The effect of flow on technetium-99m-teboroxime (SQ30217) and thallium-201 extraction and retention in rabbit heart

In order to evaluate the accuracy of blood flow measurement, the single-pass extraction, retention/wash-out and relative net uptake of 99mTc-teboroxime (SQ30217) and 201Tl were evaluated and compared in 20 isolated blood-perfused rabbit hearts at coronary flow rates ranging from 0.49 to 2.85 ml/g wet wt min-1. The average peak extraction of 201Tl (+/- s.d.) (0.67 +/- 0.11) marginally exceeded that of SQ30217 (0.62 +/- 0.12) (p = 0.06). Flow significantly affected the maximum net extraction of 201Tl and the 40-min net extractions of both 201Tl and SQ30217. Unexpectedly, the rate of 201Tl myocardial washout was significantly faster (p less than 0.05) than SQ30217 washout at all flow rates evaluated. Increasing coronary blood flow rate was associated with a more rapid clearance of both tracers from the myocardium (p less than 0.05 for both comparisons). The slope of the linear correlations between relative net SQ30217 uptake versus flow and relative net 201Tl uptake versus flow were found to be similar for up to 10 min after isotope injection. These data were interpreted to indicate that: 1. Thallium-201 might be slightly better extracted than SQ30217. 2. SQ30217 is cleared more slowly from the myocardium. 3. Thallium-201 and SQ30217 appear to be comparable tracers of myocardial perfusion for up to 10 min after injection under the single-pass conditions currently employed. 4. Additional studies are needed to clarify myocardial SQ30217 kinetics.     

A comparison of the overall first-pass kinetics of thallium-201 and technetium-99m MIBI in normoxic and low-flow ischaemic myocardium

The specific impact of ischaemia on the myocardial kinetics of thallium-201 and technetium-99m 2-methoxy-2-isobutylisonitrile (MIBI) remains a matter of debate. Using an isolated heart model perfused with red blood cell-enhanced perfusate, we compared the overall first-pass kinetics of 201Tl and MIBI under haemodynamically stable conditions of low-flow ischaemia (> 50% reduction in normal coronary flow and a > or = 20 mmHg fall in systolic contraction pressure, n = 10) and normoxia (n = 11). For both 201Tl and MIBI, we found that under ischaemic conditions (as compared with normoxia) there was a higher initial net extraction fraction (201Tl: 0.78 +/- 0.03 vs 0.72 +/- 0.06, P = 0.006; MIBI: 0.49 +/- 0.10 vs 0.39 +/- 0.11, P = 0.03), a lower clearance rate in the 30 min following extraction (% decrease in cardiac uptake: 201Tl: 30 +/- 12 vs 47 +/- 14, P = 0.02; MIBI: 5 +/- 5 vs 13 +/- 11, P = 0.02) and a higher retention fraction at 30 min (20lTl: 0.54 +/- 0.10 vs 0.39 +/- 0.12, P = 0.004; MIBI: 0.46 +/- 0.08 vs 0.33 +/- 0.12, P = 0.01). Multivariate analyses, however, revealed that all myocardial kinetic parameters of both tracers were dependent only on coronary flow rates, without any additional significant impact of the presence of ischaemia or states of contractility or oxidative metabolism. We conclude that the myocardial fractional retention of both 201Tl and MIBI is strongly correlated with the decrease in coronary flow during ischaemia. This inverse relationship with coronary flow derives from both the flow-dependent increase in the initial myocardial extraction and the decrease in the subsequent myocardial washout of the tracers.     

