Upward creep of the heart in exercise thallium 201 single photon emission tomography: clinical relevance and a simple correction method

The upward creep of the heart during myocardial single photon emission tomography (SPET) acquisition has been reported as a frequent source of false-positive results. The aim of this study was to simplify the detection and correction of this upward creep and to estimate its clinical relevance during routine patient care. To recognize the upward heart motion a straight line was fitted to the upper and lower border of consecutively displayed tomographic projection images. In this way, vertical translation of at least 1 pixel in size could be detected easily. On the assumption of a slow but continuous upward motion a fast interpolation correction method was developed. From 100 consecutive, supine, ergometric exercise studies, 1, 2 or 3 pixels of upward creep were found in 16, 4 or 3 patients, respectively. It was found that an upward creep of at least 2 pixels (7/100 cases) led to evident, mostly antero-septal defects on quantitative bull's-eyes, whereas only upward creeps of 3 pixels or more (3/100 cases) produced false-positive diagnostic results. The simple correction method offered a sufficient compensation of image and/or bull's-eye artefacts. These clinical findings could be reproduced in a computer model. Thus, it can be stated that clinically significant upward creep of the heart during stress SPET acquisition is relatively rare; it may have been overestimated in the past, and its artificial effects can be corrected by a quick and simple algorithm.     

Apparent change in cardiac geometry during single-photon emission tomography thallium-201 acquisition: a complex phenomenon

We investigated the frequency and extent of changes in heart position and geometry independent of body motion during stress single-photon emission tomography (SPET) thallium-201 myocardial perfusion imaging. Following an exercise treadmill test, patients had a 22.1-min SPET acquisition which was followed immediately by a static image acquisition for 1 min with the camera position identical to the first view of the SPET study. Point sources were placed on the body to monitor patient motion. Cardiac motion was assessed by an approach which mimicked a cross-correlation technique applied to cardiac count profiles along the horizontal and vertical directions from the first view of the SPET study and the static image. A large percentage (87.5%) of cases had some degree of horizontal or vertical motion. Pixel shifts in cardiac position of 2 pixels (12 mm) occurred in 60% of patients. In 37% of patients who moved the cardiac motion was consistent with simple translation of the heart and thus amenable to correction using proposed SPET motion-correction programs. The peak heart rate achieved during stress and the ratio of the heart rate immediately before SPET acquisition to the resting heart rate were determined to be independent predictors of patient motion during SPET acquisition. Cardiac motion changes were minimal at (13.3 ±2.2) min after cessation of exercise. The implications of these findings for the accuracy of SPET ²⁰¹Tl require further investigation.     

"Upward creep" of the heart: a frequent source of false-positive reversible defects during thallium-201 stress-redistribution SPECT

A new cause of artifactual 201Tl defects on single photon emission computed tomography (SPECT) termed "upward creep" of the heart is described. In 102 consecutive patients undergoing 201Tl SPECT, 30 (29%) demonstrated upward creep defined by an upward movement of the heart of greater than or equal to 2 pixels during acquisition. In 45 consecutive patients with a less than 5% likelihood of coronary artery disease, 17 (38%) had upward creep. Of these nine had reversible 201Tl defects localized to the inferior and basal inferoseptal walls, while none of the 28 without upward creep had defects. The 17 low likelihood patients with upward creep had longer exercise duration and higher peak heart rate than those without upward creep. In five additional low likelihood patients with upward creep in whom imaging was immediately repeated, the upward creep pattern disappeared on the repeated images. After we changed our test protocol to begin imaging 15 min postexercise, only five (14%) of 36 low likelihood patients tested demonstrated upward creep. Upward creep is probably related to a transient increase in mean total lung volume early following exhaustive exercise, resulting in a mean lower position of the diaphragm (and thus the heart) at the beginning of imaging. The frequency of this source of false-positive 201Tl studies can be reduced by delaying SPECT acquisition until 15 min postexercise.     

