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Procedure Guideline for Equilibrium Radionuclide Ventriculography

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Procedure Guideline for Equilibrium Radionuclide Ventriculography Procedure Guideline for Equilibrium Radionuclide Ventriculography Mark D. Wittry, Jack E. Juni, Henry D. Royal, Gary V. Heller and Steven C. Port Saint Louis University, St. Louis, Missouri; William Beaumont Hospital, Royal Oak, Michigan; Mallinckrodt Institute of Radiology, St. Louis, Missouri; Hartford Hospital, Hartford, Connecticut; and Cardiovascular Associates, Ltd., Milwaukee, Wisconsin a. To distinguish ischemie from nonischemic causes. Key Words: gated blood-pool imaging;practice guideline;radionu- b. To distinguish systolic from diastolic causes. clide ventriculography; cardiac function; heart 3. Evaluation of cardiac function in patients undergoing J NucíMed 1997; 38:1658-1661 chemotherapy. 4. Assessment of ventricular function in patients with PART I: PURPOSE valvular stenosis and/or insufficiency. The purpose of this guideline is to assist nuclear medicine An RVG may be used in the conditions listed above for: practitioners in recommending, performing, interpreting and (a) determining long-term prognosis, (b) assessing short- reporting the results of gated equilibrium radionuclide ventricu term risk (e.g., pre-operative evaluation) and (c) moni lography. toring the response to surgery or other therapeutic inter ventions. PART II: BACKGROUND INFORMATION AND DEFINITIONS Gated equilibrium radionuclide ventriculography (RVG) is a PART IV: PROCEDURE procedure in which the patient's blood is radiolabeled and A. Patient Preparation ECG-gated cardiac scintigraphy is obtained. Single or multiple 1. Rest measurements of left and/or right ventricular function are made. No special preparation is required for a resting RVG. Alternative terminologies for this technique include gated A fasting state is generally preferred. It is not neces cardiac blood-pool imaging, multigated acquisition (MUGA) sary to withhold any medications. The electrodes used and gated equilibrium radionuclide angiography (RNA). for cardiac gating must be placed securely to the skin Data are collected from several hundred cardiac cycles to in order to ensure an optimal ECG signal. generate an image set of the beating heart that is presented as a 2. Exercise single, composite cardiac cycle. The method can be used to The patient should be fasting for at least 3-4 hr prior assess: (a) regional and global wall motion, (b) cardiac chamber to the study, and should be both hemodynamically size and morphology and (c) ventricular systolic and diastolic and clinically stable. Exercise stress is generally function including left and right ventricular ejection fractions. preferred. Patients who are unable to exercise for An RVG may be acquired at rest, during exercise or following noncardiac reasons may undergo pharmacologie either pharmacologie or mechanical interventions. stress. It is recommended that medications that may alter the heart rate response be withheld unless med PART III: COMMON INDICATIONS ically contraindicated or the efficacy of the medica A. Parameters obtained from RVG include the following: tion is being tested by the exercise test. 1. Global ventricular systolic function. Life support instrumentation and cardiac resuscita- 2. Regional wall motion. tive drugs must be available in the immediate vicinity 3. Ventricular volumes (qualitative or quantitative). of the stress laboratory. A physician or other person 4. Responses of above parameters to exercise or other nel trained in advanced cardiac life support (ACLS) interventions. must be immediately available during the stress and 5. Systolic and diastolic indices. recovery phases. Continuous electrocardiographic 6. Stroke volume ratios. monitoring must also be performed throughout all B. Common clinical settings in which RVG may be useful phases of the stress study. Intermittent blood pressure include: measurement and electrocardiographic tracings 1. Known or suspected coronary artery disease (CAD). should be performed prior to, during and in the a. CAD without myocardial infarction (MI). recovery phases of the stress study. The patient should b. Remote MI. be clinically observed during and immediately fol c. Acute MI. lowing the stress test. Any abnormalities in symptom 2. Known or suspected congestive heart failure (CHF). atology, hemodynamics or the ECG should be moni tored until resolved. Received Dec. 18, 1996; accepted Jun. 17, 1997. For correspondence or reprints contact: Wendy J.M. Smith, Director of Health Care B. Information Pertinent to Performing the Procedure Policy, 1850 Samuel Morse Dr., Reston, VA 20190-5316 or via e-mail at An adequate history and cardiovascular examination [email protected]. Note: All 26 SNM-approved procedure guidelines are available on the Society's home should be obtained prior to diagnostic evaluation. Spe page. We encourage you to download these documents via the Internet at http: cific areas to be reviewed include the indication(s) for \\www.snm.org. If you would like information