An Intravenous 100-mL Lipid Emulsion Infusion Dramatically Improves Myocardial Glucose Metabolism Extinction in Cardiac FDG PET Clinical Practice

Abstract

Purpose Physiological myocardial accumulation of FDG impairs the diagnosis of inflammatory/infectious or tumoral myocardial detection by FDG PET/CT. We prospectively evaluated the addition, 3 hours before imaging, of an intravenous 100-mL lipid emulsion infusion (Intralipid) to a high-fat, low-carbohydrate diet (HFLCD) for at least 2 meals followed by a fast of at least 6 to 12 hours in patients referred for the diagnosis of myocardial inflammation, endocarditis, cardiac or paracardiac masses, intracardiac device, or prosthetic valve infections. Methods Data of 58 patients consecutively included (28 Intralipid patients, 30 controls with HFLCD alone) were compared. FDG uptake in normal myocardium was scored from 0 (complete myocardial suppression) to 3 (high diffuse uptake). Myocardial maximal, peak, and mean SUV and the rate of interpretable images according to the clinical indication were measured. Results Compared with controls, Intralipid infusion significantly improved the rate of score 0 (89% vs 63%, P = 0.021), of interpretable images according to the clinical indication (100% vs 72%, P = 0.0047) and decreased all myocardial SUV values (eg, SUVmax median, 1.9 [interquartile range, 1.7–2.5] vs 3.1 [interquartile range, 2.3–4.1]; P < 0.001). Conclusions A lipid emulsion infusion in addition to HFLCD better suppresses cardiac glucose metabolism than HFLCD alone.

What Is the Optimal Method on Myocardial Suppression in FDG PET/CT Evaluation of Cardiac Sarcoidosis?

“…Recently, a group from Monaco prospectively enrolled 58 patients to evaluate the addition, 3 hours before imaging, of an intravenous 100-mL lipid emulsion infusion (Intralipid) to the SNMMI/ ASNC HFLC diet protocol for the diagnosis of myocardial inflammation, endocarditis, cardiac or paracardiac masses, intracardiac device, or prosthetic valve infections. 8 They found that a lipid emulsion infusion in addition to HFLC dietary preparation (n = 28) better suppresses cardiac glucose metabolism than HFLC die alone (n = 30). Furthermore, 1 patient had complete myocardial suppression with addition of Intralipid on follow-up FDG PET/CT, whereas the patient's 4 previous PET/CT scans with SNMMI/ASNC HFLC dietary preparation failed to suppress myocardial FDG uptake.…”

Extensive Biventricular Cardiac Sarcoidosis Detected on FDG PET/CT Using a 72-Hour Ketogenic Diet Preparation Protocol

“…Over the years, our group has published our experiences of using a 72-hour ketogenic diet, that is, a high-fat, high-protein, very low-carbohydrate diet; the preparation protocol for sarcoidosis patients receiving FDG PET/CT evaluation, with a simple interpretation algorithm, avoided the complex and debatable interpretation, as well as the controversy “focal-on-diffuse” pattern 2–7 . Our approach was also supported by other groups' findings 8,9 . As illustrated in this rare case of extensive biventricular CS, the 72-hour ketogenic diet preparation can satisfactorily suppress physiological myocardial uptake of FDG, and enable FDG PET/CT evaluation of CS.…”

“…[2][3][4][5][6][7] Our approach was also supported by other groups' findings. 8,9 As illustrated in this rare case of extensive biventricular CS, the 72-hour ketogenic diet preparation can satisfactorily suppress physiological myocardial uptake of FDG, and enable FDG PET/CT evaluation of CS.…”

The role of PET in the management of sarcoidosis

“…A ketogenic diet for 72 h combined with a 3-day overnight fast prior to PET/CT resulted in more complete myocardial suppression, less indeterminate scans, and higher agreement between PET/CT reviewers [ 14 ▪▪ ]. Intravenous lipid emulsion (100 ml) 3 h prior to PET/CT led to higher rates of complete myocardial suppression of FDG uptake as compared with controls [ 16 ▪▪ ]. The combination of intravenous heparin (50 IU/kg), low-carbohydrate diet, and 12-h fast demonstrated a higher rate of complete myocardial suppression compared with the same diet combination with lower doses of intravenous heparin (15 IU/kg) [ 17 ▪▪ ].…”