Quantitative thallium-201 scintigraphy after dipyridamole infusion combined with low level exercise in healthy volunteers

To establish test specific normal limits for quantitative analysis of uptake and washout of 201Tl after dipyridamole infusion combined with low level exercise, 20 healthy volunteers were studied with low likelihood of coronary artery disease (CAD) assessed by a stepwise probability analysis based on age, sex, symptoms, resting electrocardiogram, and exercise electrocardiography. Likelihood of CAD in these volunteers was calculated as less than or equal to 1%. After dipyridamole infusion combined with low level exercise, one volunteer complained of headache; no other side effects were observed. There were no chest pain complaints. Maximal hemodynamic changes were achieved during the 6th and 7th min of the test. No ST segment depression was recorded. Visual analysis of the 201Tl scintigrams was normal in all volunteers. Mean regional washout at 4 h was 44.37% +/- 2.11%. The regional washout in the 70 degrees LAO view (46.65% +/- 1.10%) was significantly higher than in the anterior and 30 degrees LAO views (43.44% +/- 1.50% and 43.02% +/- 1.45%, respectively). Profiles of uptake and washout of 201Tl were different after dipyridamole infusion combined with low level exercise as compared to maximal exercise. Thus, in quantitative analysis of 201Tl scintigraphy after dipyridamole infusion in conjunction with low level exercise as applied in the present study, it is mandatory to use normal limits of uptake and washout of 201Tl derived from healthy volunteers who underwent the same combined protocol.     

Serial change of 123I-metaiodobenzylguanidine (MIBG) myocardial concentration in patients with dilated cardiomyopathy

123I-Metaiodobenzylguanidine (MIBG) is expected to be useful agent for functional evaluation of the myocardial sympathetic innervation. The aim of this paper is to investigate serial change of 123I-MIBG myocardial concentration in patients (pts) with dilated cardiomyopathy (DCM) as compared with 201Tl uptake. Eight pts with DCM and six non-cardiac subjects (controls) were examined. After injection of 111 MBq (3mCi) 201Tl and 111 MBq (3 mCi) 123I-MIBG, simultaneous myocardial imaging in anterior view was performed for both tracers in every 30-60 minutes during 5 hours (6 images). Myocardial uptake ratio per pixel to the injected dose was calculated for each tracer with background and cross-talk correction on each image. In pts with DCM, myocardial uptake ratio of 123I-MIBG did not differ significantly from that of controls. The washout of 123I-MIBG from the myocardium, however, was significantly increased in pts with DCM as compared with controls. The % decrease of the radioactivity in 3 hours was 46.9 +/- 13.8% in DCM, whereas 18.0 +/- 7.7% in controls (p less than 0.05). Especially, the decrease in the early phase (less than 1 hour) was significantly larger in DCM than controls (21.2 +/- 7.5% vs 5.3 +/- 4.0%, p less than 0.01). For 201Tl, on the other hand, neither uptake ratio nor washout rate, differed significantly between the two. In conclusion, the rapid washout of 123I-MIBG in the early phase may reflect some sympathetic dysfunction in pts with DCM.     

Influence of hypertensive left ventricular hypertrophy on detection of ischemic area with exercise thallium-201 myocardial scintigraphy]

Sixty-four patients with single left anterior descending artery disease having effort angina (group A: 40 patients without hypertension, group B: 10 patients with hypertrophic hypertension, group C: 14 patients with non-hypertrophic hypertension) were assessed the influence of hypertensive left ventricular (LV) hypertrophy on detection of ischemic area. The criterion of hypertrophy by two-dimensional echocardiography was > 12 mm in the wall thickness of interventricular septal or posterior wall. Population in Group B might show low detectability in ischemic area by 201Tl myocardial scintigraphy (positive thallium rate 60%, defect score 2.7 +/- 3.6), and high lung thallium uptake and high frequence of ECG positive among three groups. In semiquantitative analysis, the washout rate of the posterolateral wall and %RD (delayed %uptake-initial %uptake) of the septal wall in patients with Group B were lowest among three groups. However, the washout rate in the septal wall against the posterior wall, and the initial %uptake and the delayed %uptake of the septal wall were not significantly different among three groups. We could conclude that the decreased washout rate in nonischemic area with hypertensive LV hypertrophy might make the ischemic area masked.     

