Comparison of Thallium-201 Resting Redistribution With Technetium-99m–Sestamibi Uptake and Functional Response to Dobutamine for Assessment of Myocardial Viability
Authors: Vedat Sansoy, David K. Glover, Denny D. Watson, Mirta Ruiz, William H. Smith, Juris P. Simanis, George A. Beller
Journal: Circulation (1995)

Background 201 Tl scintigraphy is useful for determination of viability in patients with coronary artery disease and depressed left ventricular function. Whether 99m Tc sestamibi is adequate for viability detection remains controversial. The primary goal of this study was to compare 99m Tc-sestamibi uptake with 201 Tl uptake in canine models of sustained low flow and regional asynergy for determination of viability. A secondary objective was to compare myocardial uptake of these tracers with the functional response to low-dose dobutamine. Methods and Results In protocol 1, 14 open-chested, anesthetized dogs with a 50% reduction in resting left anterior descending coronary artery (LAD) flow underwent 1 hour of transient LAD occlusion followed by reperfusion through the severe stenosis. Then 1.0 mCi of 201 Tl was injected, and serial imaging was performed 5 minutes and 2 hours later. After acquisition of the delayed 201 Tl image, 10 mCi of 99m Tc sestamibi was injected, and imaging was repeated 45 minutes later. No significant difference was seen between the 201 Tl defect ratio (LAD/left circumflex coronary artery [LCx]) on redistribution images (0.62±0.02) and 99m Tc-sestamibi defect ratio (0.60±0.02). Similarly, LAD/LCx activity ratios by gamma-well counting were comparable (0.62±0.02 versus 0.59±0.04) and reflected the flow decrement. Systolic thickening was −11±3% at the time of tracer injection. In protocol 2, 16 dogs underwent serial 201 Tl and 99m Tc-sestamibi imaging during a 50% reduction in LAD flow with no superimposed transient LAD occlusion. In this model, the 99m Tc-sestamibi LAD/LCx image defect ratio (0.61±0.03) was significantly less than the 201 Tl redistribution image defect ratio (0.66±0.03, P &lt;.01). In 10 dogs, the stenosis was released, resulting in a significant increase in systolic thickening ( P =.003), which increased further in response to 5 μg · kg −1 · min −1 of dobutamine ( P =.02). In contrast, thickening increased only from −7±3% to 2±4% ( P =.004) in response to dobutamine infusion in the remaining 6 dogs with persistent severe LAD stenoses. In protocol 3, 5 dogs received both 201 Tl and 99m Tc sestamibi to compare the degree of delayed redistribution between tracers at 2 hours. The LAD/LCx microsphere flow ratios when 201 Tl and 99m Tc sestamibi were injected were 0.44±0.06 and 0.43±0.05 ( P =NS), respectively. The LAD/LCx activity ratio by gamma-well counting was greater for 201 Tl (0.56±0.08) than 99m Tc sestamibi (0.50±0.07) at 2 hours of redistribution ( P &lt;.05), indicating greater redistribution for 201 Tl. The LAD/LCx 99m Tc-sestamibi defect ratios on serial imaging improved from 0.49±0.07 to 0.52±0.07 ( P =.0005), consistent with a slight amount of 99m Tc-sestamibi redistribution. In protocol 4, no difference between 201 Tl and 99m Tc-sestamibi defect magnitudes was seen in 4 dogs undergoing 3 hours of total LAD occlusion and ligation of visible coronary collaterals. Infarct size was 68±19% of the risk area. Conclusions Although 99m Tc-sestamibi and 201 Tl defect magnitudes and regional activities were comparable in dogs with sustained low coronary flows and superimposed subendocardial infarctions and in dogs with large infarctions, approximately 5% more 201 Tl than 99m Tc-sestamibi uptake was observed in dogs with chronic low flow and severe systolic dysfunction. Substantial 99m Tc-sestamibi uptake in asynergic zones was observed in this low-flow model, with some slight resting 99m Tc-sestamibi redistribution observed on serial images. Systolic thickening was negligibly enhanced during dobutamine infusion in dogs with sustained low flow, whereas 201 Tl uptake was only mildly reduced.