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Practical and Diagnostic Considerations for Gated Myocardial Perfusion Tomography Using Sestamibi

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Practical and Diagnostic Considerations for Gated Myocardial Perfusion Tomography Using Sestamibi IMAGING Practical and Diagnostic Considerations for Gated Myocardial Perfusion Tomography Using Sestamibi M.G. Morgan and F. Mannting Nuclear Medicine Section, Department of Clinical Physiology, University Hospital, Uppsala, Sweden photon energy less appropriate for gamma cameras. Tcch­ Technetium-99m f9mTc) sestamibi makes gated single-photon netium-99m's energy, shorter half-life, and improved count­ emission computed tomography (SPECT) perfusion imaging pos­ ing statistics arc suitable for the gated SPEer technique. sible because of99mTc•s energy and counting statistics. The aim Computer systems in many nuclear medicine departments of this study was to analyze the practical and diagnostic value of do not have computation capacity and software able to ac­ gated SPECT imaging while considering the extra investment in quire and process gated SPEer data effectively. The new time and effort. We studied 73 subjects (20 nonnals. 53 patients) RISC-typc computers, faster processors (CPU), parallel pro­ using a 1-day rest/stress protocol (6 mCi at rest/24 mCi at peak cessing, and improved software arc being introduced in nu­ stress). Camera time was -50% longer than a standard nongated clear medicine and arc capable of effectively handling data SPECT study; filtering and reconstruction took 2.5 times longer. Processing of diastolic studies took -8 min. Acquisition data. from gated SPECT studies. reconstructed studies. and formatted diastolic and dynamic stud­ Some investigators have applied gated planar principles to ies occupied 5.6 times more storage space. High quality dynamic 20 tTI studies (4-8) and have shown that end-diastolic data and perfusion studies were obtained in 70!73 patients. The right improve definition of myocardial borders. In selected cases, ventricle (RV) appeared more distinct on diastolic studies than in end-diastolic 20tTI images have been used for assisting in the nongated studies (p < 0.01). The left ventricle (LV) cavity was conformation of 20 tTI redistribution (8). Gated planar sesta­ larger in diastolic studies than in nongated studies (p < 0.001). mibi imaging has been described (9-l/) and used for evalu­ leading to more useful coronal slices with cavity (p < 0.001 ). A ation of myocardial wall motion (9-11). Gated SPEer has significant inverse relation between LV size and increase in been applied in a few studies using 20tTI (12) or sestamibi number of useful coronal slices with ventricular cavity in dia­ (13-17). These studies found advantages of gated SPECT stolic studies was found (r = -0.71. p < 0.001). The extra with respect to high-contrast perfusion images and additional effort. time. and storage space required by gated SPECT was balanced by the additional diagnostic information gained from information of regional function in the form of systolic wall dynamic and diastolic images and by clearer RV and LV cavity thickening (12-14,16) or regional wall motion (12-15). visualization. Gated SPECT is particularly useful in patients In a preliminary study (18), we showed that sestamibi with smaU hearts or in patients with LV hypertrophy. gated SPECT was possible and realistic even when using conventional computers systems. The aim of this investiga­ J Nucl Med Techno/1993; 21:13-19 tion was to further evaluate the cost versus benefit of gated SPEer when applied to a larger patient population. Use of the new radiopharmaceutical, tcchnctium-99m 99 ( mTc) 2-mcthoxy-isobutyl-isonitrile (scstamibi), makes MATERIALS AND METHODS gated single-photon emission computed tomography A normal database consisting of 20 subjects (10 normal (SPEer) of myocardial perfusion realistic. Technctium-99m volunteers approved by the University Ethics Committee sestamibi has been reported to have minimal redistribution, and 10 patients, determined to be free of cardiac disease by high myocardial extraction, and high photon flux (1-J). Prior coronary angiography), II men and 9 women, mean age 51.2 to the introduction of sestamibi, the usc of thallium-201 yr ± 8.1, range 37 to 68, served as a reference population. eotTI) for imaging myocardial perfusion was restricted The lower limits of the normal uptake distribution (for rest mainly to traditional, nongatcd tomography, due to the lower and stress) were established for each myocardial level (bas­ administered dose necessitated by its longer half-life and a al, mid, and apical) and segments by computing the mean uptake and subtracting two s.d. For reprints comact: Finn Mannting, MD, PhD. Nuclear Medicine Normal databases were established and defined for the Section, Department of Clinical Physiology, University Hospital. S-751 X Uppsala. Sweden. following protocols: traditional nongatcd rest/stress MIBI VOLUME 21, NUMBER 1, MARCH 1993 13 GATED TOMOGRAPHY ····························································... _() 180" Rotation, 32 Angles '1': -·· 8 Frames I Angle 32 S I Frame LPO 45" +---4-­ FIG. 1. Schematic