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Iiitlliilllll\\ SR PT01 Form 1 WAIVER UNSW LIBRARY iiitlliilllll\\ SR PT01 Form 1 WAIVER THE UNIVERSITY OF NEW SOUTH WALES DECLARATION RELATING TO DISPOSITION OF "' PROJECT REPORT /THESIS This is to certify that I... .. ~~~ . q~Gr. .... ~~ .... .......... being a candidate for the degree of .. 1>Q.e.\ ~0... ~ .. '".' .~•. «:-. ~.......... am fully aware of the policy of the University relating to the retention and use of higher degree project reports and theses, namely that the University retains the copies submitted for examination and is free to allow them to be consulted or borrowed. Subject to the provisions of the Copyright Act, 1968, the University may issue a project report or thesis in whole or in part, in photostat or microfilm or other copying medium. In the light of these provisions I grant the University Librarian permission to publish, or to authorize the publication of my project report/thesis, in whole or in part. I also authorize the publication by University Microfilms of a 350 word abstract in Dissertation Abstracts Intern · al (applicable to doctorates only) . Signature ..... ~--------------~ Witness I q I • ::J • ~~ ... Date .. .... ............. .................................. ~ .... .... ..... ....... .. ...... SERIAL ASSESSMENT OF DISORDERS OF LEFT VENTRICQAR FUNCTION USING RADIONUCLIDE VENTRICQOGRAPHY ANTHONY P. FREEMAN A THESIS SUBMITTED FOR THE DEGREE OF DOCTOR OF MEDICINE OF THE UNIVERSITY OF NEW SOUTH WALES APRIL 1985 UNniERSITY OF N.S.W. 29SEPI986 BIOMEDICAL LIBRARY STATEMENT OF ORIGINAUTY OF STUDY "I hereby declare that this thesis is my own work and that, to the best of my knowledge and belief, it contains no material previously published or written by another person nor material which to a substantial extent has been accepted for the award of any other degree or diploma of a university or other institute of higher learning, except where due acknowledgement is made in the text of the thesis". ANTHONY PHILIP FREEMAN FRACP INDEX Acknowledgements Published Work Arising from Study Summary Chapter 1 PROLOGUE 1 Chapter 2 HISTORICAL PERSPECTIVES & CURRENT CONTROVERSIES 5 Radionuclide Ventriculography Myocardial Revascularisation Ventricular Aneurysmectomy Iron Chelation Therapy in Thalassaemia Major VALIDATION OF METHODOLOGY 27 Chapter 3 EQUIPMENT 28 Camera Characteristics Computer System Exercise Bicycle Chapter 4 GAMMA CAMERA DATA ACQUISITION 38 Design of Cardiac Phantom Choice of Frame Duration Chapter 5 RED CELL LABELLING 48 Red Blood Cell Labelling with Tc99m Comparison In Vitro versus In Vivo Technique Chapter 6 LEFT VENTRICULAR EJECTION FRACTION 56 Comparison with Contrast Angiography Reproducibility Inter-observer Error Intra-observer Error Comparison between two Analysis Programmes Normal Values in Children and Adults Chapter 7 EXERCISE LEFT VENTRICULAR FUNCTION 82 Comparison of Supine Bicycle with Erect Treadmill Exercise Chapter 8 VENTRICULAR VOLUMES 94 Cardiac Phantom Study Human Studies Chapter 9 REGIONAL WALL MOTION ASSESSMENT 123 Comparison Of Radionuclide Angiography with Contrast Angiography and Two-Dimensional Echocardiography Chapter 10 SUMMARY OF METHODOLOGY 145 CLINICAL APPLICATIONS 148 Chapter 11 MYOCARDIAL REVASCULARISA TION 149 Long Term Results of Bypass Grafting in Patients with Severely Depressed Left Ventricular Performance Chapter 12 MYOCARDIAL VIABILITY 173 Effect of Revascularisation on Resting Left Ventricular Wall Motion Abnormalities Prediction of Improvement in Left Ventricular Wall Motion Chapter 13 LEFT VENTRICULAR ANEURYSMECTOMY 199 Effects on Left Ventricular Function Preoperative Determinants of Clinical Outcome Chapter 14 IRON OVERLOAD AND THE HEART 220 Identification of Subclinical Abnormalities of Ventricular Function Effects of Iron Chelation Therapy on Left Ventricular Function Chapter 15 EPILOGUE 253 REFERENCES 257 ACKNOWLEDGEMENTS Associate Professor I. Provan C. Murray, Director of the Department of Nuclear Medicine at the Prince of Wales Hospital, was my supervisor during this project. At all times he provided the utmost in support, encouragement and direction, with continued enthusiasm throughout the four years spent in performing these studies and preparing this manuscript. My interest in this subject was initiated by Professor Ralph Blacket, who always showed interest in the project as the Director of the Department of Medicine. This whole study would not have been possible without the co-operation of the members of the Division of Cardiovascular Medicine at the Prince Henry and Prince of Wales Hospitals who permitted me to study their patients and provided unfailing co-operation. I am indebted to many of them for their interest and helpful discussion and in particular to Dr. Robert Giles who was of enormous assistance for his ongoing interest and