Tc-99m sestamibi single photon emission computed tomography for guiding percutaneous coronary intervention in patients with multivessel disease: a comparison with quantitative coronary angiography and fractional flow reserve

Abstract

To evaluate the accuracy of myocardial perfusion SPECT (MPI) in the detection and allocation of vessel specific perfusion defects (PD) using standard distribution territories in a routine clinical procedure of patients with multivessel disease (MVD). Combined quantitative coronary angiography and fractional flow reserve (QCA/FFR) measurements were used as invasive reference standard. 216 vessels in 72 MVD patients (67 +/- 10 years, 28 female) were investigated using MPI and QCA. FFR of 93 vessels with intermediate stenoses was determined. MPI detected significant stenoses according to QCA/FFR findings with a sensitivity of 85%. However, vessel-based evaluation using standard myocardial distribution territories delivered a sensitivity of only 62% (28 MPI+ out of 45 (QCA/FFR)+ findings), with specificity, PPV and NPV of 90, 62 and 90%. 7/17 false positive and 7/17 false negative findings (41%) could be attributed to incorrect allocation of reversible PD to their respective coronary arteries. 6/17 (35%) perfusion territories were classified as false negative when additional fixed PD were present. MPI had reasonable sensitivity for the detection of significant coronary artery disease in patients with multivessel disease. However, sensitivity decreased markedly, when the significance of each individual stenosis was evaluated using standard myocardial supplying territories. In this setting, 41% of false negative and false positive MPI findings resulted from incorrect allocation of reversible perfusion defects to their determining supplying vessel.

Cardiovascular imaging 2010 in the International Journal of Cardiovascular Imaging

“…Forster et al [33] evaluated the accuracy of myocardial SPECT imaging for the detection and allocation of vessel specific perfusion defects in patients with multivessel disease. They used standard distribution territories on SPECT imaging and compared this to FFR measurements in 93 vessels with intermediate stenosis in 72 patients with multivessel disease.…”

Absolute Quantification of Myocardial Perfusion

“…17 Particularly in patients with multivessel disease, the invasive FFR approach brings theoretical and practical advantages compared with SPECT because the hemodynamic relevance of a particular lesion is measured directly within the lumen of the diseased coronary vessel. 18 However, the present study notes potential limitations of the invasive reference standard. In particular, ICA/FFR in clinical practice gives accurate measurements only in proximal parts of the major coronary arteries, and arteries with high-grade stenoses are rarely accessible to the pressure wire.…”

“…With the growing availability of cyclotrons at clinical imaging centers, the former impediments to the widespread use of short-lived PET radioisotopes such as 13 N-ammonia and 15 O-water are becoming less of an issue. Moreover, the recent introduction of PET/CT hybrid scanners provides improved allocation of perfusion defects and has instigated the reintroduction of long-known agents, such as the generator product 82 Rb, as well as the implementation of newly developed 18 F-fluorine-labeled PET perfusion tracers. 11 Of all the SPECT/PET myocardial perfusion tracers, of which at least a dozen have been described to date, 15 O-water is considered the gold standard for noninvasive quantitative measurements of MBF because water is freely diffusible and has no metabolic interactions in tissue.…”

The validity of multi-center common normal database for identifying myocardial ischemia: Japanese Society of Nuclear Medicine working group database

“…Even in multi-vessel disease, the induced ischemia may not be detected in all of the stenotic artery territories [16,17]. Myocardial perfusion imaging has rather been used to identify the culprit lesion for ischemia in multiple stenotic lesions.…”