Effects of heart rate on myocardial thallium-201 uptake and clearance

The effects of heart rate on the myocardial uptake and clearance of 201Tl were studied prospectively in seven healthy men, mean age 43 +/- 7 (s.d.) yr. Initial and delayed (3 hr) thallium images were obtained in three views after three bicycle exercise tests: to maximal, 80% and 60% of predicted maximal heart rate. The mean of three views initial myocardial 201Tl uptake was higher at maximal than at both 80% and 60% of predicted maximal heart rate, being 81% (p less than 0.01) and 60% (p less than 0.01) of maximal activity, respectively. The myocardial activity in the delayed images was identical. There was a linear relationship between heart rate and the initial myocardial activity, r = 0.86 (p less than 0.001). The mean (range) 201Tl clearance was 58% (51-65), 47% (34-56), and 34% (22-49) (all differences p less than 0.01), respectively. Concordance among the three individual views in estimating clearance was best for the highest exercise level. There was a linear relationship between heart rate and clearance, r = 0.80 (p less than 0.001). Clearance was altered by only 1.67 x 10%/heart bpm (0.024 hr/heart beat). Clearance in the liver, spleen and lungs increased at submaximal exercise levels. Thus, a linear relationship between heart rate and clearance is the result of changes in the initial exercise myocardial 201Tl activity. Submaximal exercise may reduce reproducibility of clearance estimation, and the change of myocardial clearance with heart rate seems less than previously suggested.     

Early dynamic 201Tl SPECT in the evaluation of brain tumours

OBJECTIVE: To estimate the usefulness of early dynamic 201Tl single photon emission computed tomography (SPECT) studies in distinguishing the histological malignancy of brain tumours. METHODS: Dynamic 201Tl SPECT was performed for 3 min per scan for 15 min immediately after the administration of 201TlCl in 110 patients with brain tumours (111 lesions). The data obtained each 3 min were used for dynamic SPECT, and the five sets of data obtained were added to acquire static SPECT data. For static SPECT, the static thallium index (STI) was calculated as the ratio of 201Tl uptake in the tumour to that of the contralateral normal brain. The ratio of the 201Tl uptake for each 3 min was defined as the dynamic thallium index (DTI). The dynamic thallium rate (DTR), as a per cent, was calculated as DTR=(DTI for every 3 min)/STI H 100. The five values were approximated as a linear function and the slope (%/min) was calculated. RESULTS: In static SPECT, there was no significant difference between the STI of malignant tumours (glioblastoma and anaplastic astrocytoma) and that of benign tumours (low-grade glioma, meningioma, pituitary adenoma, neurinoma and haemangioblastoma) (3.7+/-1.5, 5.0+/-3.5, respectively). On dynamic SPECT, DTI increased markedly over 15 min for malignant tumours. In contrast, the DTI of benign tumours increased slightly, steadily or decreased. The slope of the linear functions calculated from the DTRs was much higher in the malignant tumour group than in the benign tumour group (P<0.001). CONCLUSIONS: We suggest that the performance of 201Tl dynamic SPECT for 15 min is useful for distinguishing malignant brain tumours from benign brain tumours and reduces the examination stress of patients.     

Dynamic 99Tcm-ECD SPET correlates well with 201Tl indices in brain tumours

The dynamic 99Tcm-ethyl cysteinate dimer (99Tcm-ECD) single photon emission tomographic (SPET) characteristics of brain tumours were investigated and compared with 201Tl-chloride SPET indices. Thirty-five patients with histologically confirmed benign and malignant tumours were evaluated using dynamic and standard 99Tcm-ECD. Twenty-eight patients were also examined using standard 201Tl SPET. The following 201Tl indices were calculated: early uptake ratio, delayed uptake ratio, washout rate and retention index. The relationship between uptake of 99Tcm-ECD on dynamic SPET and 201Tl indices was analysed. Nine patients showed positive uptake on dynamic 99Tcm-ECD SPET, all of whom had benign tumours, including five meningothelial meningiomas, three pituitary adenomas of the chromophobe type and one chemodectoma without malignancy. The mean early uptake ratio of the tumours with positive uptake was significantly higher than that of the tumours with negative uptake (17.1 +/- 5.5 vs 9.0 +/- 5.7, P = 0.004). The mean washout rate of the tumours with positive uptake was significantly higher than that of the tumours with negative uptake (61.0 +/- 27.7 vs 0.35 +/- 30.9, P = 0.0004). The mean retention index of the tumours with positive uptake was significantly lower than that of the tumours with negative uptake (0.27 +/- 0.12 vs 0.88 +/- 0.48, P = 0.000006). Only benign tumours showed positive uptake on dynamic 99Tcm-ECD SPET. The 201Tl indices correlated well with the uptake of 99Tcm-ECD on dynamic SPET. The results suggest that dynamic 99Tcm-ECD SPET can identify the benign character of tumours of the brain.     