guidance, not only in relation to cardiological aspects but also his readiness to share his experience in nuclear cardiology. In addition I would like to thank Dr. Warren Walsh who similarly provided continuing guidance and support. I would also like to acknowledge the co-operation of all the Nuclear Medicine technicians in the Department, particularly in relation to patient care and most especially to Mrs. Jenny Dixon, Chief Technologist, and Miss Penny Steele, Senior Technologist in the Computer Section. A member of the Department of Medical Physics, Mrs Brenda Walker, was always available to provide advice about relevant aspects of the physical principles behind many of the techniques used. This period of research would not have been possible without provision of a postgraduate research scholarship from The National Heart Foundation of Australia. This work was greatly facilitated by a computer system donated by the Raymond E. Purves Foundation. Finally, without the encouragement, support and patience of my wife, Kerry, I would not have completed this thesis. PUBLISHED WORK ARISING FROM THESE STUDIES Freeman, A.P ., Giles, R. W., Mcilveen, B., Murray, I.P .C.: Radionuclide ejection fraction:. comparison of response to treadmill and bicycle exercise. Eur. J. Nucl. Med. 7:393-396;1982. Freeman, Z.S., Freeman, A.P.: Coronary bypass surgery:A re-appraisal. Aust. N.Z. J. Med. 309-320; 1982. Freeman, A.P., Walsh, W.F., Giles, R. W., Choy, D., Murray, I.P.C.: Early left ventricular dysfunction in thalassaemia major:potential efficacy of intensive chelation therapy. Ann. Intern. Med. 99. 450-454;1983. Freeman, A.P., Walsh, W.F., Giles, R.W., Choy, D., Murray, I.P.C.: Early and long term results of myocardial revascularisation in patients with severely depressed left ventricular performance. Am J Cardia! 54. 749- 754; 1984. Freeman, A.P., Giles, .R.W., Walsh, W.F., Wilcken, D.t:.L., Fisher, R., Murray, I.P.C;: Regional left ventricular wall motion assessment: Comparison of 2-dimensional echocardiography and radionuclide angiography with contrast angiography in healed myocardial infarction. Am J Cardiel In Press July, 1985. Morgan, A.P., Freeman, A.P., Mclean,R.G., Jarvie B.H., Giles R. W.: Late cardiac,thyroid and pulmonary sequelae of mantle radiotherapy for Hodgkin's disease. Inter J Radial Oneal Bioi Phys. In Press. ABSTRACTS Freeman A.P., Choy D. Wright J.S., Murray I.P., Walsh W.F.: Does coronary bypass surgery or aneurysmectomy improve cardiac performance in patients with severe left ventricular dysfunction. Aust. N.Z. J. Med. 11:491;1981. Freeman A.P., Choy D., Murray I.P., Berdoukas V., Walsh W.F.: Unsuspected cardiac dysfunction in patients with thalassaemia. Aust. N.Z. J. Med. 11: 491; 1981. Murray, I.P .C., Giles, R., Mcilveen, S.M., Freeman, A., Molk, G.M., Freeman, J.M.: The radionuclide ejection fraction response to stress: A comparison of three methods. Aust. N.Z. J. Med., 11:438; 1981. Choy, D., Hosch!, R., Freeman, A., Murray, I.P .C., Berdoukas, Y., Walsh, W., Molk, G., Dixon, J.: Left ventricular function and kidney /bone ratio in patients with congenital transfusion dependent anaemias and chronic iron overload. Aust. N.Z. J. Med. 11, 581; 1981. Freeman, A.P., Walsh, W.F., Hickey, A., MacArthur, C., Choy, D., Murray, I.P.C., Wilcken, D.E.L.: Comparative assessment of regional wall motion I by two dimensional echocardiography, radionuclide angiography and contrast ventriculography. Aust. N.Z. J. Med. 12:309; 1982. Freeman, A.P., Walsh, W. F., Giles, R.W., Choy, D., Murray, I.P.C.: Thallium imaging predicts improvement in resting left ventricular wall motion abnormalities following revascularisation. Aust. N.Z. J. Med. 13:416;1983. Freeman, A.P ., Walsh, W. F., Giles, R. W., Murray, IPC.:Left ventricular aneurysm resection: determinants of clinical outcome. Aust. N.Z. J. Med. 14:5 92;1984 Bowman, L.K., Freeman, A.P ., Horton, D.A.,Newman, D.C., Wright, J.S., Walsh, W.F.: The volume overloaded heart : long tern, effects of valve replacement in the patient with depressed ventricular performance. Aust.N.Z. Med. 14: 592;1984 Freeman, A.P ., Giles, R. W., Berdoukas V., Walsh W., Murray IPC.: High dose chelation therapy reverses left ventricular dysfunction due to transfusional iron overload in patients with thalassemia major. JACC.5,2: 445;1985. Walker, B.M., Freeman, A.P., Steele P., Giles R. W., Murray, I.P.C. Comparison of three non-geometric methods of radionuclide estimation of left ventricular volumes Aust. N.Z. J. Med. In Press. ABSTI::;;ACT In this th~·r:;ir.;., gated equilibrium radionucl ide angiography was evaluated and applied to assess the effects of therapy. In ttr.IO discrete patient groups. A correlation of 0.93 was obtained for measurement of left ventricular ejection fraction (LVEF) when compared with contrast
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