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Published online before print November 21, 2002, 10.1148/radiol.2261012108
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(Radiology 2003;226:138-144.)
© RSNA, 2002

Cardiac Imaging

Acute Myocardial Infarction: Myocardial Viability Assessment in Patients Early Thereafter—Comparison of Contrast-enhanced MR Imaging with Resting 201Tl SPECT1

Kakuya Kitagawa, MD, Hajime Sakuma, MD, Tadanori Hirano, MD, Shinya Okamoto, MD, Katsutoshi Makino, MD and Kan Takeda, MD

1 From the Departments of Radiology (K.K., T.H.) and Internal Medicine (S.O., K.M.), Matsusaka Central Hospital, Mie, Japan; and Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan (K.K., H.S., K.T.). From the 2001 RSNA scientific assembly. Received December 28, 2001; revision requested February 28, 2002; revision received April 18; accepted June 28. Address correspondence to K.K. (e-mail: kakuya@clin.medic.mie-u.ac.jp).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To compare contrast material–enhanced magnetic resonance (MR) imaging with resting thallium 201 (201Tl) single photon emission computed tomography (SPECT) for predicting myocardial viability in patients early after acute myocardial infarction.

MATERIALS AND METHODS: Inversion-recovery contrast-enhanced MR images and resting 201Tl SPECT images were obtained in 22 patients after acute myocardial infarction. The 201Tl SPECT images were obtained 4.3 days ± 0.2 (standard error) after the onset of myocardial infarction. Contrast-enhanced MR imaging was performed 7.9 days ± 1.6 after 201Tl SPECT. Transmural extent of hyperenhancement on contrast-enhanced MR images and regional 201Tl activity were quantitatively analyzed with a 12-segment model. Regional wall thickening on follow-up cine MR images obtained 67 days ± 17 after contrast-enhanced MR imaging was used as an index for myocardial viability. Statistical analyses were performed with the {chi}2 and two-tailed Student t tests.

RESULTS: Both contrast-enhanced MR and resting 201Tl SPECT images showed significant correlations with regional wall thickening on follow-up cine MR images. The sensitivity, specificity, and accuracy of contrast-enhanced MR imaging in the prediction of viable myocardium were significantly higher than those of resting 201Tl SPECT (98.0% vs 90.3%, P < .01; 75.0% vs 54.4%, P < .05; and 92.0% vs 81.1%, P < .001, respectively).

CONCLUSION: Delayed contrast-enhanced MR imaging can help predict myocardial viability as seen on follow-up cine MR images after acute myocardial infarction, with significantly improved sensitivity, specificity, and accuracy in comparison with those of resting 201Tl SPECT.

© RSNA, 2002

Index terms: Heart, function • Heart, MR, 511.121413, 511.12143 • Heart, SPECT, 511.12162 • Myocardium, infarction, 511.771


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
In patients early after acute myocardial infarction, myocardial stunning may cause reversible left ventricular dysfunction. Therefore, regional left ventricular wall motion at a resting state cannot be used to evaluate myocardial viability because both necrotic and viable myocardium may demonstrate impaired contractile function in the acute stage (1,2). The distinction between viable and nonviable myocardial segments is an important and challenging clinical question (3).

It has been known for many years that regions of acute myocardial infarction exhibit high signal intensity on T1-weighted magnetic resonance (MR) images after administration of extracellular MR imaging contrast agents (4–6). With the recent introduction of an inversion-recovery breath-hold MR imaging sequence, infarcted myocardium can be visualized with substantially improved contrast and image quality (7). Results from a recent study in which this technique was used demonstrated that transmural extent of hyperenhancement within the 1st week after myocardial infarction can be used to predict improvement in contractile function 2–4 months later (3). Clinically, resting thallium 201 (201Tl) single photon emission computed tomography (SPECT) has been widely used to evaluate myocardial viability in patients with chronic coronary arterial disease and acute myocardial infarction (8–16).

The purpose of the current study was to compare contrast material–enhanced MR imaging with resting 201Tl SPECT for predicting myocardial viability in patients early after acute myocardial infarction.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients
The study protocol was approved by the institutional review board, and all patients gave informed consent. Thirty consecutive patients (18 men and 12 women) admitted to the coronary care units at our hospital (Matsusaka Central Hospital, Mie, Japan) were prospectively enrolled; they had myocardial infarction, defined as typical chest pain, characteristic abnormal findings at electrocardiography, and increased cardiac creatine kinase-MB fraction enzyme level (>13 U/L). Patients were included if they had no history of myocardial infarction, underwent successful percutaneous transluminal coronary angioplasty with less than 50% residual stenosis, and were clinically stable. Eight patients were excluded from data analysis because follow-up cine MR images were not obtained. No patient was excluded because of technical failure or poor image quality.

