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Open Access 01-06-2018 | Original Article

Subacute cardiac rubidium-82 positron emission tomography (⁸²Rb-PET) to assess myocardial area at risk, final infarct size, and myocardial salvage after STEMI

Authors: Adam Ali Ghotbi, MD, Andreas Kjaer, MD, DMSc, Lars Nepper-Christensen, MD, Kiril Aleksov Ahtarovski, MD, PhD, Jacob Thomsen Lønborg, MD, PhD, Niels Vejlstrup, MD, DMSc, Kasper Kyhl, MD, Thomas Emil Christensen, MD, Thomas Engstrøm, MD, DMSc, Henning Kelbæk, MD, DMSc, Lene Holmvang, MD, DMSc, Lia E. Bang, MD, DMSc, Rasmus Sejersten Ripa, MD, DMSc, Philip Hasbak, MD

Published in: Journal of Nuclear Cardiology | Issue 3/2018

Abstract

Background

Determining infarct size and myocardial salvage in patients with ST-segment elevation myocardial infarction (STEMI) is important when assessing the efficacy of new reperfusion strategies. We investigated whether rest ⁸²Rb-PET myocardial perfusion imaging can estimate area at risk, final infarct size, and myocardial salvage index when compared to cardiac SPECT and magnetic resonance (CMR).

Methods

Twelve STEMI patients were injected with ^99mTc-Sestamibi intravenously immediate prior to reperfusion. SPECT, ⁸²Rb-PET, and CMR imaging were performed post-reperfusion and at a 3-month follow-up. An automated algorithm determined area at risk, final infarct size, and hence myocardial salvage index.

Results

SPECT, CMR, and PET were performed 2.2 ± 0.5, 34 ± 8.5, and 32 ± 24.4 h after reperfusion, respectively. Mean (± SD) area at risk were 35.2 ± 16.6%, 34.7 ± 11.3%, and 28.1 ± 16.1% of the left ventricle (LV) in SPECT, CMR, and PET, respectively, P = 0.04 for difference. Mean final infarct size estimates were 12.3 ± 15.4%, 13.7 ± 10.4%, and 11.9 ± 14.6% of the LV in SPECT, CMR, and PET imaging, respectively, P = .72. Myocardial salvage indices were 0.64 ± 0.33 (SPECT), 0.65 ± 0.20 (CMR), and 0.63 ± 0.28 (PET), (P = .78).

Conclusions

⁸²Rb-PET underestimates area at risk in patients with STEMI when compared to SPECT and CMR. However, our findings suggest that PET imaging seems feasible when assessing the clinical important parameters of final infarct size and myocardial salvage index, although with great variability, in a selected STEMI population with large infarcts. These findings should be confirmed in a larger population.

Ibrahim T, Bülow HP, Hackl T, Hörnke M, Nekolla SG, Breuer M, et al. Diagnostic value of contrast-enhanced magnetic resonance imaging and single-photon emission computed tomography for detection of myocardial necrosis early after acute myocardial infarction. J Am Coll Cardiol. 2007;49:208–16.CrossRefPubMed

Csonka C, Kupai K, Kocsis GF, Novak G, Fekete V, Bencsik P, et al. Measurement of myocardial infarct size in preclinical studies. J Pharmacol Toxicol Methods. 2010;61:163–70.CrossRefPubMed

Hausenloy DJ, Erik Botker H, Condorelli G, Ferdinandy P, Garcia-Dorado D, Heusch G, et al. Translating cardioprotection for patient benefit: position paper from the Working Group of Cellular Biology of the Heart of the European Society of Cardiology. Cardiovasc Res. 2013;98:7–27.CrossRefPubMed

(4) Longacre LS, Kloner RA, Arai AE, Baines CP, Bolli R, Braunwald E et al. New horizons in cardioprotection. In: Proceedings of a National Heart, Lung, and Blood Institute (NHLBI) workshop, vol. 124. September 21-21, 2010. Rockville, Maryland, USA. Circulation 2011. p. 1172-9.

