Evaluation of myocardial viability in asymptomatic patients early after infarction with perfusion/metabolism single-photon-emission computed tomographic imaging and dobutamine echocardiography

Objective: To study the impact of detection of viability of myocardium in asymptomatic patients early (3-10 days) after Q-wave myocardial infarction on segmental recovery of left ventricular function after elective revascularization. Methods: Patients were studied with low-dose dobutamine echocardiography (LDDE) and single photon-emission computed tomography with sestamibi and [¹⁸F]-fluorodeoxyglucose (FDG) imaging. Viability of myocardium was defined as detection of improvement in segmental thickening of left ventricle by LDDE (versus baseline echocardiographic data), uptake of (99m)Tc sestamibi > 50% of maximum counts, uptake of [¹⁸F]-FDG > 50% of maximum normal, combined uptake of (99m)Tc sestamibi or [¹⁸F]-FDG > 50% of normal maximum, uptake of [¹⁸F]-FDG > 50% or mismatched pattern (uptake of [¹⁸F]-FDG greater than that of (99m)Tc sestamibi). Functional recovery was defined as improvement of segmental thickening of left ventricle detected at follow-up 8 weeks after infarction (versus baseline resting echocardiographic data). Interpretation of the tests was blinded with respect to the angiographic data and the results of the alternative method. Results: In total 18 patients with 133 left-ventricle segments with abnormal contractile function at baseline were analysed; 29% were hypocontractile and 71% were noncontractile. Examination with LDDE showed that 18% of the segments had normal contractility and 26% were hypocontractile; the respective percentages were 29 and 28% according to follow-up resting echocardiography. Radionuclide tests for viability of myocardium gave positive results in 57% (uptake of [¹⁸F]-FDG > 50%) and 62% (uptake of (99m)Tc sestamibi > 50%) of cases. With respect to segmental analysis, there was a 25-27% positive concordance, a 24-27% negative concordance, and a 48-50% discordance between the LDDE and the radionuclide definitions of viability of myocardium. Additionally, there was no significant difference among sensitivities and specificities for the definitions of viability. The sensitivity was 69% for the uptake of (99m)Tc sestamibi > 50% criterion, and the highest specificity was 66% for the LDDE. Incorporation of imaging with [¹⁸F]-FDG into the analysis yielded a marginally higher sensitivity of 71% for the criterion of uptake of [¹⁸F]-FDG or (99m)Tc sestamibi > 50%, versus imaging with the (99m)Tc sestamibi alone. Conclusion: LDDE was more specific and radionuclide imaging more sensitive for detection of viability of myocardium in asymptomatic patients early after infarction. Possibly defective myocardial metabolization of glucose in the period early after infarction and the specific LDDE protocol applied account for the limited benefit of these studies in terms of facilitating prediction of segmental functional recovery after revascularization in this clinical setting. (C) 2000 Lippincott Williams and Wilkins.