Circulation, Vol 85, 627-634, Copyright © 1992 by American Heart Association
V Dilsizian, NM Freedman, SL Bacharach, P Perrone-Filardi and RO Bonow
BACKGROUND. Thallium reinjection immediately after stress- redistribution
imaging identifies ischemic but viable myocardium in as many as 50% of the
regions characterized by conventional redistribution imaging as
irreversibly injured. However, we have previously shown that some regions
in which irreversible defects persist despite reinjection are metabolically
active, and hence viable, by positron emission tomography. In the current
study, we determined whether the severity of reduction in thallium activity
within irreversible defects on redistribution images and the magnitude of
change in regional thallium activity after reinjection can further
discriminate viable from nonviable myocardium in such defects. METHODS AND
RESULTS. We studied 150 patients with coronary artery disease by exercise
thallium tomography using the rest-reinjection protocol. The three sets of
images (stress, redistribution, and reinjection) were then analyzed
quantitatively. The increase in regional thallium activity from
redistribution to reinjection was computed, normalized to the increase
observed in a normal region, and termed "differential uptake." Of the 175
myocardial regions designated to have irreversible thallium defects on
conventional 3-4 hour redistribution images, 132 had only mild-to- moderate
reduction in thallium activity (51-85% of normal activity), and 43 had
severe reduction in thallium activity (less than or equal to 50% of normal
activity). Thallium reinjection resulted in enhanced relative activity in
60 of 132 (45%) of the mild-to-moderate irreversible defects and 22 of 43
(51%) of the severe irreversible defects, leaving roughly half of these
defects remaining irreversible after reinjection. However, in regions that
appeared to remain irreversible despite reinjection, the magnitude of
differential uptake differed between mild-to-moderate (74 +/- 14%) and
severe (35 +/- 16%) irreversible defects (p less than 0.001). All regions
with mild-to- moderate defects demonstrated greater than 50% differential
uptake after reinjection. In contrast, all except two of the regions with
severe irreversible defects demonstrated differential uptake of less than
50%. Fifteen patients also underwent positron emission tomography at rest
with 18F-fluorodeoxyglucose (FDG) and 15O-water. FDG uptake was present in
91% of regions with mild-to-moderate reduction in thallium activity, and
the results of differential uptake and FDG data were concordant in 81% of
these regions. CONCLUSIONS. These data indicate that the magnitude of
thallium uptake after reinjection differs between mild-to-moderate and
severe irreversible defects on standard 3-4 hour redistribution images. The
substantial differential uptake of thallium (greater than 50%) after
reinjection in mild-to-moderate defects, even when relative thallium
activity does not increase appreciably (and the defect appears to remain
irreversible), coupled with preserved metabolic activity by positron
emission tomography, supports the concept that such mild-to-moderate
irreversible defects represent viable myocardium.
ARTICLES
Regional thallium uptake in irreversible defects. Magnitude of change in thallium activity after reinjection distinguishes viable from nonviable myocardium
Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892.
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