Myocardial 201Tl washout after combined dipyridamole submaximal exercise stress: reference values from different patient groups

Dipyridamole stress is favorable in patients unable to exercise maximally for 201Tl myocardial scintigraphy. Aside from an analysis of uptake defects, proper washout analysis can be limited by heart rate variations when isolated dipyridamole stress is used. Heart rate standardized 201Tl washout kinetics after a combined dipyridamole and submaximal exercise stress protocol (CDSE), feasible in elderly patients as well as in patients with peripheral artery disease, were therefore studied to investigate the 201Tl washout after CDSE in differently defined patient groups: Group I comprised 19 patients with documented heart disease and angiographically excluded coronary artery disease (CAD); group II contained 17 patients with a very low likelihood of CAD determined by both normal exercise radionuclide ventriculography and normal 201Tl uptake. Group III comprised 56 patients with a 50% pretest likelihood of CAD but normal 201Tl uptake. Mean washout values were nearly identical in all groups. Despite similar uptake patterns, however, washout standardized by CDSE was significantly lower than the normal washout values after maximal treadmill exercise. Thus an obviously lower 201Tl washout after CDSE than after maximal treadmill exercise must be considered if washout analysis criteria after dipyridamole are applied to evaluate ischemic heart disease. Nevertheless, heart rate elevation achieved by additional submaximal exercise stress seems necessary, adequate and clinically safe for standardisation of washout analysis in dipyridamole 201Tl scintigraphy.     

The optimum time for tumour imaging with thallium-201

Following the intravenous injection of 75 MBq 201Tl-chloride we have assessed the uptake kinetics in the myocardium and in the primary tumour in 56 patients with lung cancer, 26 with breast cancer and 13 with mediastinal lymphoma. The time of maximal tumour uptake ranged from 8-20 min post-injection and did not differ significantly between lung cancer (mean +/- SD = 11.9 +/- 3.34 min), breast cancer (11.21 +/- 1.88 min) and lymphoma (11.76 +/- 3.25 min). The time of maximum cardiac uptake of 201Tl was 11.61 +/- 3.25 min. There was no significant washout of 201Tl from the tumours in the first hour after injection in the various malignant lesions studied. The time of maximal tumour to background activity was 18.3 +/- 0.59 min for lung cancer, 13.0 +/- 1.16 min for breast cancer and 16.7 +/- 1.04 min for lymphoma. The time course of 201Tl uptake in the tumours suggests that the mechanism of uptake is similar to that in the myocardium. The optimal time of 201Tl tumour imaging is from 20-60 min following injection and did not differ in various tumours studied.     

Thallium-201 scintigraphy in bone and soft-tissue tumors: a comparison of dynamic, early and delayed scans