Motion detection and correction using multi-rotation 180° single-photon emission tomography for thallium myocardial imaging

Patient and organ motion is a potentially limiting factor in gamma camera single-photon emission tomography (SPET) imaging, as highlighted in stress thallium myocardial SPET, where the heart may exhibit a systematic axial motion (cardiac creep) following stress. Multi-rotation SPET has previously been described as a means of obtaining better raw data for motion detection and correction. This study describes the validation of a computerised motion detection algorithm applied to multi-rotation SPET, and reports measured motions in thallium myocardial stress SPET studies from a single-headed gamma camera. Forty-two patients underwent pharmacological stress (dipyridamole) with leg raising, with injection of 75 MBq thallium-201 and imaging after a 10-min delay to detect or evaluate coronary artery disease. Multi-rotation gamma camera SPET was performed with a single-headed gamma camera, with five sequential rapid (4.5 min) continuous SPET mode rotations over 180°. A one-dimensional cross-correlation alignment technique was applied to the projection images to perform motion detection and correction in the axial direction prior to combining the five data sets for tomographic reconstruction. Validation of the cross-correlation alignment analysis was carried out by performing imaging with measured whole-body axial motions in nine subjects, and by reproducibility measurements on multi-rotation data sets. The effect of the applied motion correction was evaluated by calculating mean differences between image pairs before and after shifting, and the general reliability of the automatic motion detection was checked to within one pixel by visual assessment of 160 image pairs. Validation measurements of the cross-correlation technique gave a mean absolute error of 1.5±0.4 mm (0.24±0.06pixels) with a maximum error of 3.7 mm (0.6 pixels). In 40 subjects undergoing pharmacological stress ²⁰¹Tl myocardial SPET imaging, the mean cardiac axial creep movement was calculated as 3.1±0.7 mm (0.49±0.11 pixels), with 13 out of 40 (32%) having a calculated motion of 1 pixel (6.3 mm) or more. The automatic image shift was visually judged to be within 1 pixel in all 160 image pair analyses, and the mean pixel value difference between image pairs was reduced following image shifting. It is concluded that multi-rotation 180° SPET imaging provides raw data which allow objective and accurate motion detection of cardiac motion in thallium stress myocardial imaging, whilst the one-dimensional cross-correlation technique demonstrates adequate accuracy and reliability to be applied as an automatic motion screening technique on these data. Received 14 March and in revised form 27 July 1998     

A physiologic approach to decreasing upward creep of the heart during myocardial perfusion imaging

When body position changes from erect to supine, the effect of gravity on the organs also changes and is a possible underlying mechanism for upward creep of the heart during SPECT acquisitions. We hypothesized that if we provide enough time for the organs to settle after a positional change, the range of this vertical motion causing reconstruction artifacts can be decreased. Our aim was to evaluate the effect that a 5-min bed rest on the imaging table before both rest and stress SPECT acquisitions would have on upward creep of the heart. METHODS: Before both stress and rest SPECT acquisitions, the first 101 consecutive patients (group A) had a 5-min bed rest and the remaining 99 patients (group B) did not have any bed rest after they were positioned on the imaging table. Upward creep was detected by comparing the distance between the lower edge of the image and the lowest part of the heart silhouette on the last projection image of detector 2 and the first projection image of detector 1. RESULTS: Upward creep was found in 53% (54/101) and 55% (56/101) of patients in group A and in 89% (88/99) and 86% (85/99) of patients in group B in stress and rest SPECT studies, respectively. Upward creep of the heart was decreased prominently in group A, and this decrease was statistically significant (p < 0.001). CONCLUSION: We conclude that before SPECT acquisition, at least a 5-min bed rest on the imaging table significantly decreases vertical motion of the heart.     

Quantitative assessment of motion artifacts and validation of a new motion-correction program for myocardial perfusion SPECT.