Bøtker HE, Kaltoft AK, Pedersen SF, Kim WY. Measuring myocardial salvage. Cardiovasc Res. 2012;94:266–75.CrossRefPubMed

Gibbons RJ. Tc-99 m SPECT sestamibi for the measurement of infarct size. J. Cardiovasc Pharmacol Ther. 2011;16:321–31.CrossRefPubMed

Lonborg J, Vejlstrup N, Mathiasen AB, Thomsen C, Jensen JS, Engstrom T. Myocardial area at risk and salvage measured by T2-weighted cardiovascular magnetic resonance: reproducibility and comparison of two T2-weighted protocols. J. Cardiovasc Magn Reson. 2011;13:50.CrossRefPubMedPubMedCentral

Gibbons RJ, Verani MS, Behrenbeck T, Pa Pellikka, O’Connor MK, Mahmarian JJ, et al. Feasibility of tomographic 99mTc-hexakis-2-methoxy-2-methylpropyl-isonitrile imaging for the assessment of myocardial area at risk and the effect of treatment in acute myocardial infarction. Circulation. 1989;80:1277–86.CrossRefPubMed

Korver FW, Hassell M, Smulders MW, Bekkers SC, Gorgels AP. Correlating both Aldrich and Hellemond score with cardiac magnetic resonance imaging endocardial surface area calculations in the estimation of the area at risk. Electrocardiography scores and endocardial surface area calculations: do they correlate? J Electrocardiol. 2013;46:229–34.CrossRefPubMed

10.

Rodriguez-Palomares JF, Alonso A, Marti G, Aguade-Bruix S, Gonzalez-Alujas MT, Romero-Farina G, et al. Quantification of myocardial area at risk in the absence of collateral flow: The validation of angiographic scores by myocardial perfusion single-photon emission computed tomography. J Nucl Cardiol. 2013;20:99–110.CrossRefPubMed

11.

Wagner A, Mahrholdt H, Holly TA, Elliott MD, Regenfus M, Parker M, et al. Contrast-enhanced MRI and routine single photon emission computed tomography (SPECT) perfusion imaging for detection of subendocardial myocardial infarcts: an imaging study. Lancet. 2003;361:374–9.CrossRefPubMed

12.

Carlsson M, Ubachs JFA, Hedström E, Heiberg E, Jovinge S, Arheden H. Myocardium at risk after acute infarction in humans on cardiac magnetic resonance: quantitative assessment during follow-up and validation with single-photon emission computed tomography. JACC Cardiovasc Imaging. 2009;2:569–76.CrossRefPubMed

13.

Ghotbi AA, Kjaer A, Hasbak P. Review: Comparison of PET rubidium-82 with conventional SPECT myocardial perfusion imaging. Clin Physiol Funct Imaging. 2013;34:163–70.CrossRefPubMedPubMedCentral

14.

Beller GA, Conroy J, Smith TW. Ischemia-induced alterations in myocardial (Na+ + K+)-ATPase and cardiac glycoside binding. J Clin Invest. 1976;57:341–50.CrossRefPubMedPubMedCentral

15.

Muller AL, Freed D, Dhalla NS. Activation of proteases and changes in Na+-K+ -ATPase subunits in hearts subjected to ischemia-reperfusion. J Appl Physiol. 1985;2013(114):351–60.

16.

Hadamitzky M, Langhans B, Hausleiter J, Sonne C, Kastrati A, Martinoff S, et al. The assessment of area at risk and myocardial salvage after coronary revascularization in acute myocardial infarction: comparison between CMR and SPECT. JACC Cardiovasc Imaging. 2013;6:358–69.CrossRefPubMed

17.

Gibbons RJ, Christian TF, Hopfenspirger M, Hodge DO, Bailey KR. Myocardium at risk and infarct size after thrombolytic therapy for acute myocardial infarction: implications for the design of randomized trials of acute intervention. J Am Coll Cardiol. 1994;24:616–23.CrossRefPubMed

18.

Eek C, Grenne B, Brunvand H, Aakhus S, Endresen K, Hol PK, et al. Strain echocardiography and wall motion score index predicts final infarct size in patients with non-ST-segment-elevation myocardial infarction. Circulation Cardiovascular imaging. 2010;3:187–94.CrossRefPubMed

19.

Carlsson M, Arheden H, Higgins CB, Saeed M. Magnetic resonance imaging as a potential gold standard for infarct quantification. J Electrocardiol. 2008;41:614–20.CrossRefPubMed

20.

Cerqueira MD. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002;105:539–42.CrossRefPubMed

21.

Busk M, Kaltoft A, Nielsen SS, Bottcher M, Rehling M, Thuesen L, et al. Infarct size and myocardial salvage after primary angioplasty in patients presenting with symptoms for <12 h vs 12-72 hours. Eur Heart J. 2009;30:1322–30.CrossRefPubMed

22.

Kaltoft A, Nielsen SS, Terkelsen CJ, Bottcher M, Lassen JF, Krusell LR, et al. Scintigraphic evaluation of routine filterwire distal protection in percutaneous coronary intervention for acute ST-segment elevation myocardial infarction: a randomized controlled trial. J Nucl Cardiol. 2009;16:784–91.CrossRefPubMed

23.

