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The role of nuclear imaging in the failing heart: myocardial blood flow, sympathetic innervation, and future applications.

Boogers MJ, Fukushima K, Bengel FM, Bax JJ - Heart Fail Rev (2011)

Bottom Line: Currently, sympathetic nerve imaging with 123-iodine metaiodobenzylguanidine (123-I MIBG) is often used for the assessment of cardiac innervation.A large number of studies have shown that an abnormal myocardial sympathetic innervation, as assessed with 123-I MIBG imaging, is associated with increased mortality and morbidity rates in patients with heart failure.Also, cardiac 123-I MIBG imaging can be used to risk stratify patients for ventricular arrhythmias or sudden cardiac death.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands. j.m.j.boogers@lumc.nl

ABSTRACT
Heart failure represents a common disease affecting approximately 5 million patients in the United States. Several conditions play an important role in the development and progression of heart failure, including abnormalities in myocardial blood flow and sympathetic innervation. Nuclear imaging represents the only imaging modality with sufficient sensitivity to assess myocardial blood flow and sympathetic innervation of the failing heart. Although nuclear imaging with single-photon emission computed tomography (SPECT) is most commonly used for the evaluation of myocardial perfusion, positron emission tomography (PET) allows absolute quantification of myocardial blood flow beyond the assessment of relative myocardial perfusion. Both techniques can be used for evaluation of diagnosis, treatment options, and prognosis in heart failure patients. Besides myocardial blood flow, cardiac sympathetic innervation represents another important parameter in patients with heart failure. Currently, sympathetic nerve imaging with 123-iodine metaiodobenzylguanidine (123-I MIBG) is often used for the assessment of cardiac innervation. A large number of studies have shown that an abnormal myocardial sympathetic innervation, as assessed with 123-I MIBG imaging, is associated with increased mortality and morbidity rates in patients with heart failure. Also, cardiac 123-I MIBG imaging can be used to risk stratify patients for ventricular arrhythmias or sudden cardiac death. Furthermore, novel nuclear imaging techniques are being developed that may provide more detailed information for the detection of heart failure in an early phase as well as for monitoring the effects of new therapeutic interventions in patients with heart failure.

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Cardiac sympathetic nerve imaging with 123-iodine metaiodobenzylguanidine (123-I MIBG) can be used to assess global (panel A) and regional (panel B) sympathetic innervation in patients with heart failure. a Global reduction of 123-I MIBG uptake (sympathetic denervation) in a patient with advanced heart failure. The heart-to-mediastinum (H/M) ratio on late planar imaging was calculated by dividing the mean counts per pixel within the heart (H) by the mean counts per pixel within the upper mediastinum (M). In this example, the late H/M ratio was 1.31. b An example of regional abnormalities in sympathetic innervation is illustrated below (as indicated by regional defect in 123-I MIBG uptake, white arrow)
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Fig2: Cardiac sympathetic nerve imaging with 123-iodine metaiodobenzylguanidine (123-I MIBG) can be used to assess global (panel A) and regional (panel B) sympathetic innervation in patients with heart failure. a Global reduction of 123-I MIBG uptake (sympathetic denervation) in a patient with advanced heart failure. The heart-to-mediastinum (H/M) ratio on late planar imaging was calculated by dividing the mean counts per pixel within the heart (H) by the mean counts per pixel within the upper mediastinum (M). In this example, the late H/M ratio was 1.31. b An example of regional abnormalities in sympathetic innervation is illustrated below (as indicated by regional defect in 123-I MIBG uptake, white arrow)

Mentions: Scintigraphic assessment of cardiac sympathetic innervation and activation can be performed with the use of SPECT tracers [8, 30]. Currently, cardiac sympathetic neuronal imaging has been performed most commonly with radionuclide imaging of the norepinephrine analog metaiodobenzylguanidine (MIBG) labeled with 123-iodine (123-I) [31–33]. Over the last decades, it has been shown that 123-I MIBG represents a safe and reliable SPECT tracer that can be used to depict the sympathetic nerve system in patients with heart failure [31–35]. MIBG represents a false neurotransmitter that can be cleared from the sympathetic cleft by either the uptake-1 (neuronal) or uptake-2 (non-neuronal) mechanisms. Of note, a small amount of MIBG can also be transferred into sympathetic neurons or cardiomyocytes by means of passive diffusion [8, 30]. 123-I MIBG is suitable for non-invasive mapping of the sympathetic nervous system as it shows resistance to metabolic degradation by monoamine oxidase or catechol-o-methyl transferase within the sympathetic neuron, leading to enhanced accumulation of 123-I MIBG within storage vesicles of the neurons. At present, 123-I MIBG images are usually acquired with a two-step protocol at 10–20 min (early imaging) and 3–4 h (delayed imaging) after tracer administration [36]. Planar and SPECT imaging are performed in the early and late phase of the 123-I MIBG imaging protocol. Planar images are usually acquired from the left-anterior oblique view and provide information on global sympathetic innervation pattern (Fig. 2a), whereas tomographic images (SPECT imaging) are used to assess regional abnormalities in cardiac sympathetic innervation (Fig. 2b).Fig. 2


The role of nuclear imaging in the failing heart: myocardial blood flow, sympathetic innervation, and future applications.