Patient motion during myocardial perfusion SPECT can produce images that show artifactual perfusion defects. The relationship between the degree of motion and the extent of artifactual perfusion defects is not clear for either single- or double-head detectors. Using both single- and double-head detectors and quantitative perfusion SPECT (QPS) software, we studied the pattern and extent of defects induced by simulated motion and validated a new automatic motion-correction program for myocardial perfusion SPECT. METHODS: Vertical motion was simulated by upward shifting of the raw projection datasets in a returning pattern (bounce) and in a nonreturning pattern at 3 different phases of the SPECT acquisition (early, middle, and late), whereas upward creep was simulated by uniform shifting throughout the acquisition. Lateral motion was similarly simulated by left shifting of the raw projection datasets in a returning pattern and in a nonreturning pattern. Simulations were performed using single- and double-head detectors, and simulated motion was applied to projection images from 8 patients who had normal 99mTc-sestamibi SPECT findings. Additionally, images from 130 patients with actual clinical motion were assessed before and after motion correction. The extent of perfusion defects was assessed by QPS, and a 20-segment, 5-point scoring system was used to assess the effect of motion on the presence and extent of perfusion defects. RESULTS: Of 12 bounce simulations, the bouncing motion failed to produce significant (>3%) perfusion defects with either the single- or the double-head detector. With the single-head detector, early shifting created the largest defect, whereas with the double-head detector, shifting during the middle of the acquisition created the largest defect. With regard to upward creep, defects were of larger extent with the double- than the single-head detector. With the single-head detector, 8 of 20 simulated motion patterns yielded significant perfusion defects of the left ventricle, 7 (88%) of which were significantly improved after motion correction. With the double-head detector, 12 of 20 patterns yielded significant defects, all of which improved significantly after correction. Of 2,600 segments in the 130 patients with actual clinical motion, only 1.3% (30/2,259) of segments that were considered normal (score = 0 or 1) changed to abnormal (score = 2-4) after motion correction, whereas 27% (92/341) of abnormal segments were reclassified as normal after motion correction. CONCLUSION: Artifactual perfusion defects created by simulated motion are a function of the time, degree, and type of motion and the number of camera detectors. Application of an automatic motion-correction algorithm effectively decreases motion artifacts on myocardial perfusion SPECT images.     

Major upward creep of the heart during exercise thallium-201 myocardial SPECT in a patient with chronic obstructive pulmonary disease.

We report on a patient in whom we observed an unusually important upward creep of the heart on postexercise 201TI tomographic acquisition. When uncorrected, this led to reconstruction of grossly abnormal tomograms, which were normal after correction of upward creep of the heart. This phenomenon may be related to the patient's history of chronic obstructive pulmonary disease. Special attention should be given to upward creep artifact in such pulmonary diseases.     

Prone SPET scintimammography

Prone single photon emission tomography (SPET) was performed in 24 patients with suspected primary or recurrent breast cancer to determine if this technique offers more accurate imaging than that obtained from planar scintimammography. All patients were imaged on a specially designed couch with two cushion inserts. The first insert was lined with lead and was used to perform prone lateral planar scintimammography 5 min after the injection of 740 MBq 99Tcm-MIBI. The second insert did not contain lead and was used to perform a prone SPET acquisition for 30 min immediately after planar imaging. The results of both studies were read independently and there was agreement between the two techniques in 23 cases (96%). All cases of cancer proven on histology were found on planar imaging, but a 4-mm ductal cancer was missed on prone SPET. This was thought to be due to activity from this medial cancer being obscured by the star artefact produced by back-projection reconstruction from activity in the heart. There were two false-positive studies with both techniques. However, prone SPET enabled better localization and characterization of breast cancers than planar imaging. Prone SPET imaging of the breast produces results similar to prone lateral imaging and may be used instead of planar imaging if a reduced total acquisition time is desirable. Care must be taken when reading scans in the presence of small tumours near the heart when back-projection reconstruction techniques are used.     

