Paradoxical regional myocardial uptake between 201Thallium and 123I-BMIPP SPECT in patients with cardiomyopathy

 The clinical significance of the paradoxical mismatched phenomenon between ²⁰¹Tl and ¹²³I-BMIPP is still unknown. We report two cases that revealed paradoxical regional myocardial uptake between two tracers in patients with cardiomyopathy. There may be abnormal myocardium in these patients where active transportation of ²⁰¹Tl is disturbed and passive transportation of ¹²³I-BMIPP is not disordered. Received: July 31, 2002 / Accepted: September 21, 2002 Correspondence to K. Ueshima     

Early diagnosis of interferon-induced myocardial disorder in patients with chronic hepatitis C: evaluation by myocardial imaging with 123I-BMIPP

Interferon (IFN) therapy for chronic hepatitis C is sometimes associated with cardiac complications. In the present study, we performed myocardial imaging with ¹²³I-labeled β-methyl-p-iodophenylpentadecanoic acid (¹²³I-BMIPP) in order to evaluate myocardial disorders caused by IFN. We studied 40 healthy subjects (H group) and 25 patients with chronic hepatitis C who had been treated with IFN (IFN group). A Holter electrocardiogram (ECG) was performed and the autonomic nervous function was assessed by analyzing the spectral variability and 1/f fluctuation of heart rate. Myocardial planner imaging with ¹²³I-BMIPP was performed to obtain the time activity curve for 20 min immediately after administration of ¹²³I-BMIPP (dynamic study). Early and delayed myocardial single photon emission computed tomography (SPECT) images were expressed as Bull's eyes and the myocardium was divided into four segments to calculate the washout rate for each segment on early and late SPECT images (early and late SPECT study). No significant differences in autonomic nervous function were observed between the two groups in heart rate variability. In a dynamic study, the reduction rate from the time activity curve was significantly higher in the IFN group compared with the H group (reduction rate, IFN group, 5.3 ± 3.7% vs H group, 1.2 ± 3.3%; P < 0.05). In the early and delayed myocardial SPECT study, the washout rate for the IFN group was significantly increased in all myocardial areas compared to that in the H group. However, the metabolic disorder of fatty acids caused by IFN was reversed on the se-cond ¹²³I-BMIPP myocardial scintigraphy examination several months after IFN therapy. These results indicate that metabolic disorders of fatty acids caused by IFN therapy can be detected before abnormalities are observed by Holter-ECG or echocardiography. Received: October 21, 1998 / Accepted: August 27, 1999     

In vivo imaging of hepatic fatty acid metabolism in patients with nonalcoholic steatohepatitis using semiquantative (123)I-BMIPP liver scan.

Recent progress of studies in NASH displays multi-disciplinary characters of the pathogeneses. Despite these advances, the strategic use of imaging modalities such as CT, US, and MRI, remains a relatively low priority in clinical situations, because these can only visualize the presence of fatty infiltration to the hepatic parenchyma, impossible to figure out the dynamic function of NASH liver. Morphological alteration such as CT value, MR signal intensity and echo-grade do not distinguish NASH from simple fatty liver. In this presentation, from a radiologic viewpoint, we show the feasibility of in vivo fatty acid imaging with (123)I-beta-methyl-p-iodophenyl-pentadecanoic acid (BMIPP). BMIPP is an (123)I labeled fatty acid analog for imaging damaged myocardium, using conventional nuclear imaging equipment. Under normal conditions, the energy source for myocardial utilization is dependent on the beta-oxidation of fatty acids. For energy production in ischemic myocardium, the drastic switch from reduced beta-oxidation of fatty acids to glucose metabolism is well known. BMIPP can detect the area of reduced fatty acids metabolism on myocardial imaging and the data can be converted into semiquantitative analysis. Therefore, we speculate that the use of BMIPP to in vivo hepatic imaging in NASH could highlight a lot of matters of NASH. Details of this presentation include: (1) Hepatic imaging with BMIPP; (2) Clearance of BMIPP from NASH liver; (3) semiquantitative analysis of hepatic BMIPP clearance and clinical features of NASH; (4) Profiles of NASH categorized by BMIPP imaging and (5) Preliminary data of BMIPP clearance in patients with Tamoxifen-induced NASH. The core of our stance in this presentation is searching for valuable advice on clinical use of BMIPP in patients with NASH from specialists in the field of HEPATOLOGY.     

