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1 Assessment of Myocardial Viability Jamshid Maddahi, M.D., FACC, FASNC Professor Molecular and Medical Pharmacology (Nuclear Medicine) and Medicine (Cardiology) David Geffen School of Medicine at UCLA Director, Biomedical Imaging Institute Definition of Myocardial Viability Potential for improvement of myocardial dysfunction after revascularization 1
2 Causes of Abnormal Regional Wall Motion and Potential for Recovery after Revascularization Causes of Abnormal Regional Wall motion Recovery after Revascularization Transmural MI Nontransmural MI Hibernating Stunned Repetitively Stunned Myopathic No No Yes Spontaneous Yes No Myocardial Perfusion, Reperfusion, and Function 100 Hibernation (%) Normal Revascularization Perfusion Function Days Weeks Elapsed Time 2
3 Myocardial Perfusion, Reperfusion, and Function 100 Repetitive Stunning (%) Normal Revascularization Perfusion Function Days Weeks Elapsed Time Short Axis rest redist Vertical Long Axis rest redist rest Horizontal Long Axis redist UCLA 3
4 Rest Redist Rest Redist Rest Redist Rest Redist Question What is the likelihood of improvement of function following revascularization? A) High (>80%) B) High-intermediate (60%-70%) C) Intermediate (50%-60%) D) Low-intermediate (30%-40%) E) Low (<20%) 4
5 D.S. 1 Question Resting LVEF is 24%. What is the most likely LVEF following revascularization? A) <30% B) 30%-34% C) 35%-39% 39% D) 40%-44% E) 45%-50% 5
6 D.S. 1 PET vs. SPECT for Viability Assessment When to Use What SPECT tracers are inherently good markers of myocardial viability, but their myocardial uptake is flow dependent. About 35% of nonreversible SPECT defects are hibernating myocardium with severe reduction of blood flow. SPECT underestimates the extent of myocardial viability. 6
7 Clinical History M.L. 76 year-old male with history of MI and S/P CABG Presenting with angina and symptoms of heart failure SPECT study showed nonreversible inferior, apical, and inferolateral defects PET was performed to assess viability M.L. p51896 Vertical Long Axis Short Axis Axial Rest NH 3 Rest FDG UCLA 7
8 M.L. p51896 Rest NH 3 Rest FDG UCLA PET Viability Patterns Perfusion-R FDG-PP FDG-Fast Normal Normal Normal Tx MI Absent Absent Non-Tx MI 1-2+ Reduced Reduced Hibernating Reduced Normal Repetitively stunned Myopathic 8
9 Rest perfusion Rest FDG Horizontal long axis Vertical long axis Short axis UT Health Science Center Question What is the patient s metabolic state? A) Fasting B) Post-prandial C) Diabetic 9
10 Question What is the pattern of viability in the inferior wall? A) Hibernating B) Non-transmural infarction C) Transmural infarction D) Non-ischemic myopathy E) Repetitively stunned Pt#20 Rest perfusion Rest FDG 10
11 PET Viability Patterns Perfusion-R FDG-PP FDG-Fast Normal Normal Normal Absent Tx MI Absent Absent Absent Non-Tx MI 1-2+ Reduced Reduced Absent Hibernating Reduced Normal Normal Repetitively stunned Myopathic Clinical History C.S. 47 year-old male with no prior cardiac history, experienced sudden death at a job interview. VFib converted to NSR and was transferred to UCLA. Emergency coronary angiogram: LAD: 90% proximal, 80% mid, 90% Dx LCX: 100% OM RCA: 100% proximal Echocardiogram: EF 20-25%, 25% LVEDD 69 mm, global l hypokinesis. Normal RV size with reduced function. Mild pulmonary HTN, RVSP mmhg. Moderate MR 11
12 EKG on admission 12
13 Rest perfusion Stress perfusion Horizontal long axis Vertical long axis Short axis UT Health Science Center 13
14 PET Viability Patterns Perfusion-R FDG-PP FDG-Fast Normal Normal Normal Absent Tx MI Absent Absent Absent Non-Tx MI 1-2+ Reduced Reduced Absent Hibernating Reduced Normal Normal Repetitively stunned Normal/ 1+ reduced Normal Variable Myopathic Normal Normal Absent Added Benefits of Stress Perfusion Imaging 1. Better Identification of candidates for revascularization by detecting jeopardized myocardium 2. Differentiation of repetitively stunned from myopathic myocardium 14
15 PET Viability Patterns Perfusion-R FDG-PP Perfusion-S Normal Normal Normal Normal/ decrease Tx MI Absent Absent Absent Non-Tx MI 1-2+ Reduced 1-2+ Reduced No change/ More decrease Hibernating Reduced Normal No change/ More decrease Repetitively stunned Normal/ 1+ reduced Normal Decrease Myopathic Normal Normal Normal 15
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