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Myocardial Viability: Unresolved Issues

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Myocardial Viability: Unresolved Issues 2. Palmer MR. Bergstrom M, Pate BD. Beddoes MP. Noise distribution due to emission 9. Lange K, Carson R. EM reconstruction algorithms for emission and transmission and transmission statistics in positron emission tomography. IEEE Trans NucíSci tomography. J Comput Assist Tomog 1984;8:306-316. 1986:33:439-442. 10. Ollinger JM. Reconstruction-reprojection processing of transmission scans and the 3. Uahlbom M. Hoffman EJ. Problems in signal-to-noise ratio for attenuation correction variance of PET images. IEEE Trans Med Imag 1992:39:1122-1125. in high resolution PET. IEEE Trans NucíSci 1987:34:288-293. 11. Yu D-C. Huang S-C. Study of reprojection methods in terms of their resolution loss 4. Huang SC. Carson RE. Phelps ME. Hoffman EJ, Scheiben HR. KühlDE. A boundary and sampling errors. IEEE Trans NucíSci I993;40:l 174-1177. method for attenuation correction in positron computed tomography. J NucíMed 1981:22:627-637. 12. Alpert NM, Chesler DA, Correia JA, et al. Estimation of the local statistical noise in emission computed tomography. IEEE Trans Med Imag 1982:1:142-146. 5. Xu EZ, Mullani NA. Gould KL, Anderson WL. A segmented attenuation correction for PET. J NucíMed 1991:32:161-165. 13. Huesman RH. A new fast algorithm for the evaluation of regions of interest and 6. Meikle SR, Dahlbom M. Cherry SR. Attenuation correction using count-limited statistical uncertainty in computed tomography. Phys Med Biol 1984;29:543-552. transmission data in positron emission tomography. J NucíMed 1993:34:143-150. 14. Kendall Sir M, Stuart A, The advanced theory of statistics. New York: Macmillan: 7. Abramowitz M, Stegun 1A. Handbook of mathematical junctions. New York: Dover 1979:52-53. Publications; 1968. 15. Freedman NMT, Bacharach SL. Carson RE, Price JC. and Dilsizian V. Effect of 8. Shcpp LA. Vardi Y. Maximum likelihood reconstruction for emission tomography. smoothing during transmission processing on quantitative cardiac PET. J NucíMed IEEE Tram Med Imag I982;l:l 13-122. 1996: in press. NUCLEAR CARDIOLOGY: CURRENT PERSPECTIVE Myocardial Viability: Unresolved Issues Abdulmassih S. Iskandrian The Philadelphia Heart Institute, Presbyterian Medical Center, Philadelphia, Pennsylvania nation (6,20). A recent study (21 ), however, raised doubt about Key Words: myocardial viability assessment; PET; SPECT; MRI; the reliability of determining absolute rates of myocardial two-dimensional echocardiography glucose uptake using the glucose tracer analog lsF-deoxy- J NucíMed 1996; 37:794-797 fluoroglucose (21 ). The presence of redistribution (reversible defect) on rest-redistribution thallium imaging is also consistent Jlhe determination or assessment of myocardial viability has, with hypoperfusion and reduced resting flow (5,16,17) in viable over the past decade, captured the imagination and interest of myocardium. The recovery of regional dysfunction in such many investigators in basic and clinical research using state-of- segments after coronary revascularization is also consistent the-art technologies such as PET, SPECT, MRI and two- with hibernation. On the other hand, the presence of redistribu dimensional echocardiography (2-DE) (1-12). The emphasis in tion on stress images or the presence of mild fixed thallium these studies has been to determine the absolute and compara defects, mild fixed sestamibi defects or improvement in wall tive accuracy of these techniques (1-3 ). There are recent studies motion during inotropic stimulation (such as dobutamine) do addressing the evaluation of the effect of viability assessment not fulfill the same criteria for hibernating myocardium because on patient outcome (13-17). The use of biochemical agents and it may be that mild fixed perfusion defects represent viable other imaging methods in viability assessment is complex with myocardium but are not markers of hibernating myocardium many unresolved issues (Table 1) to be considered in the design (8,9,17). A good example is subendocardial infarction with and implementation of clinical protocols and in routine patient admixture of scar and normal myocardium in the infarcìzone. care. The subepicardial myocardium is viable but does not have to be hibernating and this zone may very well respond to inotropic DEFINITION stimulation. If LV dysfunction is due to hibernation, it poten The issue of myocardial viability is most important in the tially may recover after coronary revascularization while such presence of left ventricular (LV) dysfunction. Viable myocar recovery may not be expected if the dysfunction is due to dium may be normal, hibernating or stunned while nonviable subendocardial scarring. This may explain the reason why myocardium represents scar (1-3). Thus, hibernating