representation of gated tomography technique. Each of the 32 ac­ quisition frames is divided into eight tempo­ ·-·L ral frames (squares), each representing 1/8 Heart Crcle n•• of an R to R interval. (R to R Interval) for 1-day or 2-day protocols and gated sestamibi SPECT the MSE operating system (equal to the TSX operating sys­ (diastolic) studies. tem) on a PDP 11/73 DEC computer (Digital Equipment Stress and rest gated SPECT was attempted in 53 consec­ Corp, Maynard MA), controlled the gated SPECT acquisi­ utive patients referred for signs or symptoms of coronary tion. The patients were connected to an ECG monitor that artery disease (CAD). One patient was excluded due to high was interfaced to the computer. Special care was taken to subdiaphragmatic activity and we were unable to obtain establish a stable ECG for each patient. Gate tolerance was gated SPECT in two patients due to arrhythmias. The study set at 15o/c. Once a stable ECG pattern was obtained, gate patient population consisted of 50 patients (31 men and 19 interval time was calculated. This calculation was based on women) with signs or symptoms of CAD. Mean age for the a 16 beat average. Data were acquired over a 180° rotation patient population was 55.3 yr ± 12.3, range 13 to 74. for a total of 32 angles, 32 sec, and 8 temporal frames/angle (Fig. 1), in a 64 x 64 matrix. All studies were acquired on the Stress Testing same gamma camera (SX 300, Picker International, High­ Symptom limited, upright, bicycle ergometry was per­ land Heights, OH) using a high resolution, hexagonal, par­ formed according to a standard protocol. The patients were allel-hole collimator. asked not to take any cardiovascular medication 24 hr prior Immediately following the rest SPECT, the patients were to examination. Baseline ECG, heart rate, blood pressure, stressed according to the protocol described earlier. At peak and respiration rate were recorded at rest, immediately be­ exercise, 24 mCi of YYmTc-sestamibi was injected. Fifteen fore start with the patient in position on the bicycle, and min after completion of stress testing, all patients ingested a every 2 min during exercise. Workload started at 20 Wand high fat snack. Stress sestamibi SPECT imaging began was increased by 20 W, every 2 min. The test was terminated 1-hour postinjection, using the same acquisition protocol at maximal exertion or dyspnea, or at maximal tolerable used during the rest SPECT sestamibi acquisition. chest pain, or if significant ventricular arrhythmia devel­ When interfering subdiaphragmatic activity was observed oped. during patient positioning, start of data acquisition was de­ layed for 10 to 15 min. These patients were taken off of the Gated SPECT Imaging Protocol imaging table and instructed to walk in the corridor. This All patients were examined according to a one-day rest/ was done in an attempt to allow high, interfering hepatic or stress protocol (19). Six mCi of YYmTc-sestamibi was injected bowel activity to move away from the cardiac region. at rest. The patients were asked to ingest a high fat meal -15 All studies were filtered with a 2-D, count-adaptive, FFT, min after injection. Rest SPECT imaging began 1-hr postin­ Metz filter (20) using an array processor (AP 400, Analogic jection. A 20o/c symmetrical window was centered at 140 Corp., Wakefield, MA). Reconstruction was performed on keY. A commercially available software, Gated SPETS (Nu­ the PDP 11/73 DEC computer using the reconstruction part clear Diagnostics AB, Stockholm, Sweden), running under of the Gated SPETS software. All gated sestamibi SPECT 14 JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY studies were reconstructed using eight temporal frames. At­ anterior wall endocardium to the inferior wall endocardium tenuation correction was performed after body outline defi­ at the widest dimension of the LV cavity. Also, a line was nition (21). Software zoom (x2) was applied during the re­ drawn from the septal endocardium to the lateral wall endo­ construction. Reconstruction was performed by filtered cardium. The mean of the two ventricular cavity measure­ backprojection (ramp filter). Standard transverse and true ments was calculated for determination of both the nongated cardiac sagittal (long-axis) and coronal (short-axis) slices and diastolic LV cavity size in nongated and diastolic stud­ were created after individual determination of the heart axis. ies. The number of useful coronal slices, defined as those Formatting slices containing LV cavity, was determined for the non­ The 256-frame, reconstructed coronal and sagittal studies gated and diastolic studies. The coronal studies were dis­ (each study, 32 spatial frames x 8 temporal frames) were played on a high resolution color monitor. Nongated and formatted into various types of studies. The formatted data diastolic studies were viewed separately. The same color were saved as new, additional patient studies. For this in­ table was used for viewing both nongated and diastolic stud­ vestigation, the reconstructed sagittal and coronal data for ies. The number of coronal slices with identifiable LV cavity stress and rest studies were formatted as follows.
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