Anti-SS-A/Ro antibody positivity as a risk factor for relapse in patients with polymyositis/dermatomyositis

Objective: The objective of this study is to elucidate predictors of relapse in patients with polymyositis and dermatomyositis (PM/DM).

Methods: Fifty PM/DM patients who achieved disease stabilization at Okayama University Hospital in 2004–2014 were enrolled retrospectively. Candidate predictors such as demographic factors, clinical symptoms, laboratory data, and treatment status were compared.

Results: The mean age of enrolled patients was 58 years; 34 were female. The patient groupings were as follows: 21 with PM, 27 with DM, and two with clinically amyopathic DM. During a mean observation period of 685 d, 5 patients (10%) died and 20 (40%) relapsed. The relapsed patients displayed baseline muscle weakness less frequently (85% versus 100%, p?=?.03) and anti-SS-A/Ro antibody more frequently (65% versus 27%, p?=?.007). Anti-SS-A/Ro-positive patients exhibited a higher relapse rate than anti-SS-A/Ro-negative patients (log-rank test, p?=?.03). Anti-SS-A/Ro-positive patients also exhibited higher anti-Jo-1 antibody positivity and lower levels of serum complement. After adjusting anti-Jo-1 antibody positivity, age, sex, CK <500?IU/L, and lung involvement, anti-SS-A/Ro positivity was still an independent risk factor for higher relapse-rate (odds ratio, 5.5; 95% confidence interval, 1.4–25.1).

Conclusions: Anti-SS-A/Ro antibody positivity may be a useful biomarker for prediction of relapse.     

Serum uric acid is independently associated with hypertension in patients with polymyositis and dermatomyositis

Serum uric acid (UA), as an antioxidant, has been associated with hypertension in the general population. Hypertension is highly prevalent in patients with polymyositis and dermatomyositis (PM/DM). Owning elevated levels of reactive oxygen species, patients with PM/DM have lower concentrations of UA in comparison with healthy people. We explored a potential association between UA levels and hypertension in PM/DM and evaluated whether this association is independent of hypertension risk factors, PM/DM characteristics and relevant drugs. A total of 472 PM/DM patients were assessed. UA and related laboratory data were measured. Demographic, hypertension-related factors, PM/DM characteristics and drug use were assessed as potential covariates. Results were analyzed using logistic models to test the independence of the association between UA and hypertension. UA levels were higher in hypertension subjects compared to non-hypertensive PM/DM patients [284.70 (239.93-357.38) vs 264.00(222.50-322.75), p = .017]. When adjusted for hypertension risk factors, PM/DM characteristics and drugs, the odds of being a hypertensive PM/DM patient per 1 μmol/L UA increase were significantly increased: odds ratio = 1.473 (95% confidence interval:1.063-2.042, p = .020). This cross-sectional study suggests that UA levels are independently associated with hypertension in PM/DM patients.     

Flowcytometric analysis of bronchoalveolar lavage fluid cells in polymyositis/dermatomyositis with interstitial pneumonia