myocar improvement in wall motion on echocardiography with dobut dium is viable but viable myocardium is not necessarily amine has not been a specific marker of recovery of LV hibernating. Hibernation refers to systolic LV dysfunction in the function after revascularization (22). presence of hypoperfusion that recovers after coronary revas- A similar issue may be raised with perfusion imaging. For cularization (1,2,18). It may represent a downregulation of example, Figure 1 depicts the resting myocardial perfusion on a contractile function in response to reduced resting myocardial radionuclide tomogram; area 1 is a region with normal tracer blood flow. Stunned myocardium refers to systolic LV dysfunc uptake; area 2 is a region with mild fixed defect; area 3 is a tion that persists after an ischemie episode despite restoration of region with severe fixed defect and area 4 is a region with flow (19). The distinction between viability and hibernation is important to the understanding of differences between various TABLE 1 diagnostic methods that use different markers such as flow, List of Unresolved Issues in Myocardial Viability metabolism or function. The flow-metabolism mismatch pattern determined by PET (which reflects reduced resting flow but 1. Definition of viable myocardium preserved, albeit altered, metabolism) represents the main 2. Quantification of viable myocardium stream description of the pathophysiological changes in hiber 3. Correlation between perfusion and function 4. Patient selection 5. Time of follow-up assessment Received Jul. 10, 1995; revision accepted Oct. 8, 1995. For correspondence or reprints contact: Abdulmassih S. Iskandrian, MD, William 6. Completeness of revascularization Penn Synder III Professor of Medicine, Director, Cardiovascular Research Center, 7. Perioperative myocardial infarction Medical College of Pennsylvania and Hahnemann University, 230 Broad St., Philadel 8. Endpoints phia, PA 19102. 794 THE JOURNALOFNUCLEARMEDICINE•Vol. 37 •No. 5 •May 1996 reversible defect. If reversibility is a marker of hibernation, then TABLE 2 only 1 of the 4 regions has hibernating myocardium (reversible Relation between Regional Myocardial Perfusion and Wall Motion defect implies reduced resting myocardial blood flow due to Item Perfusion Wall motion Issues to be considered severe coronary stenosis and viable myocardium). On the other hand, if normal uptake, mild fixed defect and reversible defect 1. Normal Normal NA are considered as markers of viable myocardium, then three of 2. Normal Abnormal Stunning, remodeling, relative the four regions contain viable myocardium. The question is: perfusion, malregistration, primary cardiomyopathy* which pattern determines the recovery of LV function in this patient? Based on the mismatch pattern by PET, the answer is 3. Abnormal Abnormal Hibernation ±scar and/or normal one region (1,2,6). myocardium 4. Abnormal Normal Malregistration, misinterpretation QUANTITATION (attenuation artifacts) Although it is feasible that a given myocardial region may be entirely hibernating or entirely scarred, more often than not "Concomitant primary cardiomyopathy and coronary artery disease. there is a mixture of normal, stunned, hibernating and scarred NA = not applicable. myocardium (1 ). The relative proportion of hibernating myo cardium to other abnormalities in a given segment will deter nuclide angiograms, which provide three-dimensional informa mine the extent of recovery of regional function after coronary tion, may be preferred to allow more precise segmental regis revascularization. Thus, in Figure 1, if area 4 is a region with tration (7). severe defect that is completely reversible, it may be more important than if it is a mild defect that is partially reversible PATIENT SELECTION because, in the first example, there is more hibernating myo Many of the published studies involve patients with mild-to- moderate LV dysfunction (4,13-16,22). The selection bias may cardium. Similarly, the total extent of hibernation in the LV myocardium will determine the extent of recovery of global LV explain why the various diagnostic techniques provide compa function measured as ejection fraction (EF). The mere presence rable accuracy in predicting recovery of LV function after of hibernation is not in itself a justification for coronary revascularization (Fig. 2). It is possible that, as LV dysfunction revascularization. With SPECT, problems related to attenua becomes more severe, the accuracy of these techniques diverge. tion, scatter and partial volume effect may make quantitative Myocardial viability assessment is most important in patients assessment of hibernating myocardium less reliable than PET. with severe LV dysfunction who have no disabling angina but have congestive heart failure because if angina exists that alone
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