Fakhri Y, Busk M, Schoos MM, Terkelsen CJ, Kristensen SD, Wagner GS, et al. Evaluation of acute ischemia in pre-procedure ECG predicts myocardial salvage after primary PCI in STEMI patients with symptoms >12 hours. J Electrocardiol. 2016;49:278–83.CrossRefPubMed

24.

Feiring AJ, Johnson MR, Kioschos JM, Kirchner PT, Marcus ML, White CW. The importance of the determination of the myocardial area at risk in the evaluation of the outcome of acute myocardial infarction in patients. Circulation. 1987;75:980–7.CrossRefPubMed

25.

Wackers FJ. Call for a standard unit of defect size. J Nucl Cardiol. 2014;21:682–4.CrossRefPubMed

26.

Watson DD. Thoughts on Wackers’ call for a standard unit of defect size. J Nucl Cardiol. 2014;21:685.CrossRefPubMed

27.

O’Connor MK, Gibbons RJ, Juni JE, O’Keefe J, Ali A. Quantitative myocardial SPECT for infarct sizing: Feasibility of a multicenter trial evaluated using a cardiac phantom. J Nucl Med. 1995;36:1130–6.PubMed

28.

Kim HW, Van Assche L, Jennings RB, Wince WB, Jensen CJ, Rehwald WG, et al. Relationship of T2-Weighted MRI Myocardial Hyperintensity and the Ischemic Area-At-Risk. Circ Res. 2015;117:254–65.CrossRefPubMedPubMedCentral

29.

Ather S, Iqbal F, Gulotta J, Aljaroudi W, Heo J, Iskandrian AE, et al. Comparison of three commercially available softwares for measuring left ventricular perfusion and function by gated SPECT myocardial perfusion imaging. J Nucl Cardiol. 2014;21:673–81.CrossRefPubMed

30.

Schomig A, Kastrati A, Dirschinger J, Mehilli J, Schricke U, Pache J, et al. Coronary stenting plus platelet glycoprotein IIb/IIIa blockade compared with tissue plasminogen activator in acute myocardial infarction. Stent versus Thrombolysis for Occluded Coronary Arteries in Patients with Acute Myocardial Infarction Study Investigators. N Engl J Med. 2000;343:385–91.CrossRefPubMed

31.

Nordlund D, Klug G, Heiberg E, Koul S, Larsen TH, Hoffmann P, et al. Multi-vendor, multicentre comparison of contrast-enhanced SSFP and T2-STIR CMR for determining myocardium at risk in ST-elevation myocardial infarction. Eur Heart J Cardiovasc Imaging. 2016;17:744–53.CrossRefPubMedPubMedCentral

32.

Fuernau G, Eitel I, Franke V, Hildebrandt L, Meissner J, de Waha S, et al. Myocardium at risk in ST-segment elevation myocardial infarction comparison of T2-weighted edema imaging with the MR-assessed endocardial surface area and validation against angiographic scoring. JACC Cardiovasc Imaging. 2011;4:967–76.CrossRefPubMed

33.

Ito H. Etiology and clinical implications of microvascular dysfunction in patients with acute myocardial infarction. Int Heart J. 2014;55:185–9.CrossRefPubMed

34.

Fuller W, Parmar V, Eaton P, Bell JR, Shattock MJ. Cardiac ischemia causes inhibition of the Na/K ATPase by a labile cytosolic compound whose production is linked to oxidant stress. Cardiovasc Res. 2003;57:1044–51.CrossRefPubMed

35.

Uren NG, Crake T, Lefroy DC, de Silva R, Davies GJ, Maseri A. Reduced coronary vasodilator function in infarcted and normal myocardium after myocardial infarction. N Engl J Med. 1994;331:222–7.CrossRefPubMed

36.

Af Maes, Van de Werf F, Mesotten LV, Flamen PB, Kuzo RS, Nuyts JL, et al. Early assessment of regional myocardial blood flow and metabolism in thrombolysis in myocardial infarction flow grade 3 reperfused myocardial infarction using carbon-11-acetate. J Am Coll Cardiol. 2001;37:30–6.CrossRef

37.

White SK, Hausenloy DJ, Moon JC. Imaging the myocardial microcirculation post-myocardial infarction. Curr Heart Fail Rep. 2012;9:282–92.CrossRefPubMed

38.

Gibson WS, Christian TF, Pellikka PA, Behrenbeck T, Gibbons RJ. Serial tomographic imaging with technetium-99 m-sestamibi for the assessment of infarct-related arterial patency following reperfusion therapy. J Nucl Med. 1992;33:2080–5.PubMed

39.

Pellikka PA, Behrenbeck T, Verani MS, Mahmarian JJ, Wackers FJT, Raymond J et al. Serial changes in myocardial perfusion using tomographic technetium-99 m-Hexakis-2- Following reperfusion therapy of myocardial infarction (abstr). J Am Coll Cardiol, 1990.