Clinical value of triple-energy window scatter correction in simultaneous dual-isotope single-photon emission tomography with123I-BMIPP and201TI

To improve the image quality in simultaneous dual-isotope single-photon emission tomography (SPET) with iodine-123 labelled 15-(p-iodophenyl)-3-methylpentadecanoic acid (BMIPP) and thallium-201, we applied the triple-energy window method JEW) for correction of the cross-talk and scatter artifact. Seventy-one patients with coronary artery disease were included.²⁰¹T1 cross-talk into the¹²³I acquisition window (group 1,n = 30) and¹²³I cross-talk into the²⁰¹Tl window (group 2,n = 41) were studied. In group 1,¹²³I images were first obtained (single-isotope images), followed by²⁰¹Tl injection and SPET acquisition using dual-isotope windows (dual-isotope images). In group 2, the order was reversed. The dual-isotope SPET images with and without TEW were compared with the single-isotope images. Qualitative evaluation was performed by scoring the segmental defect pattern. Detectability of the mismatched fatty acid metabolism on dual-isotope SPET was evaluated by receiver operating characteristic (ROC) curve analysis. Segmental defect pattern agreement between dual and corrected single images was significantly improved by TEW correction (P<0.01). The agreement was particularly improved in segments with absence of uptake. There was no significant difference between TEW-corrected dual-isotope SPET and corresponding single-isotope SPET with regard to either % defect count or background activity. Mismatched fatty acid metabolism depicted by dual-isotope SPET predicted abnormal wall motion more accurately with TEW than without TEW. With TEW, a practical method for scatter and cross-talk correction in clinical settings, simultaneous dual¹²³I-BMIPP/²⁰¹Tl SPET is feasible for the assessment of myocardial perfusion/metabolism mismatch.     

Poststress motionlike artifacts caused by the use of a dual-head gamma camera for (201)Tl myocardial SPECT.

When performing (201)Tl myocardial SPECT using a dual-head gamma camera on patients after exercise stress, we have observed in some a sudden increase in the counting rate between the 16th and 17th images. This increase provoked motionlike artifacts, which increased the number of false-positive findings. The aim of our study was to determine possible causes for this leap in activity. METHODS: We performed myocardial SPECT using a dual-head gamma camera on 110 patients after exercise stress: in 38 patients approximately 5 min after injection (group 1), in 43 patients approximately 14 min after injection (group 2), and in 29 patients twice, at approximately 5 and 20 min after injection (group 3). We also performed dynamic data acquisition for 10 min on 18 patients after exercise stress. We compared activity in the heart region in image series obtained after exercise stress and at rest. RESULTS: Daily quality control tests eliminated the possibility of any malfunctions of the gamma camera. Careful image analysis showed no visible patient motion. Our results showed that upward creep of the heart could not be a cause of the described phenomenon. After exercise stress, a > or = 5% activity leap in the heart region on the 16th and 17th frames was more frequent in group 1 than in group 2. Two consecutive acquisitions after exercise stress showed that the leap was >5% in 24 patients (83%) and 12 patients (41%) at the first and second acquisitions, respectively (group 3). In all patients, the leap was <5% at rest. Dynamic studies showed that the activity in the heart region steadily decreased in all patients after exercise stress. We suggest that decreasing (201)Tl concentrations in myocardium or blood could be a major reason for the described artifacts. CONCLUSION: We proposed that the pharmacokinetics of (201)Tl-chloride be evaluated within a short time after injection in humans after exercise stress. Now, in our department, we have begun acquisition approximately 12 min after (201)Tl administration, and the above-mentioned phenomenon has not appeared. However, to avoid the artifacts caused by early redistribution of (201)Tl, acquisition must not begin too late.     