MR and SPECT images were evaluated in the 22 patients (14 men and eight women; mean age, 61.0 years ± 2.4 [standard error]) who underwent follow-up cine MR imaging. No clinical evidence of a recurrent coronary event was recorded before follow-up cine MR imaging in these 22 patients. At coronary angiography, the infarct-related artery was the left anterior descending coronary arterial territory in nine patients, the right coronary arterial territory in eight, and the left circumflex coronary arterial territory in five.

Protocol for 201Tl SPECT
The 201Tl SPECT was performed 4.3 days ± 0.2 after the onset of myocardial infarction. Seventy-four MBq of 201Tl was injected in each patient in a resting state at a mean of 4.3 days ± 0.2 after the onset of myocardial infarction. The 201Tl SPECT images were acquired 15 minutes after the injection by using a three-headed rotating gamma camera (GCA-9300A; Toshiba, Tokyo, Japan) equipped with low-energy high-resolution parallel-hole collimators centered on a 71-keV photo peak with a 24% window. Ninety projection images were acquired over 360°, in 4° increments, with a 64 x 64 matrix. Scatter correction was performed by using a triple-energy window method (17). Transverse images with 128 x 128 resolution were reconstructed by using Butterworth and Ramp filters. The section thickness of each SPECT image was 12.8 mm.

Protocol for MR Imaging
Inversion-recovery contrast-enhanced MR images were obtained at a mean of 7.9 days ± 1.6 (range, 1–20 days) after SPECT. The patient was placed supine in a clinical 1.5-T imager (Magnetom Vision; Siemens, Erlangen, Germany) with body-array coils placed around the chest. MR images were obtained during repeated breath holds and were electrocardiographically gated. Contrast-enhanced images were acquired in contiguous short-axis imaging planes and in a long-axis imaging plane 15 minutes after intravenous administration of 0.15 mmol of gadopentetate dimeglumine (Magnevist; Schering, Berlin, Germany) per kilogram of body weight, with a segmented inversion-recovery fast low-angle shot sequence (18). MR imaging parameters included 6.0/3.4/200–220 (repetition time msec/echo time msec/inversion time msec), a section thickness of 10 mm, a field of view of 240 x 320 mm, and an image matrix of 192 x 256.

Follow-up cine MR imaging was performed a mean of 67 days ± 17 after contrast-enhanced MR imaging. Cine MR images encompassing the entire left ventricle were acquired in nine to 11 contiguous short-axis imaging planes, with a segmented fast low-angle shot cine sequence. The following imaging parameters were used: a repetition time of 50 msec for each cine frame, an echo time of 4.8 msec, a section thickness of 10 mm, a field of view of 240 x 320 mm, and an image matrix of 192 x 256.

Image Analysis
Contrast-enhanced MR, 201Tl SPECT, and follow-up cine MR images were quantitatively assessed by using a 12-segment model that divided the left ventricular myocardium into six basal and six midventricular segments. Contrast-enhanced MR, 201Tl SPECT, and follow-up cine MR images were evaluated on separate days. In addition, studies were presented in a different randomized order of patients for each imaging modality.

Regional myocardial enhancement on inversion-recovery MR images was graded by assessing the transmural extent of hyperenhanced tissue in each segment: grade 0, no enhancement; grade I, hyperenhancement of 1%–25% of the wall thickness; grade II, hyperenhancement of 26%–50% of wall thickness; grade III, hyperenhancement of 51%–75% of wall thickness; and grade IV, hyperenhancement of 76%–100% of wall thickness. Two authors (K.K., H.S.) graded regional myocardial enhancement with consensus before evaluating cine MR images.

The 201Tl uptake on 201Tl SPECT images was analyzed quantitatively. The region of interest was placed by an author (K.K.). In each patient, the myocardial region of interest with the maximum count was used as the normal reference region for that patient (19). The mean 201Tl activity in each segment was normalized to the activity in the reference region. The 201Tl uptake was graded on the basis of severity of reduction in 201Tl activity: grade 0, 86%–100% of peak activity; grade I, 60%–85% of peak; grade II, 50%–59% of peak; and grade III, 0%–49% of peak.