OBJECTIVE: Interstitial lung disease (ILD) is a complication occurring in 10-30% of patients with polymyositis/dermatomyositis (PM/DM) as well as in those with progressive systemic sclerosis (PSS). Clinical features are different between these two disease states, notably with respect to the duration of manifestations, pathological findings, response to steroid therapy etc. However, dissimilarities in pulmonary inflammatory cell characteristics, which, if present at all, would be of critical importance, remain as yet to be clarified. METHODOLOGY: The phenotypes of lymphocytes and alveolar macrophages in bronchoalveolar lavage fluid (BALF) were analysed to elucidate phenotypic peculiarity of pulmonary inflammatory cells of ILD in PM/DM. Eight PM/DM patients with ILD (mean age 47.9 years) were examined by bronchofibrescopy under local anaesthesia. Bronchoalveolar lavage was performed from the right middle lobe using four 50 mL aliquots of normal saline and the recovered fluid was compared with BALF of ILD in PSS. RESULTS: Bronchoalveolar lavage fluid cells of PM/DM patients with ILD showed an increased percentage of CD8+ lymphocytes, in particular CD8+ histocompatibility leucocyte antigen-DR positive lymphocytes and CD8+ CD11b-lymphocytes, both of which represent cytotoxic T cells. However, phenotypic differences in these lymphocytes were not found between PM and DM. The percentage of alveolar macrophages with expression of histocompatibility leucocyte antigen-DQ was significantly different among the three groups (PM/DM, PSS, healthy volunteers). CONCLUSIONS: Cytotoxic T cells may be major pulmonary inflammatory cells of ILD in PM/DM with no apparent difference between PM and DM. In contrast, ILD in PSS was suggested as being likely to be characterized by activated macrophage.     

Transbronchial biopsy is clinically useful in classifying patients with interstitial pneumonia associated with polymyositis and dermatomyositis

Background and objective: The histological type of intraluminal fibrosis is an important prognostic factor for interstitial pneumonia. We therefore examined whether transbronchial lung biopsy (TBLB) specimens are useful for predicting the clinical course and prognosis of patients with interstitial pneumonia associated with polymyositis and dermatomyositis (PM/DM), with particular attention to the different types of intraluminal fibrosis. Methods: Twenty‐five cases of interstitial pneumonia associated with PM/DM were classified according to the pattern of intraluminal fibrosis as assessed by TBLB, and the clinical course and response to treatment were compared. Interstitial fibrosis was evaluated by sequential thin‐section CT scans. Results: In 19 of 25 (76%) cases, there was sufficient intraluminal fibrosis to perform an evaluation. Intraluminal fibrosis was classified as bud (polyp) type or mural incorporation type (either alone or mixed with bud type). The bud type was seen in five cases and these improved following treatment with corticosteroids only. The mural incorporation type was seen in 14 cases. In 11 of these 14 cases, progressive long‐term fibrosis developed and four cases were fatal, in spite of corticosteroid and immunosuppressive therapy. The response to drugs (P < 0.01) and survival (P < 0.05) were significantly greater in patients with bud‐type than mural incorporation‐type intraluminal fibrosis. Conclusions: Classification of the pattern of intraluminal fibrosis as assessed by TBLB is useful for predicting the response to treatment, clinical course and prognosis of interstitial pneumonia associated with PM/DM.     

KL-6: a serological biomarker for interstitial lung disease in patients with polymyositis and dermatomyositis