OBJECTIVE: It has been reported that delayed scan of thallium-201 (201Tl) scintigraphy is useful for differentiating malignant tumors from benign lesions and for evaluating treatment response. However, physiological muscle uptake which usually increases in delayed scans, often makes it difficult to evaluate 201Tl uptake and its washout in bone and soft-tissue tumors. The purpose of this study was to evaluate whether the delayed scan is necessary and whether a dynamic scan is useful in the evaluation of bone and soft-tissue tumors. METHODS: We studied 175 cases of bone and soft-tissue tumors (malignant 45, benign 130). Dynamic scans were acquired every 5 seconds for 10 minutes after 201Tl injection, and time activity curves (TACs) were generated by adaptive smoothing methods. Early and delayed scans were acquired at 10-15 minutes and 2 hours after injection. 201Tl images were visually interpreted and the radioactivity count ratio (T/N) of tumors to normal tissues and washout rate [WR = (early T/N - delayed T/N)/early T/N] were defined. RESULTS: When there were no 201Tl uptake in dynamic (n = 67) and early scans (n = 68), no tumor uptake was also appreciated in delayed scans, and all but two cases of negative scans were benign. In 107 lesions, although there were significant differences in T/Ns between malignant and benign lesions both on early scans (2.84 +/- 1.45 vs. 2.05 +/- 1.13, p < 0.05) and delayed scans (2.17 +/- 1.03 vs. 1.58 +/- 0.64, p < 0.05), there was a substantial overlap. The T/Ns decreased in delayed scans (i.e., WR > 0) in 100 of 107 cases due to increase of surrounding muscle uptake, and there was no difference in WR between malignant tumors and benign lesions (0.21 +/- 0.14 vs. 0.19 +/- 0.14). CONCLUSIONS: For evaluating bone and soft-tissue tumors, delayed scan had little clinical usefulness and it may be time consuming. Dynamic scan would be useful for demonstrating the differences between tumor blood flow and 201Tl uptake in tumors.     

Kinetic analysis of 18F-fluorodihydrorotenone as a deposited myocardial flow tracer: comparison to 201Tl.

The goals of this investigation were to assess the accuracy of (18)F-fluorodihydrorotenone ((18)F-FDHR) as a new deposited myocardial flow tracer and to compare the results to those for (201)Tl. METHODS: The kinetics of these flow tracers in 22 isolated, erythrocyte- and albumin-perfused rabbit hearts were evaluated over a flow range encountered in patients. The 2 flow tracers plus a vascular reference tracer ((131)I-albumin) were introduced as a bolus through a port just above the aortic cannula. Myocardial extraction, retention, washout, and uptake parameters were computed from the venous outflow curves with the multiple-indicator dilution technique and spectral analysis. RESULTS: The mean +/- SD initial extraction fractions for (18)F-FDHR (0.85 +/- 0.07) and (201)Tl (0.87 +/- 0.05) were not significantly different, although the initial extraction fraction for (18)F-FDHR declined with flow (P < 0.0001), whereas the initial extraction fraction for (201)Tl did not. The washout of (201)Tl was faster (P < 0.001) and more affected by flow (P < 0.05) than was the washout of (18)F-FDHR. Except for the initial extraction fraction, (18)F-FDHR retention was higher (P < 0.001) and less affected by flow (P < 0.05) than was (201)Tl retention. Reflecting its superior retention, the net uptake of (18)F-FDHR was better correlated with flow than was that of (201)Tl at both 1 and 15 min after tracer introduction (P < 0.0001 for both comparisons). CONCLUSION: The superior correlation of (18)F-FDHR uptake with flow indicates that it is a better flow tracer than (201)Tl in the isolated rabbit heart. Compared with the other currently available positron-emitting flow tracers ((82)Rb, (13)N-ammonia, and (15)O-water), (18)F-FDHR has the potential of providing excellent image resolution without the need for an on-site cyclotron.     

Myocardial uptake of iodinated free fatty acids and 201Tl in experimental ischemia

