; RVEF (%) 46 ± 14 VS 43 ± 17. In patients with DCM, LVEF values calculated from GBPS showed very good correlation with MUGA (r=0.91) and echocardiography (r=0.83; all p<0.0001). Bland-Altman plot showed overestimation for GBPS-LVEF values compared to MUGA. RVEF values calculated by FPRNV and QBS-SPECT also showed good correlation (r=0.87; p<0.0001). Bland-Altman plot for RVEF values showed a tendency for an overestimation of higher RVEF values with GBPS. Patients with DCM also tend to suffer from right ventricular cardiomyopathy. Isolated right sided cardiomyopathy is also a known entity. Since RVEF is an essential parameter in guiding the management of these patients, FPRNV is usually ordered to obtain RVEF. Given the practical difficulties with FPRNV like good bolus administration, GBPS automated software can be warranted to calculate RVEF, as a good correlation is shown between the two techniques, in our study. Also, there is a good association between MUGA and GBPS for LVEF measurement. The automated QBS algorithm for LVEF and RVEF calculation using GBPS is feasible for clinical routine diagnostic in DCM patients.

Keywords: Gated Blood Pool SPECT, Dilated cardiomyopathy, validation


Comparison of LVEF assessed by gated blood pool SPECT QBS with multigated acquisition in patients with CAD and severe LV dysfunction

Senthil R, Harisankar CNB, Kashyap Raghava, Bhattacharya A, Singh B, Mittal BR

Department of Nuclear Medicine, PGIMER, Chandigarh-160 012, India

Left ventricular ejection fraction is an important predictor of prognosis in patients with coronary artery disease and LV dysfunction. Multigated acquisition is considered as the gold standard technique to assess the LVEF. However accuracy of LVEF assessed by automated GBPS processing software is not clear. The aim of the study was to evaluate commercially available automated GBPS processing software for left ventricular EF measurement in CAD patients with severe LV dysfunction referred to our dept for evaluation of LV function. Patients with CAD and severe LV dysfunction were prospectively included in the study. These patients underwent Multigated acquisition and Gated blood pool SPECT QBS. Planar multigated radionuclide angiography (MUGA), and GBPS were performed at rest after in vivo labeling of red blood cells. Planar MUGA was done in single head gamma camera with low energy all purpose collimator. Data was acquired in frame mode with the cardiac cycle divides into 24 bins. The data was acquired for average of 8 million counts in the GE Millenium MPR camera. GBPS was done in L-mode acquisition, 16 Frames/cycle, over 180º Step and shoot acquisition (for 20 sec/view, total 60 views) with GE Infinia Hawkeye4 camera. LVEF was calculated. Spearman's coecient (r) of correlation was calculated for the two sets of values with significance level kept at P<0.05. Bland-Altman plots were inspected to visually assess the agreement between measurements from two methods. Twenty patients (16 males and 4 females; mean age59 years) were prospectively included. The average ejection fraction values were 27.8% for MUGA (range 10%-48%) and 32.8% for Gated blood pool SPECT QBS (Range 13% to 62%). LVEF calculated by Gated blood pool SPECT QBS showed good correlation (Spearman's coecient (r=0.813) with MUGA. The Bland-Altman plot for LVEF measured by Gated blood pool SPECT QBS showed good agreement with MUGA. The study findings indicate good correlation and agreement between Gated blood pool SPECT QBS and MUGA for LVEF calculation in CAD patients with severe LV dysfunction.



Normal parameters of left ventricular synchrony on phase analysis using equilibrium radionuclide angiocardiography-Results in Indian population

Singh Harmandeep, Patel Chetan, Sharma G 1 , Sharma P, Malhotra A

Department of Nuclear Medicine, AIIMS, New Delhi, 1 Cardiology, AIIMS, New Delhi, India

Equilibrium radionuclide angiocardiography (ERNA) is routinely used to assess cardiac function. Phase analysis in ERNA can be employed to evaluate the left ventricular (LV) dyssynchrony. This can be done qualitatively on visual phase analysis and quantitatively by measuring the LV mean phase angle (mPA) and standard deviation (SD) of LV mPA. However, there is lack of normal data which can be used to quantify the dyssynchrony to assess patients of cardiac resynchronization therapy (CRT). The aim of this study was to quantify the normal mPA and SD mPA for left ventricular synchrony on phase analysis on ERNA. Methods: We retrospectively analyzed the studies of one hundred patients who were referred for ERNA to our department. We selected patients with no previous history of cardiac disease and who had normal left ventricular function on ERNA. All patients underwent ERNA as per the standard protocol. Each study was processed using vendor provided 'XT- ERNA' software for calculation of LVEF, Fourier first harmonic analysis for assessment of LV mPA and SD LV mPA expressed in degrees. Studies were processed twice by an observer to assess intra-observer variability and by a second observer to evaluate inter-observer variability. Results: One hundred patients (37 male, 63 female) were evaluated. The mean age of study group was 46 years (median-45; range 15-73). The mean heart rate was 86 beats/minute (median-83; range 55-144). All patients had normal LV ejection fraction (LVEF) taken as ≥ 50% on ERNA, the mean LVEF was 61% (median 60; range 53-65). On phase analysis, the LV mPA was observed to be 174.3 ± 18.5º and SD of LV mPA value was 9 ± 2.7 degrees. There was no statistically significant difference in these parameters between males and females (P 0.690). There was no statistically significant intra-observer and inter-observer variability. Conclusion: Phase analysis of ERNA appears to be an accurate and reproducible technique for the evaluation of left ventricular synchrony. We seek to apply the normal limits for left ventricular synchrony on phase analysis in clinical settings to assess the patients of CRT.

Keywords: ERNA, phase analysis, dyssynchrony


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