Wall thickening on cine MR images was determined with commercial software (MASSPlus; MEDIS Medical Imaging Systems, Leiden, the Netherlands) in which a modified centerline method was used (20). One author (K.K.) manually traced the epicardial and endocardial borders of the myocardium. The result was expressed as the percentage of systolic wall thickening according to the following formula: percentage of systolic wall thickening = [(end-systolic wall thickness - end-diastolic wall thickness)/end-diastolic wall thickness] x 100%. Mean percentage of systolic wall thickening in each hyperenhancement and 201Tl uptake grade was calculated.

Statistical Analysis
The hyperenhancement grade for contrast-enhanced MR images and the 201Tl uptake grade were compared with the regional left ventricular wall thickening on follow-up cine MR images. For calculation of the sensitivity and specificity of contrast-enhanced MR imaging, hyperenhancement of 0%–50% of the wall thickness (grade 0–II) was used to determine viable myocardium (21). For resting 201Tl SPECT, 60%–100% of the peak activity (grade 0–I) was used to detect viable myocardium (14,19).

All values were expressed as a mean value plus or minus standard error. The sensitivity, specificity, predictive values, and accuracy were calculated with the corresponding 95% CIs. The {chi}2 test was used to compare proportions. The mean percentages of systolic wall thickening in each hyperenhancement and 201Tl uptake grade were compared by using the two-tailed Student t test. A P value less than .05 was considered to indicate a statistically significant difference.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
On contrast-enhanced MR images, 115 (44%) of the 264 segments showed hyperenhancement, including 17 grade I segments, 43 grade II segments, 14 grade III segments, and 41 grade IV segments. The 201Tl uptake was reduced to less than 85% of the peak activity in 178 (67%) of the 264 segments, including 122 grade I segments, 22 grade II segments, and 34 grade III segments. Follow-up cine MR imaging demonstrated 94 (36%) of 264 dysfunctional segments, including 26 segments with mild hypokinesia, 21 segments with severe hypokinesia, and 21 segments with akinesia or dyskinesia.

Relationship between Transmural Extent of Hyperenhancement and Regional Wall Motion
The transmural extent of hyperenhancement on contrast-enhanced MR images showed a significant correlation with the regional wall thickening on follow-up cine MR images (Fig 1). The proportion of segments with preserved wall motion decreased as the transmural extent of hyperenhancement increased (P < .001). For example, preserved wall thickening greater than 20% was observed in 95% (141 of 149) of grade 0 segments, 94% (16 of 17) of grade I segments, 81% (35 of 43) of grade II segments, 21% (three of 14) of grade III segments, and 2% (one of 41) of grade IV segments. In addition, the mean percentage of systolic wall thickening between segments of grades I and II, II and III, and III and IV was significantly different.



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  		Figure 1. Plot illustrates the relationship between transmural extent of hyperenhancement on contrast-enhanced MR images and percentage of systolic wall thickening on follow-up cine MR images in 264 segments in 22 patients after acute myocardial infarction. Significant differences were observed in mean percentage of systolic wall thickening between segments of grades I and II, grades II and III, and grades III and IV. {bullet} = mean percentage of systolic wall thickening in each hyperenhancement grade, {diamond} = myocardial wall segment, n.s. = not significant. Error bars represent standard error.

 
Relationship between 201Tl Uptake and Regional Wall Motion
The 201Tl uptake showed a significant relationship with the regional wall thickening on follow-up cine MR images (Fig 2). The proportion of segments with preserved wall motion decreased as the 201Tl uptake decreased (P < .001). Preserved wall thickening greater than 20% was found in 91% (78 of 86) of grade 0 segments, 81% (99 of 122) of grade I segments, 55% (12 of 22) of grade II segments, and 21% (seven of 34) of grade III segments. Significant differences in mean percentage of systolic wall thickening were observed between segments of grades 0 and I and grades I and II.



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  		Figure 2. Plot illustrates the relationship between resting 201Tl uptake and percentage of systolic wall thickening on follow-up cine MR images in 264 segments in 22 patients after acute myocardial infarction. Significant differences were observed in mean percentage of systolic wall thickening between segments of grades 0 and I and grades I and II. {bullet} = mean percentage of systolic wall thickening in each 201Tl uptake grade, {diamond} = myocardial wall segment, n.s. = not significant. Error bars represent standard error.