In an experimental study, we evaluated the uptake of (131I)-17-iodo heptadecanoic acid (131I-HDA), (125I)-15-4 (4-iodophenyl) pentadecanoic acid (125I-PPA) and thallium-201 (201Tl) in the dog heart. Twenty dogs were studied and divided into 3 groups: in group A, 10 dogs (4 normal, 6 with coronary artery occlusion) were studied with 131I-HDA and 201Tl; in group B, 5 dogs (with occlusion) received 125I-PPA and 201Tl; and in group C, 5 dogs (with occlusion) were studied with 125I-PPA and 131I-HDA. Two min after administration of the compounds the hearts were excised and stored in formaldehyde. After sectioning of the left ventricle, total uptake was counted and expressed in percentage of injected dose. Uptake in the normal myocardium (group A) was 4.2 +/- 0.6% for 131I-HDA and 4.6 +/- 0.7% for 201Tl; in the occluded dog hearts (group A) we measured values of 2.6 +/- 0.4% for 131I-HDA (p less than 0.001) and 3.4 +/- 0.6% for 201Tl (p less than 0.01). Uptake of 131I-HDA, 125I-PPA and 201Tl in groups B and C was not significantly different: group B, 125I-PPA 2.8 +/- 0.8% and 201Tl 2.5 +/- 0.5%; group C, 125I-PPA 1.9 +/- 0.7% and 131I-HDA 1.6 +/- 0.6%. Moreover, regional distribution of both iodinated fatty acids was quite comparable with the distribution of 201Tl. We conclude that 131I-HDA and 125I-PPA show similar uptake as 201Tl and are distributed according to coronary artery perfusion, which underscores their value as myocardial imaging agents.     

Effects of ouabain on 201Tl and 99mTc MIBI kinetics in rat myocardium--in vivo study using miniature CsI detector]

The aim of this study is to investigate the effect of ouabain (inhibitor of Na-K ATPase) in the myocardial uptake and clearance of 201Tl and 99mTc MIBI using rats. Time activity curves of three groups were measured by CsI miniature detector for 15 min after the administration of each radiopharmaceutical. Groups were divided as follows; 1) control group (CON group), 2) early phase as 15 min after the administration of ouabain (OU15 group), and 3) late phase as 120 min after the administration of ouabain (OU120 group). Main organs of rats including myocardium were resected at 1 min and 15 min after the administration of 201Tl or 99mTc MIBI under the anesthesia of pento-barbital sodium. The uptake (%ID/g) of 201Tl or 99mTc MIBI was measured by well type scintillation counter. The uptake of 201Tl of OU15 group was significantly higher than CON group (OU15: 10.81 +/- 1.90, CON: 1.86 +/- 0.42) and cleared more rapidly. On the contrary, OU120 group showed lower uptake (1.70 +/- 0.21) and slower clearance than OU15 group. Time activity curve of OU15 group indicated the accelerated washout compared with CON group. However, OU120 group showed significantly the reduced washout (CON group: 19%, OU15 group: 22%, OU120 group: 9%). On the other hand, the uptake and time activity curves of 99mTc MIBI were not influenced by ouabain administration. In conclusion, myocardial uptake and clearance of 99mTc MIBI were not related to Na-K ATPase activity, while those of 201Tl were markedly influenced by Na-K ATPase.     

Comparative myocardial extraction of two technetium-labeled BATO derivatives (SQ30217, SQ32014) and thallium

The transcapillary exchange of a new class of 99mTc-labeled compounds (BATO) were compared to 201Tl in isolated, blood perfused rabbit hearts. During variable blood flow (0.15-2.44 ml/min/g), peak and net extraction (Emax and Enet, respectively), and capillary permeability-surface area product (PScap) were determined with paired indicator-dilution techniques. Serial bolus injections of 201Tl, [111In]albumin, and [99mTc]BATO; chloro[tris(cyclohexanedionedioxime)methyl boronic acid]Tc (SQ30217, n = 8) and a hydroxy-substituted derivative (SQ32014, n = 5) were given to a total of 13 hearts. Mean (+/- s.d.) SQ30217 Emax and Enet were 0.72 +/- 0.09 and 0.55 +/- 0.18, respectively, which were higher than thallium values of 0.57 +/- 0.10 and 0.46 +/- 0.17 (p less than 0.03). Mean SQ30217 PScap was 1.1 +/- 0.4 ml/min/g and was also higher than corresponding thallium determinations (0.7 +/- 0.3; p less than 0.001). SQ32014 Emax, Enet, and PScap were all significantly less than thallium values (p less than 0.001). Thallium and SQ30217 values for Emax and PScap were closely correlated with blood flow (r greater than or equal to 0.73), whereas those for SQ32014 were weakly correlated (r = 0.09). A small clinical pilot study (n = 3) was performed, which showed that SQ32014 was a poor myocardial perfusion agent in man. In summary, transcapillary exchange of SQ30217 is greater than thallium, which in turn, is greater than SQ32014. Therefore, SQ30217 appears to have good clinical potential, but SQ32014 does not.     