Myocardial metabolic imaging by means of fluorine-18 deoxyglucose/technetium-99m sestamibi dual-isotope single-photon emission tomography

The detection of preserved glucose uptake in hypoperfused dysfunctional myocardium by fluorine-18 deoxyglucose (FDG) positron emission tomography (PET) represents the method of choice in myocardial viability diagnostics. As the technique is not available for the majority of patients due to cost and the limited capacity of the PET centres, it was the aim of the present work to develop and test FDG single-photon emission tomography (SPET) with the means of conventional nuclear medicine. The perfusion marker sestamibi (MIBI) was used together with the metabolic tracer FDG in dual-isotope acquisition. A conventional SPET camera was equipped with a 511-keV collimator and designed to operate with simultaneous four-channel acquisition. In this way, the scatter of 18F into the technetium-99m energy window could be taken into account by a novel method of scatter correction. Thirty patients with regional wall motion abnormalities at rest were investigated. The results of visual wall motion analysis by contrast cine-ventriculography in nine segments/heart were compared with the results of quantitative scintigraphy. The scintigraphic patterns of MIBI and FDG tracer accumulation were defined as normal, matched defects and perfusion-metabolism mismatches. Spatial resolution of the system was satisfactory, with a full width at half maximum (FWHM) of 15.2 mm for ¹⁸F and 14.0 mm for ^99mTe, as measured by planar imaging in air at 5 cm distance from the collimator. Image quality allowed interpretation in all 30 patients. 88% of segments without relevant wall motion abnormalities presented normal scintigraphic results. Seventy-five akinetic segments showed mismatches in 27%, matched defects in 44% and normal perfusion in 29%. We conclude that FDG-MIBI dual-isotope SPET is technically feasible with the means of conventional nuclear medicine. Thus, the method is potentially available for widespread application in patient care and may represent an alternative to the ²⁰¹T1 reinjection technique.     

Performance of the automated motion correction program for the calculation of left ventricular volume and ejection fraction using quantitative gated SPECT software

The effectiveness of the automated motion correction software (INSTILL, Philips Medical Systems Co. Ltd., Andover, USA) proposed by Matsumoto et al. to prevent motion artifact in quantitative gated SPECT, was tested with a technetium-99m point source and cardiac phantom. INSTILL well corrected the error due to point source movement during acquisition up to a distance of 5 pixels (32.8 mm) in the right and caudal directions, as well as with a distance of up to 7 pixels (45.9 mm) of oblique (caudal-right 45 degree) movement inside the coronal plane. End-diastolic volume (EDV), end-systolic volume (ESV) and ejection fraction (EF) were also well adjusted with INSTILL, for up to 3 pixels (19.7 mm) movement of the dynamic cardiac phantom during acquisition in the right, caudal and oblique directions. The respective maximum error with one, two and three pixel movement was 9, 24 and 23 ml in EDV, and 8, 22 and 21 ml in ESV. The maximum error of EF was 3% in all conditions without INSTILL. After using INSTILL, the maximum residual errors of both EDV and ESV were 7 ml and that of EF was 3% in all conditions. Quantitative gated SPECT software with INSTILL will calculate EDV, ESV and EF against movement of patients in the coronal plane. INSTILL is therefore concluded to be a reliable software for motion correction in clinical use.     

Correction for patient and organ movement in SPECT: application to exercise thallium-201 cardiac imaging

We describe a technique for correction of artifacts in exercise 201Tl single photon emission computed tomography (SPECT) images arising from abrupt or gradual translational movement of the heart during acquisition. The procedure involves the tracking of the "center of the heart" in serial projection images using an algorithm which we call "diverging squares". Each projection image is then realigned in the x-y plane so that the heart center conforms to the projected position of a fixed point in space. The shifted projections are reconstructed using the normal filtered backprojection algorithm. In validation studies, the motion correction procedure successfully eliminated movement artifacts in a heart phantom. Image quality was also improved in over one-half of 36 exercise thallium patient studies. The corrected images had smoother and more continuous left ventricular walls, greater clarity of the left ventricular cavity, and reduced streak artifacts. Rest injected or redistribution images, however, were often made worse, due to reduced heart to liver activity ratios and poor tracking of the heart center. Analysis of curves of heart position versus projection angle suggests that translation of the heart is common during imaging after exercise, and results from both abrupt patient movements, and a gradual upward shift of the heart. Our motion correction technique appears to represent a promising new approach for elimination of movement artifacts and enhancement of resolution in exercise 201Tl cardiac SPECT images.     

