Myocardial blood flow at rest and contractile reserve in patients with chronic coronary artery disease and left ventricular dysfunction

doi:10.1016/S1071-3581(99)90020-X

Journal of Nuclear Cardiology

Volume 6, Issue 5, September–October 1999, Pages 487-494

https://doi.org/10.1016/S1071-3581(99)90020-X Get rights and content

Abstract

Background. The mechanisms that determine chronic left ventricular dysfunction in coronary artery disease (in particular, critical reductions in coronary artery blood flow leading to hibernating myocardium) may affect the ability of the myocardium to respond to inotropic stimulation with dobutamine. This study was designed to investigate the relatinship between resting myocardial blood flow and contractile reserve in patients with coronary artery disease and chronic left ventricular dysfunction.

Methods and Results. Twenty-three patients (21 men and 2 women; age 61 ± 9 years) underwent transesophageal echocardiography during infusion of dobutamine (2.5 μg/kg to 40 μg/kg per minute) and positron emission tomography (PET) with ¹⁵O-water (9 patients) or ¹³N-ammonia (14 patients). Systolic wall thickening at each dose of dobutamine and resting myocardial blood flow were quantitatively analyzed in 8 anatomically matched regions at mid-ventricular level. Myocardial regions with preserved contraction had higher blood flow compared with regions with basal dyssynergy (0.99 ± 0.3 vs 0.65 ± 0.3 mL/min/gm; P < .0001). Among myocardial regions with preserved resting contraction, no relation was observed between blood flow and the response to dobutamine (r = 0.06). In contrast, among myocardial regions with diminished resting contraction, a significant correlation was observed between resting blood flow and contractile reserve (r = 0.53; P < .0001). The maximum increase in percent systolic wall thickening with dobutamine was 32.8% ± 14% in regions with normal blood flow, 21.5% ± 17% in regions with mildly to moderately reduced blood flow, and 10.7% ± 10% in regions with severely reduced blood flow (P < .0001).

Conclusions. These findings emphasize the importance of resting myocardial blood flow for the preservation of contractile reserve in patients with coronary artery disease and left ventricular dysfunction. Because a positive inotropic response to dobutamine is more likely to occur in dyssynergic regions with preserved rather than reduced myocardial blood flow, regional perfusion may determine in which circumstances dobutamine echocardiography contributes to the assessment of myocardial viability.

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Cited by (13)