Myocardial201Tl washout after combined dipyridamole submaximal exercise stress: Reference values from different patient groups

Dipyridamole stress is favorable in patients unable to exercise maximally for²⁰¹Tl myocardial scintigraphy. Aside from an analysis of uptake defects, proper washout analysis can be limited by heart rate variations when isolated dipyridamole stress is used. Heart rate standardized²⁰¹Tl washout kinetics after a combined dipyridamole and submaximal exercise stress protocol (CDSE), feasible in elderly patients as well as in patients with peripheral artery disease, were therefore studied to investigate the²⁰¹Tl washout after CDSE in differently defined patient groups: Group I comprised 19 patients with documented heart disease and angiographically excluded coronary artery disease (CAD); group II contained 17 patients with a very low likelihood of CAD determined by both normal exercise radionuclide ventriculography and normal²⁰¹Tl uptake. Group III comprised 56 patients with a 50% pretest likelihood of CAD but normal²⁰¹Tl uptake. Mean washout values were nearly identical in all groups. Despite similar uptake patterns, however, washout standardized by CDSE was significantly lower than the normal washout values after maximal treadmill exercise. Thus an obviously lower²⁰¹Tl washout after CDSE than after maximal treadmill exercise must be considered if washout analysis criteria after dipyridamole are applied to evaluate ischemic heart disease. Nevertheless, heart rate elevation achieved by additional submaximal exercise stress seems necessary, adequate and clinically safe for standardisation of washout analysis in dipyridamole²⁰¹Tl scintigraphy.     

Fast washout of thallium-201 from area of myocardial infarction: possible artifact of background subtraction

A recent report described a pattern of "reverse redistribution" on poststreptokinase 201Tl studies which was believed to be due to rapid washout of 201Tl from the infarct area related to reperfusion of the infarct vessel. We have also observed the phenomenon of rapid washout of 201Tl from the area of infarction in the absence of thrombolytic therapy. This study was undertaken to test the hypothesis that rapid washout of 201Tl from an area of infarction is an artifact of background subtraction usually employed in analysis of washout. A total of 61 patients with previous myocardial infarction who underwent cardiac catheterization and exercise 201Tl imaging were examined. Thallium-201 images were analyzed using a validated quantitative method employing interpolative background correction. Abnormally increased 201Tl washout was noted in 11 infarct segments in 10 (18%) patients. Infarct segments with rapid washout had significantly less initial uptake, and more severe associated wall motion abnormalities than infarct segments with normal washout. When quantitative analysis was repeated without background subtraction, no segments with rapid washout were observed. A phantom model was constructed to further test our hypothesis. The frequency of observed rapid washout was directly related to the severity of the initial defect and was entirely dependent upon utilizing background correction during the quantitative analysis. Our study suggests that rapid washout of 201Tl in an area of previous infarction reflects an artifact of background subtraction involved with standard quantitative analysis.     

Oxygen uptake and heart rate responses during hypoxic exercise in children and adults