Abstract. Fathi M, Barbasso Helmers S, Lundberg IE (Karolinska University Hospital, Stockholm; Karolinska Institutet, Karolinska University Hospital, Stockholm; and Institute of Environmental Medicine, Karolinska Institutet, Stockholm; Sweden). KL‐6: a serological biomarker for interstitial lung disease in patients with polymyositis and dermatomyositis. J Intern Med 2012; 271 : 589–597. Objectives. To investigate whether Caucasian patients with polymyositis (PM) or dermatomyositis (DM) and interstitial lung disease (ILD) have elevated serum levels of KL‐6 compared with patients without ILD and whether KL‐6 could be used as a marker for ILD activity and treatment efficacy of ILD in PM/DM. Design and methods. Thirty patients with PM/DM (seven with ILD) and 17 age‐ and sex‐matched healthy controls were included in a retrospective, cross‐sectional analysis. Twelve patients were followed for longitudinal evaluation. ILD was defined as restrictive lung function impairment with radiographic signs of ILD. Serum KL‐6 levels were measured using a sandwich enzyme immunoassay kit. Groups were compared by Mann–Whitney U‐test. Results. PM/DM patients with ILD had significantly higher median serum KL‐6 levels compared with those without ILD: 995 (range 533–2318) versus 322 (range 132–1225) U mL^?1 (P = 0.0002). Median serum levels of healthy controls were 225 (range 136–519) U mL^?1. Serum levels of KL‐6 were inversely correlated with percentages of forced expiratory volume in 1 s (FEV₁), vital capacity (VC), total lung capacity (TLC), forced VC, diffusing capacity of carbon monoxide (DLco), maximal voluntary ventilation at 40 breaths min^?1 and residual volume (RV). Changes in KL‐6 levels showed a significant inverse correlation with changes in percentage FEV₁, TLC, DLco and RV. At a cut‐off level of 549 U mL^?1 (mean ± 2.5 SD for controls), the sensitivity and specificity for diagnosis of ILD were 83% and 100%, respectively. Conclusion. The level of serum KL‐6 may serve as measure of ILD in patients with PM/DM and is a promising biomarker for use in clinical practice to assess clinical response to treatment.     

Clinical experience with technetium-99m teboroxime scintigraphy in patients referred for myocardial perfusion evaluation

A series of 30 patients (25 males, 5 females, age=28–73 years) with a clinical indication of thallium-201 stress/4 hours redistribution scintigraphy has been studied using stress/rest (n=7) or rest/stress (n=23) protocols with technetium-99 m teboroxime (CARDIOTEC, Squibb Diagnostics) in order to assess the clinical usefulness of this new molecule and to compare it to thallium. In all cases coronary artery disease was known or highly suspected, with a history of myocardial infarction in 18 cases (subacute n=6, remote n=12) and/or previous by-pass surgery or PTC A in 5 cases. Medical treatment was not discontinued at the time of stress testing. Coronary angiography was available for 27 patients.Exercise tests for both tracers were carried out on an ergometric bicycle during the same day and the levels of exercise achieved for the thallium studies were very similar to those achieved for teboroxime.Imaging was performed in three planar projections and sudies were evaluated using a model with 4 territories: septal and anterior assumed to correspond to the LAD artery, lateral and latero-posterior (=LCX), inferior and posterior (=RCA) and apex. Classification of results was: normal, ischemic, infarcted and infarcted with ischemia.With reference to the thallium-201 results, agreement was found in 86% (37/43) of normal regions and in 82% (63/77) of abnormal regions. Relative to documented coronary artery lesions (27 patients) sensitivity and specificity of thallium and teboroxime for exact correspondence between arteries and territories were, respectively: thallium, se=71%, sp=64%, teboroxime, se=67%, sp=75%.These results indicate the ability of Cardiotec to evaluate myocardial perfusion with an important time saving since the complete study durations (stress and rest) were: thallium=4h 34 min –22 min and teboroxime=1 h 57 min –41 min.     

Effect of nicorandil on abnormal coronary flow reserve assessed by exercise201Tl scintigraphy in patients with angina pectoris and nearly normal coronary arteriograms

Summary The purpose of the present study is to assess the effect of nicorandil, a coronary vasodilator with a mechanism of potassium channel opening, on the abnormal myocardial²⁰¹Tl perfusion evoked by exercise. Eleven patients who had a history of typical angina, positive exercise electrocardiograms, positive²⁰¹Tl scintigraphy, nearly normal coronary arteriograms, and negative coronary vasospasm underwent exercise²⁰¹Tl scintigraphies under no medication (baseline test) and administration of nicorandil (nicorandil test).²⁰¹Tl was injected at a matched workload in both tests. Nicorandil did not alter heart rate, blood pressure, or the rate-pressure product at the end of the exercise, but it significantly improved the extent score from 0.37±0.22 to 0.20±0.15 (p<0.05) and the severity score from 33.9±32.2 to 13.5±16.4 (p<0.05), and also significantly hastened the²⁰¹Tl mean washout rate from 30.5±14.8% to 37.4±13.1% (p<0.05). Anginal symptoms disappeared in 3 of 5 cases and ST depression improved in 5 of 7 cases after nicorandil. We conclude that nicorandil augments coronary flow reserve, possibly due to a reduction of vasotone in the small coronary arteries.     