on the development process of this testing, medications, symptomatology, cardiac risk fac guideline or to order a compendium of all 26 procedure guidelines for $20.00, please contact Wendy J.M. Smith, Society of Nuclear Medicine at (703) 708-9000, ext. 242 or tors and prior cardiac procedures (diagnostic or therapeu via e-mail at [email protected]. tic). The patient's cardiac rhythm should be noted, as 1658 THEJOURNALOFNUCLEARMEDICINE•Vol. 38 •No. 10 •October 1997 TABLE 1 TABLE 2 Radiation Dosimetry for Adults Radiation Dosimetry for Children (5-yr-old) receivingthe largestradiation receiving dose*mGy the largest dose* Radiopharmaceutical"To-labeled(mCi)555-1 (rad)0.023Heart(0.085)0.020Heart(0.074)Effectivedose*mSv(rem)0.0085(0.031)0.0079(0.029) activity radiation dose* Radiopharmaceutical"To-labeledMBq/kg(mCi/kg)7-1 mGy(rad)0.062 mSv(rem)0.025 RBCs*"Tc i.V.(15-30)370-740110 5 i.v. RBCst"Te (0.2-0.4)5-10 Heart (0.093)0.023 albumin*AdministeredactivityMBqi.V.(10-20)Organ (0.23) albumin*Administered i.v. 0.054 (0.1-O.3)Organ Heart (0.085) (0.20)Effective *Per MBq (per mCi). TICRP53, page 210. *Per MBq (per mCi). *ICRP53, page 173. nCRPSS, page 210. »ICRP53,page 173. marked heart rate variability may limit the ability to both perform and interpret the RVG. Physical limitations may tor. An appropriate ECG gating device should limit or preclude the performance of a study requiring interface with the acquisition computer. The si physical exercise. A resting 12-lead electrocardiogram multaneity of the gating device's R-wave trigger should be reviewed prior to an exercise study. and the patient's QRS complex should be verified C. Precautions prior to initiation of the study. An appropriate R-R 1. It is mandatory that the OSHA guidelines for safe interval beat acceptance window should be se handling of human blood products be followed at all lected to account for heart rate variability and times when techniques labeling autologous red blood ectopy. Systolic function determinations are less cells are used. susceptible to heart rate variability than diastolic 2. When an in vitro method is used for radiolabeling function measurements. "List" mode acquisition is autologous red blood, a fail-safe policy and procedure useful for making a composite cardiac cycle from must be in place and implemented to assure that a heterogenous population of beats. misadministration of labeled cells to the wrong pa b. Acquisition Parameters tient is prevented. A minimum of 16 frames per R-R interval are 3. Patients with potentially unstable cardiac rhythms required for an accurate assessment of ventricular (e.g., paroxysmal supraventricular or ventricular wall motion and assessment of ejection fraction. A tachycardia) or implanted devices (e.g., implantable higher framing rate (32-64 frames per R-R) is defibrillators) may require special precautions as heart rate response to exercise may be unpredictable. necessary for detailed measurement of diastolic D. Radiopharmaceuticals filling parameters. For the adult, the usual administered activity is 555-1110 Images should be acquired such that the heart MBq (15-30 mCi) of autologous red blood cells labeled occupies approximately 50% of the usable field of with 99mTc(Table 1) using either the in vivo, modified in view. Typical acquisitions are for a total of 3-7 vitro or in vitro techniques. The usual administered million counts. Supine imaging is performed in a activity in children is 7-15 MBq/kg (0.2-0.4 mCi/kg) minimum of three views to visualize all wall with a minimum dose of 70-150 MBq (2-4 mCi) (Table segments of the left ventricle. The left anterior oblique acquisition (LAO) is obtained at 45°or an 2). The largest absorbed radiation dose to an organ is to the heart (about 0.02 mSv/MBq). 99mTc-labeled red angle which allows the best separation of the right blood cells distribute within the blood-pool with an and left ventricles (best septal or best separation estimated volume of distribution of approximately view). An anterior acquisition is obtained in a 4%-7% of body weight. The estimated biological half- straight (0°)anterior projection or at an angle approximately 45°less than the "best septal" view. life is approximately 24-30 hr. Approximately 25% of the administered dose is excreted in the urine in the first The lateral acquisition is obtained as a left cross- 24 hr. table lateral or at an angle that is approximately 45°greater than the best septal view. A 70°LAO Labeling is least consistent with the in vivo, interme diate with the modified in vitro and most consistent with acquisition may be used instead of a left cross- the in vitro method. Technetium-99m radiolabeled hu table lateral view. Left posterior oblique (LPO) or man serum albumin (HSA) is an alternative to radiola right anterior oblique (RAO) acquisitions may be beled red blood cells. of additional benefit. A slant-hole collimator may E. Image Acquisition be used for angulation in the caudal-cephalic plane 1. Rest study to help separate the ventricles from the atria. a. Instrumentation Stress Study Acquisition is performed by a gamma camera a.
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