Negative Contractile Reserve With Low-Dose Dobutamine in Patients With Ischemic Cardiomyopathy Investigated by Gated Myocardial Perfusion SPECT
2010, Revista Espanola de Cardiologia
Analizar la respuesta contráctil negativa (RCN) del ventrículo izquierdo (VI) en la gated-SPECT con bajas dosis de dobutamina (BDD) en pacientes con miocardiopatía isquémica (MI).
Se estudió prospectivamente a 68 pacientes (media de edad, 60 ± 11 años; 7 mujeres) con MI mediante gated-SPECT en reposo y durante la infusión de BDD. Se relacionó la RCN (aumento de la puntuación del engrosamiento ≥ 1 unidad) con los criterios gammagráficos de viabilidad y los resultados de la coronariografía.
El 42,6% (29/68) de los pacientes presentó uno o más segmentos con RCN. En el 14,7% (n = 10) de los pacientes se observó una disminución de la fracción de eyección ≥ 4% con las BDD. Estos pacientes se caracterizaron por tener un mayor número de segmentos con RCN (2,8 ± 2,5 frente a 0,87 ± 0,4; p = 0,042), con un valor de corte en el análisis de curva ROC ≥ 2 segmentos con RCN (sensibilidad, 70%; especificidad, 74%; +LR, 2,71; –LR, 0,40). El 94% (74/79) de los segmentos con RCN correspondía a miocardio vivo (normal o viable gammagráficamente). De los 17 segmentos con acinesia o hipocinesia severa y RCN, 12 (71%) tenían criterios gammagráficos de viabilidad y en su mayoría (10/12) correspondían a territorios con arteria coronaria abierta.
La RCN no es un fenómeno infrecuente en los pacientes con MI y se relaciona con una disminución de la función sistólica general del VI. Mayoritariamente se observa en segmentos con criterios gammagráficos de viabilidad y dependientes de una arteria coronaria abierta.
To investigate negative contractile responses in the left ventricle during lowdose dobutamine (LDD) gated single-photon emission computed tomography (SPECT) in patients with ischemic cardiomyopathy.
Sixty-eight consecutive patients (mean age, 60±11 years; 7 male) with ischemic cardiomyopathy (i.e., left ventricular ejection fraction [LVEF] ≤40%) were evaluated using gated-SPECT at rest and during LDD infusion. Associations between a negative contractile reserve (i.e., a ≥1-grade improvement in wall thickening score with LDD infusion) and scintigraphic viability criteria and coronary angiography findings were analyzed.
Some 42.6% (29/68) of patients had a negative contractile reserve in one or more segments. In 14.7% (n=10), the LVEF decreased by ≥4% with LDD. These patients had more segments with a negative contractile reserve (2.8±2.5 vs. 0.87±0.40; P=.042), and the cut-off value on receiver operating characteristic curve analysis was ≥2 segments with a negative contractile reserve (sensitivity 70%, specificity 74%, positive likelihood ratio 2.71, negative likelihood ratio 0.40). Some 94% (74/79) of segments with a negative contractile reserve were in viable myocardium (i.e. normal or viable on scintigraphy). Twelve of 17 segments with akinesia or severe hypokinesia and a negative contractile reserve satisfied scintigraphic viability criteria, with the majority (10/12) lying in territories supplied by a patent coronary artery.
A negative contractile reserve was not uncommon in patients with ischemic cardiomyopathy and was associated with a general decrease in left ventricular systolic function. It was observed mainly in myocardial segments that appeared viable on scintigraphy and were supplied by a patent coronary artery.
Assessment of myocardial viability in dysfunctional myocardium by resting myocardial blood flow determined with oxygen 15 water PET
2003, Journal of Nuclear Cardiology
Background. There is controversy about the role of decreased resting blood flow as the pathophysiologic correlate of hibernating myocardium. The aim of this study was an absolute quantification of volumetric myocardial blood flow (MBFvol) in dysfunctional myocardium with different viability conditions as defined by fluorine 18 deoxyglucose (FDG) positron emission tomography (PET) while taking into consideration the functional recovery after revascularization. The impact of MBFvol in the diagnosis of functional recovery was also investigated. Methods and Results. Forty-two patients with severe coronary artery disease and dysfunctional myocardium underwent resting oxygen 15 water PET, as well as FDG PET and technetium 99m tetrofosmin single photon emission computed tomography, all attenuation-corrected. Relative FDG and Tc-99m tetrofosmin uptake (normalized to the segment with 100% Tc-99m tetrofosmin uptake), as well as MBFvol (myocardial blood flow multiplied by the water-perfusable tissue fraction to account for the flow to the entire segment volume), were determined in 18 myocardial segments per patient. Viability in dysfunctional segments (estimated by ventriculography) with reduced Tc-99m tetrofosmin uptake of 70% or lower was classified as viable (FDG >70%, mismatch) or nonviable (FDG ≤70%, match). Fifteen patients underwent revascularization and were followed up. Mismatch segments with improved function were classified as hibernating myocardium. Mean MBFvol in viable myocardium was slightly reduced (0.60 ± 0.02 mL · min^–1 · mL^–1) compared with that in normokinetic myocardium (0.64 ± 0.01 mL · min^–1 · mL^–1) (P = .036) and was significantly higher than in nonviable myocardium (0.36 ± 0.01 mL · min^–1 · mL^–1) (P < .001). Receiver operating characteristic analysis confirmed an FDG uptake greater than 70% as the optimal threshold to predict functional recovery (diagnostic accuracy [ACC], 76%). MBFvol in hibernating myocardium (0.62 ± 0.04 mL · min^–1 · mL^–1) was not significantly reduced compared with that in normokinetic myocardium (0.66 ± 0.02 mL · min^–1 · mL^–1) and was significantly higher than in persistently dysfunctional myocardium (0.51 ± 0.04 mL · min^–1 · mL^–1) (P < .05). The ACC of MBFvol greater than 0.40 mL · min^–1 · mL^–1 as the threshold to predict functional recovery was 61% but did not improve the accuracy of FDG PET by itself. Conclusions. In patients with severe coronary artery disease and dysfunctional myocardium, MBFvol as determined with O-15 water differs significantly between viable and nonviable myocardium as determined by FDG PET and is not significantly reduced in hibernating compared with normokinetic myocardium. Therefore chronically reduced resting blood flow appears unlikely to be the pathophysiologic correlate of the functional state of hibernation. However, MBFvol does not improve the ACC of FDG PET by itself. (J Nucl Cardiol 2003;10:34-45)
Simple quantification of myocardial perfusion by pixel-by-pixel graphical analysis using carbon-11 acetate: comparison of the K-complexes of carbon-11 acetate and nitrogen-13 ammonia
2008, Nuclear Medicine Communications
Biochemical and bioimaging markers for risk assessment and diagnosis in major cardiovascular diseases: A road to integration of complementary diagnostic tools
2007, Journal of Internal Medicine
Assessing the function of coronary microcirculation in short-term hibernating myocardium by intracoronary Doppler ultrasound
2006, Chinese Journal of Medical Imaging Technology
Tagged MRI and PET in severe CAD: Discrepancy between preoperative inotropic reserve and intramyocardial functional outcome after revascularization
2004, American Journal of Physiology - Heart and Circulatory Physiology

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Original articleMyocardial blood flow at rest and contractile reserve in patients with chronic coronary artery disease and left ventricular dysfunction

Abstract

J Am Coll Cardiol

Am J Med

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

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Original article
Myocardial blood flow at rest and contractile reserve in patients with chronic coronary artery disease and left ventricular dysfunction

Prediction of improvement of regional left ventricular function after surgical revascularization: a comparison of low-dose dobutamine echocardiography with ²⁰¹Tl single-photon emission computed tomography