 
Diagnostic Performance of Contrast-enhanced MR Imaging and 201Tl SPECT in the Prediction of Myocardial Viability
The Table summarizes the sensitivity, specificity, predictive values, and accuracy, and their 95% CIs, for contrast-enhanced MR imaging and resting 201Tl SPECT in the prediction of preserved wall thickening (>20%) at follow-up cine MR imaging. Contrast-enhanced MR imaging had a sensitivity of 98.0% (95% CI: 96.0%, 100%), specificity of 75.0% (95% CI: 64.7%, 85.3%), and accuracy of 92.0% (95% CI: 88.7%, 95.3%). The sensitivity, specificity, and accuracy of resting 201Tl SPECT were 90.3% (95% CI: 86.2%, 94.4%), 54.4% (95% CI: 42.6%, 66.2%), and 81.1% (95% CI: 76.4%, 85.8%), respectively. Significant differences were observed between the two modalities in sensitivity (P < .01), specificity (P < .05), and accuracy (P < .001).


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  		Sensitivity, Specificity, Predictive Values, and Accuracy of Contrast-enhanced MR Imaging and Resting 201Tl SPECT in the Prediction of Myocardial Viability

 
Decreased 201Tl uptake (<60% of peak) resulted in false-negative findings in 19 (34%) of 56 grade II or III segments in the prediction of myocardial viability (Fig 3). These false-negative segments on 201Tl SPECT images were frequently found in the inferior wall—14 (74%) of 19 segments. In contrast, false-negative results were found in only four (7%) of the 55 grade III or IV segments on contrast-enhanced MR images.



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  		Figure 3. Contrast-enhanced MR images obtained with a segmented inversion-recovery fast low-angle shot sequence (6.0/3.4/200) in A, short-axis and B, long-axis imaging planes and resting 201Tl SPECT images obtained in C, short-axis and D, long-axis imaging planes in a 59-year-old man with inferior myocardial infarction. Transmural extent of hyperenhancement in the inferior wall (white arrows) was less than 50% of wall thickness, which indicates preserved regional viability. The 201Tl SPECT images show reduced uptake of less than 60% of peak, which indicates nonviable myocardium (black arrows). Follow-up short-axis cine MR images obtained with a segmented fast low-angle shot sequence (50/4.8) at E, the end of diastole and F, the end of systole demonstrate preserved regional contractile function in the inferior wall (arrowheads).

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
REFERENCES
 
In this study, we evaluated the diagnostic values of inversion-recovery contrast-enhanced MR imaging and 201Tl SPECT in the prediction of functional recovery of regional myocardial contraction in patients after acute myocardial infarction. Delayed contrast-enhanced MR imaging of the myocardium with an inversion-recovery breath-hold sequence has become increasingly interesting as a noninvasive method for demonstrating infarcted myocardium in patients with coronary arterial disease and myocardial infarction (3,22). However, the comparative diagnostic values of contrast-enhanced MR imaging and other noninvasive methods such as 201Tl SPECT have not been well evaluated in patients after acute myocardial infarction. We found that the sensitivity, specificity, and accuracy of contrast-enhanced MR imaging in the prediction of myocardial viability were significantly higher than those of 201Tl SPECT.

Contrast-enhanced MR Imaging of Myocardial Infarction
Authors of a study (23) in animal models demonstrated that contrast-enhanced MR imaging with a segmented inversion-recovery fast low-angle shot sequence can accurately delineate the transmural extent of infarction and is useful for differentiating reversible and irreversible myocardial injuries regardless of wall motion abnormality at rest, the age of infarction, or the reperfusion status. In another study (21), in which clinical patients were evaluated, no functional recovery was observed in 90% of the myocardial segments that exhibited hyperenhancement in 51%–75% of the wall thickness. In our study, contrast-enhanced MR imaging demonstrated high sensitivity (98.0%) in the prediction of regional myocardial viability when hyperenhancement of 50% of wall thickness was used as a cutoff value.

Resting 201Tl SPECT of Myocardial Infarction
For many years, resting 201Tl SPECT has been used for evaluating myocardial viability in patients with chronic coronary arterial disease and acute myocardial infarction (10,16,24). Authors of a review (25) reported that the cumulative average sensitivity and specificity in the prediction of improvement in regional function after myocardial revascularization were 90% and 54%, respectively. In our study, the sensitivity and specificity of 201Tl SPECT in the prediction of myocardial viability were 90.3% and 54.4%, respectively. The results in this study were similar to those previously reported (10,14). We used less than 60% of peak activity as a cutoff value for nonviable myocardium, since this value was previously reported to be optimal in the prediction of myocardial viability (14,19).