The evaluation and calibration of fan-beam collimators

The aims of this study were (a) to determine the true focal length of a fan-beam collimator and (b) to calibrate image size (mm/pixel) for each collimator to permit inter-comparison of image data acquired on different gamma camera systems. A total of six fan-beam collimators on three dual-head gamma camera systems were evaluated using a set of four cobalt-57 point source markers. The markers were arranged in a line in the transverse plane with a known separation between them. Tomographic images were obtained at three radii of rotation. From reconstructed transaxial images the distance between markers was measured in pixels and used to determine pixel size in mm/pixel. The system value for the focal length of the collimator was modified by up to ±100 mm and transaxial images were again reconstructed. To standardize pixel size between systems, the apparent radius of rotation during a single-photon emission tomography (SPET) acquisition was modified by changes to the effective collimator thickness. SPET images of a 3D brain phantom were acquired on each system and reconstructed using both the original and the modified values of collimator focal length and thickness. Co-registration and subtraction of the reconstructed transaxial images was used to evaluate the effects of changes in collimator parameters. Pixel size in the reconstructed image was found to be a function of both the radius of rotation and the focal length. At the correct focal length, pixel size was essentially independent of the radius of rotation. For all six collimators, true focal length differed from the original focal length by up to 26 mm. These differences in focal length resulted in up to 6% variation in pixel size between systems. Pixel size between the three systems was standardized by altering the value for collimator thickness. Subtraction of the co-registered SPET images of the 3D brain phantom was significantly improved after optimization of collimator parameters, with a 35%–50% reduction in the standard deviation of residual counts in the subtraction images. In conclusion, we have described a simple method for measurement of the focal length of a fan-beam collimator. This is an important parameter on multidetector systems for optimum image quality and where accurate co-registration of SPET to SPET and SPET to MRI studies is required. Received 17 October and in revised form 12 December 1998     

Transmission scanning in emission tomography

Attenuation correction in single-photon (SPET) and positron emission (PET) tomography is now accepted as a vital component for the production of artefact-free, quantitative data. The most accurate attenuation correction methods are based on measured transmission scans acquired before, during, or after the emission scan. Alternative methods use segmented images, assumed attenuation coefficients or consistency criteria to compensate for photon attenuation in reconstructed images. This review examines the methods of acquiring transmission scans in both SPET and PET and the manner in which these data are used. While attenuation correction gives an exact correction in PET, as opposed to an approximate one in SPET, the magnitude of the correction factors required in PET is far greater than in SPET. Transmission scans also have a number of other potential applications in emission tomography apart from attenuation correction, such as scatter correction, inter-study spatial co-registration and alignment, and motion detection and correction. The ability to acquire high-quality transmission data in a practical clinical protocol is now an essential part of the practice of nuclear medicine. Received: 19 February 1998 / Accepted: 19 March 1998     

