Assessment of left ventricular dysfunction by nuclear cardiology

Nuclear cardiology techniques may be of help in evaluating the patient with symptoms of congestive heart failure and ventricular dysfunction in two respects: quantification of functional parameters by radionuclide angiography, and differentiation of viable from nonviable myocardium by perfusion and metabolic imaging. Left ventricular ejection fraction and volumes can be accurately assessed by equilibrium radionuclide angiography with a count-based method without any geometric assumptions. Indeed, because of its high reproducibility, this method is particularly suited for making sequential measurements in the same patient. The distinction between viable or reversible and scarred or irreversible dysfunctional myocardium can be made on the basis of myocardial perfusion, cell membrane integrity, and metabolic activity. Thallium myocardial imaging is used clinically to assess the first two parameters based on experimental data. Two clinical methods may be applied to the detection of viability: stress-redistribution-reinjection imaging or rest-redistribution imaging. In both of these, the severity of the reduction in thallium activity should be assessed to discriminate viable from nonviable myocardium. Stress-redistribution-reinjection thallium imaging should be the first approach, if possible, because inducible ischemia is a much more significant clinical variable in a patient with ventricular dysfunction in terms of management and risk assessment than is knowledge of myocardial viability. Positron emission tomography (PET) provides enhanced image resolution and correction for body attenuation, thereby overcoming the two major limitations of thallium imaging. In addition, it provides the capacity to quantitate regional blood flow and to assess regional metabolic activity independent of flow. Overall, the accuracies of thallium imaging (around 70%) and PET imaging (around 82%) are similar for the prediction of segmental changes after revascularization. However, in patients with poor global left ventricular function, the accuracy of PET seems to be better. Further studies are needed in a large number of patients evaluated for regional and global function to establish algorithms using thallium and PET imaging in dysfunctional myocardium. Dobutamine echocardiography should also be evaluated in these algorithms