Boogers MJ, Fukushima K, Bengel FM, Bax JJ - Heart Fail Rev (2011)

Cardiac sympathetic nerve imaging with 123-iodine metaiodobenzylguanidine (123-I MIBG) can be used to assess global (panel A) and regional (panel B) sympathetic innervation in patients with heart failure. a Global reduction of 123-I MIBG uptake (sympathetic denervation) in a patient with advanced heart failure. The heart-to-mediastinum (H/M) ratio on late planar imaging was calculated by dividing the mean counts per pixel within the heart (H) by the mean counts per pixel within the upper mediastinum (M). In this example, the late H/M ratio was 1.31. b An example of regional abnormalities in sympathetic innervation is illustrated below (as indicated by regional defect in 123-I MIBG uptake, white arrow)
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3118005&req=5

Fig2: Cardiac sympathetic nerve imaging with 123-iodine metaiodobenzylguanidine (123-I MIBG) can be used to assess global (panel A) and regional (panel B) sympathetic innervation in patients with heart failure. a Global reduction of 123-I MIBG uptake (sympathetic denervation) in a patient with advanced heart failure. The heart-to-mediastinum (H/M) ratio on late planar imaging was calculated by dividing the mean counts per pixel within the heart (H) by the mean counts per pixel within the upper mediastinum (M). In this example, the late H/M ratio was 1.31. b An example of regional abnormalities in sympathetic innervation is illustrated below (as indicated by regional defect in 123-I MIBG uptake, white arrow)
Mentions: Scintigraphic assessment of cardiac sympathetic innervation and activation can be performed with the use of SPECT tracers [8, 30]. Currently, cardiac sympathetic neuronal imaging has been performed most commonly with radionuclide imaging of the norepinephrine analog metaiodobenzylguanidine (MIBG) labeled with 123-iodine (123-I) [31–33]. Over the last decades, it has been shown that 123-I MIBG represents a safe and reliable SPECT tracer that can be used to depict the sympathetic nerve system in patients with heart failure [31–35]. MIBG represents a false neurotransmitter that can be cleared from the sympathetic cleft by either the uptake-1 (neuronal) or uptake-2 (non-neuronal) mechanisms. Of note, a small amount of MIBG can also be transferred into sympathetic neurons or cardiomyocytes by means of passive diffusion [8, 30]. 123-I MIBG is suitable for non-invasive mapping of the sympathetic nervous system as it shows resistance to metabolic degradation by monoamine oxidase or catechol-o-methyl transferase within the sympathetic neuron, leading to enhanced accumulation of 123-I MIBG within storage vesicles of the neurons. At present, 123-I MIBG images are usually acquired with a two-step protocol at 10–20 min (early imaging) and 3–4 h (delayed imaging) after tracer administration [36]. Planar and SPECT imaging are performed in the early and late phase of the 123-I MIBG imaging protocol. Planar images are usually acquired from the left-anterior oblique view and provide information on global sympathetic innervation pattern (Fig. 2a), whereas tomographic images (SPECT imaging) are used to assess regional abnormalities in cardiac sympathetic innervation (Fig. 2b).Fig. 2

Bottom Line: Currently, sympathetic nerve imaging with 123-iodine metaiodobenzylguanidine (123-I MIBG) is often used for the assessment of cardiac innervation.A large number of studies have shown that an abnormal myocardial sympathetic innervation, as assessed with 123-I MIBG imaging, is associated with increased mortality and morbidity rates in patients with heart failure.Also, cardiac 123-I MIBG imaging can be used to risk stratify patients for ventricular arrhythmias or sudden cardiac death.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands. j.m.j.boogers@lumc.nl

ABSTRACT
Heart failure represents a common disease affecting approximately 5 million patients in the United States. Several conditions play an important role in the development and progression of heart failure, including abnormalities in myocardial blood flow and sympathetic innervation. Nuclear imaging represents the only imaging modality with sufficient sensitivity to assess myocardial blood flow and sympathetic innervation of the failing heart. Although nuclear imaging with single-photon emission computed tomography (SPECT) is most commonly used for the evaluation of myocardial perfusion, positron emission tomography (PET) allows absolute quantification of myocardial blood flow beyond the assessment of relative myocardial perfusion. Both techniques can be used for evaluation of diagnosis, treatment options, and prognosis in heart failure patients. Besides myocardial blood flow, cardiac sympathetic innervation represents another important parameter in patients with heart failure. Currently, sympathetic nerve imaging with 123-iodine metaiodobenzylguanidine (123-I MIBG) is often used for the assessment of cardiac innervation. A large number of studies have shown that an abnormal myocardial sympathetic innervation, as assessed with 123-I MIBG imaging, is associated with increased mortality and morbidity rates in patients with heart failure. Also, cardiac 123-I MIBG imaging can be used to risk stratify patients for ventricular arrhythmias or sudden cardiac death. Furthermore, novel nuclear imaging techniques are being developed that may provide more detailed information for the detection of heart failure in an early phase as well as for monitoring the effects of new therapeutic interventions in patients with heart failure.

Show MeSH
Related in: MedlinePlus