The evaluation and calibration of fan-beam collimators

The aims of this study were (a) to determine the true focal length of a fan-beam collimator and (b) to calibrate image size (mm/pixel) for each collimator to permit inter-comparison of image data acquired on different gamma camera systems. A total of six fan-beam collimators on three dual-head gamma camera systems were evaluated using a set of four cobalt-57 point source markers. The markers were arranged in a line in the transverse plane with a known separation between them. Tomographic images were obtained at three radii of rotation. From reconstructed transaxial images the distance between markers was measured in pixels and used to determine pixel size in mm/pixel. The system value for the focal length of the collimator was modified by up to +/-100 mm and transaxial images were again reconstructed. To standardize pixel size between systems, the apparent radius of rotation during a single-photon emission tomography (SPET) acquisition was modified by changes to the effective collimator thickness. SPET images of a 3D brain phantom were acquired on each system and reconstructed using both the original and the modified values of collimator focal length and thickness. Co-registration and subtraction of the reconstructed transaxial images was used to evaluate the effects of changes in collimator parameters. Pixel size in the reconstructed image was found to be a function of both the radius of rotation and the focal length. At the correct focal length, pixel size was essentially independent of the radius of rotation. For all six collimators, true focal length differed from the original focal length by up to 26 mm. These differences in focal length resulted in up to 6% variation in pixel size between systems. Pixel size between the three systems was standardized by altering the value for collimator thickness. Subtraction of the co-registered SPET images of the 3D brain phantom was significantly improved after optimization of collimator parameters, with a 35%-50% reduction in the standard deviation of residual counts in the subtraction images. In conclusion, we have described a simple method for measurement of the focal length of a fan-beam collimator. This is an important parameter on multidetector systems for optimum image quality and where accurate co-registration of SPET to SPET and SPET to MRI studies is required.     

Recovery correction for quantitation in emission tomography: a feasibility study

In emission tomography, the spread of regional tracer uptake to surrounding areas caused by limited spatial resolution of the tomograph must be taken into account when quantitating activity concentrations in vivo. Assuming linearity and stationarity, the relationship between imaged activity concentration and true activity concentration is only dependent on the geometric relationship between the limited spatial resolution of the tomograph in all three dimensions and the three-dimensional size and shape of the object. In particular it is independent of the type of object studied. This concept is characterized by the term "recovery coefficient". Recovery effects can be corrected for by recovery coefficients determined in a calibration measurement for lesions of simple geometrical shape. This method works on anatomical structures that can be approximated to simple geometrical objects. The aim of this study was to investigate whether recovery correction of appropriate structures is feasible in a clinical setting. Measurements were done on a positron emission tomography (PET) scanner in the 2D and 3D acquisition mode and on an analogue and digital single-photon emission tomography (SPET) system using commercially available software for image reconstruction and correction of absorption and scatter effects. The results of hot spot and cold spot phantom measurements were compared to validate the assumed conditions of linearity and stationarity. It can be concluded that a recovery correction is feasible for PET scanners down to lesions measuring about 1.5xFWHM in size, whereas with simple correction schemes, which are widely available, an object-independent recovery correction for SPET cannot be performed. This result can be attributed to imperfections in the commercially available methods for attenuation and scatter correction in SPET, which are only approximate.     

Should SPET attenuation correction be more widely employed in routine clinical practice? Against

The development of reliable and accurate devices for the correction of nonuniform soft tissue attenuation is essential for the future clinical use of SPET myocardial perfusion imaging. In addition to abolishing false-positive defects, which is the chief goal, such corrected SPET images may allow for improved detection of coronary artery disease and perhaps ultimately for true quantification of regional myocardial blood flow. Although progress has been made, most existing attenuation correction devices are not yet ready for prime time. To date the literature shows as many positive results as negative results. There is considerable uncertainty, confusion, and skepticism about the true reliability and value of currently available attenuation correction packages. Although commonly referred to as "attenuation correction devices," these packages are in fact much more complex systems and contain novel mechanical designs, novel image acquisition and image reconstruction algorithms, scatter correction, and depth-dependent resolution compensation, in addition to attenuation correction. Each of these variables needs to be better understood and tested prior to clinical implementation. Although the general concepts are shared, there are as may different approaches to attenuation correction as there are vendors. In order to minimize the confusion of potential buyers about such complex systems, it is desirable that, before attenuation correction is implemented in routine clinical practice, each attenuation correction device is rigorously tested using a standardized testing protocol. Potential buyers of equipment should be able to compare the results of testing with various devices against predefined criteria in order to make an educated decision. Such standards have as yet not been developed. At the present time it is unclear whether attenuation correction of cardiac SPET will remain the emperor's new clothes or will develop into a fashionable Armani suit. Until further progress has been made, one cannot recommend attenuation correction devices for routine clinical practice.     