多发性肌炎/皮肌炎合并急性呼吸衰竭临床特点分析及治疗

目的 探讨多发性肌炎/皮肌炎合并急性呼吸衰竭患者的临床特点及治疗方法.方法 回顾性分析11例多发性肌炎/皮肌炎合并急性呼吸衰竭患者的临床资料、治疗方法及预后的差异.结果 患者起病时和出现呼吸衰竭时肌酸激酶（CK）、补体C4、免疫球蛋白M（IgM）水平及血氧饱和度（SaO2）、氧分压（PO2）比较,差异有统计学意义（P＜0.05）;丙氨酸氨基转移酶（ALT）、天门冬氨酸氨基转移酶（AST）、乳酸脱氢酶（LDH）、白蛋白（ALB）、球蛋白（GLO）、红细胞沉降率（ESR）、C反应蛋白（CRP）、降钙素原（PCT）、补体C3、IgG、IgA比较差异无统计学意义（P＞0.05）.11例患者均合并急性亚急性肺间质病变及肺部感染,均予激素、免疫抑制剂、丙种球蛋白大剂量冲击治疗、血浆置换、抗感染等综合性治疗,5例患者在疾病不同时期死亡,7例予血浆置换治疗患者中6例好转,长期随诊病情缓解.结论 多发性肌炎/皮肌炎合并急性呼吸衰竭患者死亡率高,CK下降对于是否出现急性呼吸衰竭无指导意义,血浆置换对此类患者治疗有效,可明显改善患者预后.     

Epidemiologic analysis of the clinical features of Japanese patients with polymyositis and dermatomyositis

Objectives: This study aimed to investigate the clinical characteristics of polymyositis/dermatomyositis (PM/DM) in Japan by analyzing data from the nationwide registration system.

Methods: The data of the registration system in 2009 were analyzed to investigate patient numbers, sex, clinical symptoms, therapies, complications, and prognosis of PM/DM.

Results: The total number of PM/DM cases was approximately 17,000, and the female/male sex ratio was 2.7:1. Almost all patients improved as a result of therapy, but many suffered from sequelae such as muscle weakness.

Conclusions: The results characterize significant aspects of Japanese PM/DM patients. However, a further prospective survey is required to clarify the true epidemiology and natural history of PM/DM.     

123I-metaiodobenzylguanidine scintigraphy in the detection of irregular regional sympathetic innervation in long QT syndrome

Twelve patients with the long QT syndrome were studied to determinethe usefulness of ¹²³I-metaiodobenzylguanidine (MIBG) single-photonemission tomography (SPECT) at 2 h and 6 h after injection;the results were compared to 10 healthy volunteers (controls).Uptake of MIBG in the left ventricle at 2 h after injectionwas significantly reduced in patients with the long QT syndrome(1.43±0.13) vs 1.66±0.15 in controls, heart-to-mediastinumratio, P <0.002) and washout after 6 h was faster on a planarview image. Decreased MIBG uptake could be observed preferentiallyin the anterior and lateral walls near the apex. The half-timevalues of MIBG washout from the left ventricle were significantlyreduced in the long QT syndrome (6.4±1.5 h) comparedto controls (16.7±15.3 h, P <0.002). In three cases,the same pattern of disturbed activity distribution was maintainedeven after surgical left cardiac sympathetic denervation. Thepresent results strongly support the hypothesis that an inhomogenousregional distribution of sympathetic nerve terminals accompaniedby an overall reduction in their absolute number may play animportant role in the pathogenesis of the long QT syndrome.Additional functional disturbances, possibly related to theuptake of catecholamines in the left ventricle may coexist withregional inhomogeneity of nerve terminals. The differences observedfrom one case to the other may be related to the variation inseverity of the disease. MIBG SPECT imaging seems an interestingnew tool for the quantitative assessment of presynaptic sympatheticnerve terminal disturbances in the left ventricle of patientswith the long QT syndrome.     