Comparison between Contrast-enhanced MR Imaging and Resting 201Tl SPECT
In our study, delayed contrast-enhanced MR imaging had significantly better sensitivity, specificity, predictive values, and accuracy than did resting 201Tl SPECT in the prediction of regional myocardial viability. In addition, contrast-enhanced MR imaging showed substantially higher negative predictive value owing to a decreased number of false-negative segments. A lack of specificity for depicting viable myocardium with 201Tl SPECT, mostly related to defects in the inferior wall, has been frequently recognized (26,27). In agreement with the results of previous articles, the false-negative segments on 201Tl SPECT images were frequently found in the inferior wall in the current study.

Another fundamental point of difference between the MR imaging and SPECT methods is that contrast-enhanced MR imaging can depict both viable and nonviable myocardium, while 201Tl SPECT delineates only viable myocardium. Because of the high spatial resolution of MR images, the transmural extent of myocardial infarction can be delineated. However, because of the limited spatial resolution of SPECT images, regional tracer activity is usually expressed as a percentage of the activity measured in the normal reference region, and the criterion for viability is represented by a fixed threshold of regional tracer activity. Accordingly, regional tracer uptake can be influenced not only by the activity of the viable myocardium in the region of interest but also by the relative activity and wall thickness in the reference area. With contrast-enhanced MR imaging, regional myocardial viability is expressed as the transmural extent of hyperenhancement without use of the remote reference area. Thus, contrast-enhanced MR imaging can be used to predict myocardial viability more accurately than can resting 201Tl SPECT.

Study Limitations
Several potential limitations should be acknowledged in the present study. The number of patients was relatively small, and contrast-enhanced MR imaging and 201Tl SPECT were not performed the same day. The area with hyperenhancement on contrast-enhanced MR images may decrease from the acute phase to the subacute and chronic phases (23). Therefore, the area of nonviable myocardium can be slightly larger if contrast-enhanced MR images were acquired earlier after onset of myocardial infarction.

We did not use redistribution scanning during 201Tl SPECT. It was reported in early 1990s that delayed SPECT after resting 201Tl injection was useful for detecting myocardial viability (28,29). However, authors of several studies (14,19,30) demonstrated that initial resting SPECT images provided significantly equal or greater accuracy than did redistribution SPECT images in the prediction of myocardial viability after revascularization. The results of another study (31) also indicated that evaluation of the initial set of 201Tl SPECT images alone seems to be sufficient for the prediction of the effects of revascularization on regional systolic function at rest.

In conclusion, our study results demonstrated that delayed contrast-enhanced MR imaging can be used to predict functional recovery of regional myocardial contraction at follow-up cine MR imaging after acute myocardial infarction, with significantly improved sensitivity, specificity, and accuracy in comparison with those of resting 201Tl SPECT. Contrast-enhanced MR imaging is a method that can substitute for 201Tl SPECT in assessing myocardial viability in patients early after acute myocardial infarction.


   FOOTNOTES
 
Author contributions: Guarantors of integrity of entire study, K.K., H.S.; study concepts and design, K.K., H.S.; literature research, K.K.; clinical studies, K.K., S.O., K.M.; data acquisition, K.K., T.H.; data analysis/interpretation, K.K., H.S.; statistical analysis, K.K.; manuscript preparation, K.K.; manuscript definition of intellectual content and editing, K.K., H.S.; manuscript revision/review, T.H., K.T.; manuscript final version approval, H.S.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 

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D. J. Pennell, U. P. Sechtem, C. B. Higgins, W. J. Manning, G. M. Pohost, F. E. Rademakers, A. C. van Rossum, L. J. Shaw, and E. K. Yucel
Clinical indications for cardiovascular magnetic resonance (CMR): Consensus Panel report
Eur. Heart J., November 1, 2004; 25(21): 1940 - 1965.
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 J Am Coll CardiolHome page
R. J. Gibbons, U. S. Valeti, P. A. Araoz, and A. S. Jaffe
The quantification of infarct size
J. Am. Coll. Cardiol., October 19, 2004; 44(8): 1533 - 1542.
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 RadiologyHome page
M. Saeed, R. Lee, A. Martin, O. Weber, G. A. Krombach, S. Schalla, M. Lee, D. Saloner, and C. B. Higgins
Transendocardial Delivery of Extracellular Myocardial Markers by Using Combination X-ray/MR Fluoroscopic Guidance: Feasibility Study in Dogs
Radiology, June 1, 2004; 231(3): 689 - 696.
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