Gated SPET quantification of small hearts: mathematical simulation and clinical application

Quantification of gated single-photon emission tomography (SPET) in small hearts has been considered to be inaccurate. To evaluate the validity of gated SPET in a small chamber volume, mathematical simulation and clinical application to paediatric patients were performed. Myocardium with various chamber sizes from 14 ml to 326 ml was generated assuming an arbitrary resolution (6.9-15.7 mm in full-width at half-maximum), noise and zooming factors. The cut-off frequency of the Butterworth filter for preprocessing was varied from 0.16 to 0.63 cycles/cm. The chamber volume was calculated by quantitative gated SPET software (QGS). The patients, aged 2 months to 19 years (n=27), were studied by gated technetium-99m methoxyisobutylisonitrile or tetrofosmin SPET. Image magnification as large as possible was performed during data acquisition to include the whole chest using 1.25-2.0 zooming. Based on the simulation study, an underestimation of the chamber volume occurred below a volume of 100 ml. The degree of underestimation for a 37-ml volume was 49% without zooming, but it improved to 3% with 2x zooming. Filters with a higher cut-off frequency, better system resolution and hardware zooming during acquisition improved quantitative accuracy in small hearts. For the subjects under 7 years old (n=7), quantification of volume and ejection fraction (EF) was possible in 72% of the patients. In those over 7 years old, gated SPET quantification was feasible in all cases. The correlation between gated SPET end-diastolic volume (SPET EDV) and both echocardiographic end-diastolic dimension (EDD) and echocardiographic EDV was good (r=0.84 between SPET EDV and echo EDD, r=0.85 between SPET EDV and echo EDV, P<0.0001 for both). The correlation between gated SPET EF and both echocardiographic fractional shortening (FS) and echocardiographic EF was fair (r=0.69 between SPET EF and echo FS, r=0.72 between SPET EF and echo EF, P<0.0001 for both). In conclusion, quantification of gated SPET of small hearts can be improved by means of a SPET filter with a high cut-off frequency, high system resolution and appropriate zooming. Gated SPET should be attempted not only in patients with small hearts but also in paediatric patients.     

False-positive defects in technetium-99m sestamibi myocardial single-photon emission tomography in healthy athletes with left ventricular hypertrophy

Exercise ECG and myocardial single-photon emission tomography (SPET) are fundamental in the non-invasive evaluation of patients suspected of having coronary artery disease (CAD). The purpose of the present study was to investigate the influence of physiological left ventricular hypertrophy (LVH) on myocardial sestamibi SPET in healthy young and old athletes. Eighteen young male elite athletes (ten rowers, five power/weight lifters and three triathletes) and 14 well-trained elderly rowers were studied. All underwent a bicycle test as part of a 2-day sestamibi SPET protocol. Attenuation correction was not performed. The studies were evaluated visually and quantitatively analysed by the CEqual program with its reference files and with a file from a local non-athletic age-matched population. Echocardiographic LVH was an inclusion criterion in the young athletes. Exercise ECG was normal in all subjects. In at least three of the young athletes a reversible defect was observed by visual analysis. On quantitative analysis one-third of the young athletes had ”significant” (>10 pixels) defects compared with both the local reference base and the CEqual reference population. Nearly all defects were found in the anterior or inferior wall. The remaining subjects, including all old rowers, had normal SPET findings. Anterior and inferior wall defects are so common in healthy athletes with physiological LVH that the specificity of myocardial SPET, in contrast to exercise ECG, seems to be too low for evaluation of chest pain in this group. The mechanism of anterior and inferior defects may be related to hot spots (papillary muscles?) in the lateral wall. The specificity of SPET is maintained in athletes without LVH. Received 9 March and in revised form 30 May 1998