40.

Wackers FJ, Gibbons RJ, Verani MS, Kayden DS, Pellikka PA, Behrenbeck T, et al. Serial quantitative planar technetium-99 m isonitrile imaging in acute myocardial infarction: Efficacy for noninvasive assessment of thrombolytic therapy. J Am Coll Cardiol. 1989;14:861–73.CrossRefPubMed

41.

Sinusas AJ, Trautman KA, Bergin JD, Watson DD, Ruiz M, Smith WH, et al. Quantification of area at risk during coronary occlusion and degree of myocardial salvage after reperfusion with technetium-99 m methoxyisobutyl isonitrile. Circulation. 1990;82:1424–37.CrossRefPubMed

42.

Burns RJ, Gibbons RJ, Yi Q, Roberts RS, Miller TD, Schaer GL, et al. The relationships of left ventricular ejection fraction, end-systolic volume index and infarct size to six-month mortality after hospital discharge following myocardial infarction treated by thrombolysis. J Am Coll Cardiol. 2002;39:30–6.CrossRefPubMed

43.

Miller TD, Christian TF, Hopfenspirger MR, Hodge DO, Gersh BJ, Gibbons RJ. Infarct size after acute myocardial infarction measured by quantitative tomographic 99mTc sestamibi imaging predicts subsequent mortality. Circulation. 1995;92:334–41.CrossRefPubMed

44.

Enders J, Zimmermann E, Rief M, Martus P, Klingebiel R, Asbach P, et al. Reduction of claustrophobia during magnetic resonance imaging: methods and design of the “CLAUSTRO” randomized controlled trial. BMC Med Imaging. 2011;11:4.CrossRefPubMedPubMedCentral

45.

Ndrepepa G, Mehilli J, Schwaiger M, Schühlen H, Nekolla S, Martinoff S, et al. Prognostic value of myocardial salvage achieved by reperfusion therapy in patients with acute myocardial infarction. J Nucl Med. 2004;45:725–9.PubMed

46.

Eitel I, Desch S, de Waha S, Fuernau G, Gutberlet M, Schuler G, et al. Long-term prognostic value of myocardial salvage assessed by cardiovascular magnetic resonance in acute reperfused myocardial infarction. Heart (Br Cardiac Soc). 2011;97:2038–45.CrossRef

47.

Engblom H, Heiberg E, Erlinge D, Jensen SE, Nordrehaug JE, Dubois-Rande JL, et al. Sample size in clinical cardioprotection trials using myocardial salvage index, infarct size, or biochemical markers as endpoint. J Am Heart Assoc. 2016;5:e002708.CrossRefPubMedPubMedCentral

48.

Neumann FJ, Kósa I, Dickfeld T, Blasini R, Gawaz M, Hausleiter J, et al. Recovery of myocardial perfusion in acute myocardial infarction after successful balloon angioplasty and stent placement in the infarct-related coronary artery. J Am Coll Cardiol. 1997;30:1270–6.CrossRefPubMed

49.

Khan JN, Nazir SA, Horsfield MA, Singh A, Kanagala P, Greenwood JP, et al. Comparison of semi-automated methods to quantify infarct size and area at risk by cardiovascular magnetic resonance imaging at 1.5 T and 3.0 T field strengths. BMC Res Notes. 2015;8:52.CrossRefPubMedPubMedCentral

Title: Subacute cardiac rubidium-82 positron emission tomography (82Rb-PET) to assess myocardial area at risk, final infarct size, and myocardial salvage after STEMI
Authors: Adam Ali Ghotbi, MD
Andreas Kjaer, MD, DMSc
Lars Nepper-Christensen, MD
Kiril Aleksov Ahtarovski, MD, PhD
Jacob Thomsen Lønborg, MD, PhD
Niels Vejlstrup, MD, DMSc
Kasper Kyhl, MD
Thomas Emil Christensen, MD
Thomas Engstrøm, MD, DMSc
Henning Kelbæk, MD, DMSc
Lene Holmvang, MD, DMSc
Lia E. Bang, MD, DMSc
Rasmus Sejersten Ripa, MD, DMSc
Philip Hasbak, MD
Publication date: 01-06-2018
Publisher: Springer US
Published in: Journal of Nuclear Cardiology / Issue 3/2018
Print ISSN: 1071-3581
Electronic ISSN: 1532-6551
DOI: https://doi.org/10.1007/s12350-016-0694-x

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Subacute cardiac rubidium-82 positron emission tomography (⁸²Rb-PET) to assess myocardial area at risk, final infarct size, and myocardial salvage after STEMI

Abstract

Background

Methods

Results

Conclusions

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