Dermatomyositis/polymyositis associated with malignancy: our experience with ten patients and review of relevant literature

Objective: To analyse the clinical and laboratory data of patients diagnosed with malignancy associated dermatomyositis/polymyositis (DM/PM) seen between January 2002 and February 2007. Methods: The demographic, clinical, treatment and follow‐up data from the case records of all 10 patients diagnosed with malignancy‐associated inflammatory muscle diseases (IMD) namely, DM/PM, were entered in a proforma and analysed. Results: In patient nos. 1–8, malignancy was diagnosed prior to the diagnosis of myositis; in patient no. 9, it was detected during screening and patient no. 10 developed breast cancer 5 years after PM diagnosis. All the patients had typical clinical and laboratory features of IMD, except two patients, who had amyopathic dermatomyositis with predominantly cutaneous features, creatine kinase levels less than two times the upper limit of normal and minimal muscle weakness. Breast cancer (6/10) and ovarian cancer (3/10) were the most commonly associated malignancies. All but one (patient no. 8) responded to treatment. Malignancy relapsed in four patients with concurrent relapse of myositis in three. These three patients died of the malignancy. One patient was lost to follow‐up. The mean duration of follow‐up in others was 21 months (range 12–60 months). Conclusion: DM is more commonly associated with malignancy. Carcinoma of the breast was the most commonly associated malignancy. Myositis responded in most patients. Death was due to the underlying malignancy. In most cases, the two conditions occur within 1 year.     

Value of67gallium scintigraphy in primary diagnosis and follow-up of opportunistic pneumonia in patients with AIDS

Opportunistic pneumonias are a life-threatening complication in patients with AIDS. Early diagnosis and therapy is necessary to improve the prognosis. This study was designed to assess the value of⁶⁷gallium scintigraphy in the primary detection and follow-up of these special pneumonias.⁶⁷Gallium scintigraphy was performed in 40 patients: 10 normal controls and 30 HIV-positive patients with AIDS or AIDS-related complex (ARC).⁶⁷Gallium scan results were compared with current chest x-rays and the results of pathogen detection. The evaluation of positive scans was based on a quantification of the pulmonary uptake, expressed as a pulmonary/soft tissue uptake ratio. Only 8 of 30 patients had a normal scan, while 22 of 30 showed diffuse (13/22) or focal (9/22) increases of pulmonary uptake. In seven of eight patients with normal scans the chest radiograph was negative as well. The one patient with negative scan but positive chest radiograph had pulmonary Kaposi’s sarcoma. In 11 of 22 patients, the⁶⁷gallium scan and chest x-ray were positive simultaneously. In the other 11 of 22 patients with positive scans, chest radiographs were initially negative but showed pathology in five cases within 1–2 weeks. The reason for positive scans in most cases was an opportunistic lung infection; other forms of pneumonia were observed only in two cases. The defined uptake ratio was demonstrated to be a highly sensitive parameter for monitoring pneumonia and the effects of therapy in follow-up studies. In conclusion, quantitative⁶⁷gallium scintigraphy proved to be a reliable and highly sensitive method for primary detection and follow-up of opportunistic pneumonias in patients with AIDS.     

