title: Additive value of low-dose dobutamine to technetium-99m sestamibi-gated single-photon emission computed tomography for prediction of wall motion improvement in patients undergoing coronary artery bypass graft.
abstract: BACKGROUND
  The two most useful methods for myocardial viability assessment are perfusion imaging and dobutamine echocardiography.
  
  
  OBJECTIVE
  The present study investigated the additive value of a new method, dobutamine technetium 99m (99mTc)-sestamibi-gated single-photon emission computed tomography (SPECT), which combines these two modalities, to the prediction of wall motion improvement after revascularization.
  
  
  METHODS
  Fifty-five consecutive patients with ischemic cardiomyopathy, who were referred for viability evaluation, underwent resting and dobutamine (dose, 5-10 microkg/kg/min) gated SPECT with 99mTc-sestamibi. Of these patients, 36 underwent coronary artery bypass graft (CABG) within 1 month of the study and 32 had repeat resting gated SPECT within 1 year. Global and regional wall motion, wall thickness, and perfusion were simultaneously analyzed at rest and after dobutamine using the 20-segment model; the sestamibi uptake and wall motion response to dobutamine of each segment were rated quantitatively. Based on these findings, the segments were categorized as normal, viable, or nonviable. The predictive values for wall motion improvement were assessed by perfusion, using cutoffs of 50 and 60% of sestamibi uptake, and thereafter by the addition of dobutamine response in the segments that were rated nonviable.
  
  
  RESULTS
  Of the 1,080 myocardial segments studied, 906 (84%) had abnormal wall motion and were analyzed for viability. Concordance between perfusion and wall motion response to dobutamine was 60% with the 50% cutoff of sestamibi uptake, and increased to 65% with the 60% sestamibi cutoff (p < 0.04). The respective predictive values of wall motion improvement using the 50 and 60% cutoff points were as follows: sensitivity 93 and 70%, respectively, (p < 0.01); specificity 59 and 86% (p < 0.001), respectively; accuracy 77% for both. The addition of the wall motion response to dobutamine to the assessment of the nonviable segments by perfusion (60% cutoff) increased the sensitivity from 70 to 85% (p = 0.001) and the negative predictive value from 70 to 81% (p = 0.009); the positive predictive value remained high (86 vs. 82%). No additive value of wall motion response to dobutamine was demonstrated for nonviable segments by perfusion with a 50% cutoff.
  
  
  CONCLUSIONS
  Dobutamine sestamibi-gated SPECT is a feasible method for the analysis of myocardial perfusion, function, and contractile reserve of individual myocardial segments in patients with ischemic cardiomyopathy. Viability assessment based on a threshold of 60% uptake of sestamibi, with the addition of the wall motion response to dobutamine in the nonviable segments, seems to yield better predictive values for wall motion improvement after CABG.
authors.affiliation: Nuclear Cardiology Unit, Department of Cardiology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. zafrirmd@isdn.net.il
authors.forename: Nili
authors.initials: N
authors.lastname: Zafrir
authors.forename: Alexander
authors.initials: A
authors.lastname: Arditi
authors.forename: Tuvia
authors.initials: T
authors.lastname: Ben-Gal
authors.forename: Alejandro
authors.initials: A
authors.lastname: Solodky
authors.forename: Yosef
authors.initials: Y
authors.lastname: Hassid
authors.forename: Jaqueline
authors.initials: J
authors.lastname: Sulkes
authors.forename: Alexander
authors.initials: A
authors.lastname: Battler
mesh_terms: D000368:Aged; D001794:Blood Pressure; D002316:Cardiotonic Agents / Q000008:administration & dosage*; D001026:Coronary Artery Bypass; D004280:Dobutamine / Q000008:administration & dosage*; D005240:Feasibility Studies; D005260:Female; D006339:Heart Rate; D006801:Humans; D008297:Male; D008875:Middle Aged; D009200:Myocardial Contraction; D011237:Predictive Value of Tests; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon; D016277:Ventricular Function, Left
chemical_list: D002316:Cardiotonic Agents; D019275:Radiopharmaceuticals; D004280:Dobutamine; D017256:Technetium Tc 99m Sestamibi