Control of ventilation and heart rate during exercise appears to undergo maturation, while aerobic metabolism (VO2) may not. Since we had previously found that hypoxia during exercise produced different ventilatory responses in children (C) compared to adults (A), we hypothesized that VO2 and heart rate kinetics during exercise would show similar maturational responses to hypoxia. To test this hypothesis, we examined the responses during progressive (ramp) and constant work rate tests in children and adults breathing either room air or hypoxic gas (FiO2 = 0.15). When corrected for body weight, children and adults had similar values for lactic acidosis threshold (LAT) (C: 29.1 +/- 5.0 ml.min-1.kg-1; A: 27.9 +/- 4.3) and VO2max (C: 40.7 +/- 8.6 ml.min-1.kg-1; A: 45.2 +/- 6.7) during normoxia. Hypoxia significantly lowered LAT (C: 27.5 +/- 5.4 ml.min-1.kg-1; A: 23.2 +/- 3.8; both P less than 0.05) and VO2max (C: 37.7 +/- 8.3 ml.min-1.kg-1; A: 40.1 +/- 5.3; both P less than 0.05) in both children and adults. Metabolic efficiency (delta VO2/delta work rate) and the VO2-heart rate relationship (delta VO2/delta HR/kg) were similar in the two groups and unaffected by hypoxia. During the constant work rate exercise, VO2 kinetics (time constant during phase 2 of the response (pi 1) and the O2 deficit) were similar between children and adults and were significantly slowed by hypoxia, consistent with current understanding of the control of oxidative metabolism. Finally, heart rate was increased at rest and during exercise with hypoxia, while the time to reach 75% of the end-exercise response was delayed significantly, in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison between rest technetium-99m-tetrofosmin and rest-redistribution thallium-201 SPECT in stable patients with healed myocardial infarction.

Resting (99m)Tc-tetrofosmin (TF) uptake was compared with thallium ((201)Tl) rest-redistribution (R-RD) uptake in patients with previous myocardial infarction (MI) and significant coronary artery disease (CAD) to assess the ability of TF to detect viable myocardium. We studied 30 patients (21 males and nine females, mean age 53.9+/-12.5 years) with prior MI and left ventricular dysfunction who had been referred for coronary revascularization procedures. Myocardial single photon emission computed tomography (SPECT) images were obtained 1 h after injection of 750 MBq of TF. Within 1 week of the TF study, R-RD (201)Tl SPECT imaging was performed after injection of 111 MBq of (201)Tl . Quantitative analysis was performed in 21 segments. Viability was defined as the presence of tracer uptake greater than 50% of the peak activity on baseline studies or after reversibility. There was significant correlation between the quantitative regional R-RD (201)Tl activity and the resting TF activity (r=0.88, P<0.001). Quantitative analysis showed that the uptake of the two tracers was comparable in normal segments as well as in segments with fixed (201)Tl defects. In contrast, in segments with reversible (201)Tl defects, TF uptake was significantly greater than resting (201)Tl uptake, but lower than R-RD (201)Tl uptake. There were 52 segments (47% of the severely reduced segments on TF images) that showed no viability with TF, but were viable on the redistribution (201)Tl studies. We conclude that quantitative resting TF SPECT underestimates the presence of viable myocardium compared with R-RD (201)Tl imaging on the basis of using 50% of the peak activity as the viability threshold.     

Serial change of iodine-123 metaiodobenzylguanidine (MIBG) myocardial concentration in patients with dilated cardiomyopathy.

Serial change of the metaiodobenzylguanidine iodine-123 (123I-MIBG) myocardial concentration was investigated in patients with dilated cardiomyopathy (DCM). Eight DCM patients and 6 control subjects were examined. After the injection of thallium-201 and 123I-MIBG, planar chest images were obtained simultaneously for both tracers in every 30-60 min over 5 h. Serial changes of myocardial uptake ratio (MUR) were compared for both tracers. In DCM, the initial MUR of 123I-MIBG did not differ significantly from that of the controls. The washout of 123I-MIBG from the myocardium, however, was significantly increased in DCM. In particular, the decrease in the early phase (15-45 min) was significantly larger in DCM than in the controls (21.2% +/- 7.5% vs. 5.3% +/- 4.0%, P less than 0.01), showing a significant negative correlation with the left ventricular ejection fraction (r = -0.72 P less than 0.05). For 201Tl, neither the initial MUR nor the washout rate different significantly between the two. Thus, an early rapid decrease of the 123I-MIBG myocardial concentration might characterize DCM and reflect the severity of this disease.