Cardiac scintigraphic findings of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes: A case report

A 49-year-old woman was admitted to hospital because of heart failure. She was diagnosed as having mitochondrial cardiomyopathy and diabetes mellitus. Echocardiography revealed a hypertrophic and poorly contracting left ventricle. A diagnosis of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes was established by muscle biopsy. She underwent technetium-99m-sestamibi (^99mTc-MIBI) and beta-methyl-p-¹²³I-iodophenyl-pentadecanoic acid (¹²³I-BMIPP) scintigraphic examinations. ^99mTc-MIBI single-photon emission computed tomography revealed reduced tracer uptake in the hypertrophic left ventricular inferior wall. In contrast, there was an increase in ¹²³I-BMIPP uptake in the in the region of reduced ^99mTc-MIBI uptake (^99mTc-MIBI/¹²³I-BMIPP mismatch). There was rapid washout of ^99mTc-MIBI from the myocardium (washout rate increased by 30%). Decreased ^99mTc-MIBI and increased ¹²³I-BMIPP uptake (^99mTc-MIBI/¹²³I-BMIPP mismatch) were the characteristics of cardiac involvement in mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes.     

Prognostic value of thallium-201 myocardial scintigraphy after atrial transoesophageal pacing in patients with suspected coronary artery disease

Fifty-five patients with suspected coronary artery disease underwentplanar thallium-201 myocardial scintigraphy after atrial transoesophagealpacing. Coronary angiography was carried out in all patients.Eighteen patients had no myocardial infarction, but a greaterthan 50% narrowing of at least one main vessel: initial hypoperfusionwith redistribution at 4 h occurred in 16 patients (sensitivity89%). Twenty-one patients had had a previous myocardial infarction:a reversible thallium defect was observed in 12 patients andan irreversible defect in the nine remaining patients. Sixteenpatients had normal coronary arteries: a reversible thalliumdefect was observed in three patients (specflcity 81%). Aftera mean follow-up of 22±13 months (range 6 to 40), 23cardiac events occurred: cardiac death in one patient, unstableangina in three, and revascularization procedures for recurrentangina despite medical therapy in 19 (coronary artery bypasssurgery in 7 and coronary angioplasty in 12). By univariateanalysis, the predictors of future cardiac events were a historyof previous myocardial infarction (odds ratio 55, P<0.02)multivessel coronary artery disease (odds ratio 9.6, P<0.0002),angina during atrial pacing (odds ratio 5.1, P<0.05), abnormalscintigraphy (odds ratio 17.1, P<0.001) and reversible perfusiondefect after pacing (odds ratio 7.9, P<0.002). By multivariateanalysis, multivessel disease (P<0.004) and reversible perfusiondefect after pacing (P<0.02) were the only independent predictorsof future cardiac events. In conclusion, thallium-201 myocardial scintigraphy after transoesophagealatrial pacing is accurate for the diagnosis and prognosis ofpatients with suspected coronary artery disease, and may beundertaken in patients unable to perform exercise stress testing.     

The detection of myocardial ischemia by thallium-201 myocardial scintigraphy in patients with multiple coronary arterioventricular connections.

The question of whether myocardial ischemia could be induced in 5 patients with multiple coronary arterioventricular connections by thallium-201 (201Tl) exercise stress myocardial scintigraphy was investigated. Both ST-T changes on ECG and transient myocardial perfusion defects in myocardial scintigrams were observed in 2 patients (40%). In previous reports, all multiple coronary arterioventricular connections, which were shown in angiograms, have been regarded as either Thebesian veins or embryonic sinusoids. However, it is unlikely that Thebesian veins cause myocardial ischemia judging from anatomy. If the vessels cause myocardial ischemia, they should be regarded as multiple coronary arterioventricular fistula. Angiography itself cannot differentiate multiple coronary arterioventricular fistula from Thebesian veins or remnants of embryonic sinusoids. Exercise stress myocardial scintigraphy has a high potential to detect myocardial ischemia due to intracoronary steal. Exercise stress myocardial scintigraphy was used to demonstrate myocardial ischemia in multiple coronary arterioventricular connections. It is concluded that exercise stress myocardial scintigraphy is a reliable test to differentiate multiple coronary arterioventricular fistula from Thebesian veins or remnants of embryonic sinusoids in clinical practice.