123I-MIBG Scintigraphy Research Articles

Phenotype of SDHB mutation carriers in the Netherlands.

SDHB mutation carriers are predisposed to developing paragangliomas (PGLs). The objective of this study was to assess genotype-phenotype correlations of a Dutch cohort of SDHB mutation carriers and assess potential differences in clinical phenotypes related to specific SDHB founder mutations. Forty-seven consecutive SDHB mutation carriers were included. Initial screening consisted of measurement of 24 h urinary excretion of catecholamines and their metabolites in duplicate, repeated annually if initial biochemical screening was negative. Whole-body imaging studies with magnetic resonance imaging (MRI) or computed tomography (CT) and/or (123)I-MIBG scintigraphy were performed in case of catecholamine excess, and MRI or CT scans of thorax, abdomen and pelvis were performed every 2 years regardless of catecholamine levels. Repetitive head-and-neck MRI was performed at 2 year intervals. Mean follow-up was 3.6 ± 3.6 years. Twenty-seven persons (57 %) carried the SDHB c.423+1 G>A mutation and seven persons (15 %) the SDHB c.201-4429_287-933del (exon 3 deletion) mutation. No differences were found in the clinical phenotype of carriers of these two specific SDHB mutations. By end of follow-up, 49 % of SDHB mutation carriers displayed no biochemical or radiological evidence of manifest disease, i.e. they were unaffected carriers. Three persons (6 %) had been diagnosed with a pheochromocytoma (PCC), four with a sympathetic PGL (sPGL) (9 %), 18 with a HNPGL (38 %), and two persons (4 %) had developed a malignant paraganglioma, i.e. metastatic disease. In conclusion, the two main Dutch SDHB founder mutations do not differ in clinical expression and result in a relatively mild phenotype. Over one-third of SDHB mutation carriers develop HNPGL, with sPGL/PCC in only 15 % and malignancy in only 4 %.

Nuclear medicine in the management of patients with heart failure: guidance from an expert panel of the International Atomic Energy Agency (IAEA).

Heart failure is increasing worldwide at epidemic proportions, resulting in considerable disability, mortality, and increase in healthcare costs. Gated myocardial perfusion single photon emission computed tomography or PET imaging is the most prominent imaging modality capable of providing information on global and regional ventricular function, the presence of intraventricular synchronism, myocardial perfusion, and viability on the same test. In addition, 123I-mIBG scintigraphy is the only imaging technique approved by various regulatory agencies able to provide information regarding the adrenergic function of the heart. Therefore, both myocardial perfusion and adrenergic imaging are useful tools in the workup and management of heart failure patients. This guide is intended to reinforce the information on the use of nuclear cardiology techniques for the assessment of heart failure and associated myocardial disease.

Should every patient diagnosed with a phaeochromocytoma have a ¹²³ I-MIBG scintigraphy?

Localization of phaeochromocytomas and paragangliomas (PPGLs) should involve functional imaging as anatomical imaging modalities can either fail to locate the tumour or can be suboptimal due to an anatomical abnormality or previous surgery. Functional imaging is particularly useful to fully delineate the extent of disease using the whole-body scan and the evaluation of multifocality, metastatic or recurrent disease. An increasing number of radiolabeled tracers have become available for tumour visualization during the past decade. (123) I-meta-iodobenzylguanidine scintigraphy is the most widely used functional imaging modality, and its sensitivity to identify chromaffin cell tumours varies from 85 to 88% for phaeochromocytomas and 56-76% for paragangliomas, while specificity ranges between 70 and 100% and 84-100%, respectively.

Combination of 123I-metaiodobenzylguanidine scintigraphy and flow-mediated dilation for the detection of patients with coronary spastic angina

BackgroundThis study evaluated the usefulness of cardiac sympathetic nerve activity, estimated by 123I-MIBG scintigraphy, and endothelial function, estimated by flow-mediated dilation (FMD), in the detection of coronary spastic angina (CSA). Methods and resultsWe compared 78 consecutive patients suspected of CSA with ten age-matched controls. On the basis of a spasm provocation test with acetylcholine, 53 patients were diagnosed as CSA and 25 patients were considered to have chest-pain syndrome (CPS). The total defect score (TDS) by delayed 123I-MIBG scintigraphy was significantly higher in both patient groups than in controls (P < 0.05), and was significantly higher in CSA than in CPS patients (P = 0.02). The heart/mediastinum activity (H/M) ratio by delayed 123I-MIBG scintigraphy and FMD were significantly lower in both patient groups than in controls (P < 0.05), and were lower in CSA than in CPS patients (P = 0.04). In receiver-operating curve analysis, the areas under the curve for TDS, H/M, and FMD were 0.78, 0.72, and 0.70, respectively. The combination of delayed 123I-MIBG scintigraphy and FMD showed a higher diagnostic value than either method alone. Conclusions123I-MIBG scintigraphy and FMD can distinguish CSA patients among patients complaining of chest pain at rest, with good sensitivity and specificity.

Regional heterogeneity in cardiac sympathetic innervation in acute myocardial infarction: relationship with myocardial oedema on magnetic resonance.

To assess the relationships between myocardial structure and function on cardiac magnetic resonance (CMR) imaging and sympathetic tone on (123)I-metaiodobenzylguanidine ((123)I-MIBG) scintigraphy early after myocardial infarction (MI). Ten patients underwent (123)I-MIBG and (99m)Tc-tetrofosmin rest cadmium zinc telluride scintigraphy 4 ± 1 days after MI. The segmental left ventricular (LV) relative radiotracer uptake of both (99m)Tc-tetrofosmin and early (123)I-MIBG was calculated. The day after scintigraphy, on CMR imaging, the extent of ischaemia-related oedema and of myocardial fibrosis (late gadolinium enhancement, LGE) was assessed. Accordingly, the extent of oedema and LGE was evaluated for each segment and segmental wall thickening determined. Based on LGE distribution, LV segments were categorized as "infarcted" (56 segments), "adjacent" (66 segments) or "remote" (48 segments). Infarcted segments showed a more depressed systolic wall thickening and greater extent of oedema than adjacent segments (p < 0.001) and remote segments (p < 0.001). Interestingly, while uptake of (99m)Tc-tetrofosmin was significantly depressed only in infarcted segments (p < 0.001 vs. both adjacent and remote segments), uptake of (123)I-MIBG was impaired not only in infarcted segments (p < 0.001 vs. remote) but also in adjacent segments (p = 0.024 vs. remote segments). At the regional level, after correction for (99m)Tc-tetrofosmin and LGE distribution, segmental (123)I-MIBG uptake (p < 0.001) remained an independent predictor of ischaemia-related oedema. After acute MI the regional impairment of sympathetic tone extends beyond the area of altered myocardial perfusion and is associated with myocardial oedema.

The potential role of pretransplant MIBG diagnostic scintigraphy in targeted administration of 131I-MIBG accompanied by ASCT for high-risk and relapsed neuroblastoma: a pilot study.

MIBG is an effective component in treatment of neuroblastoma. Furthermore, MIBG scintigraphy is an imaging modality in primary assessments. None of the previous studies have evaluated the role of pretransplant MIBG scintigraphy in decision making for neuroblastoma treatment. We selected therapeutic regimen based on pretransplant (131) I-MIBG scintigraphy. Twenty high-risk patients were enrolled. On day -30, patients underwent diagnostic MIBG scintigraphy. Patients were then subdivided into two groups (10 cases in each arm). MIBG-avid subgroup received MIBG (12 mCi/kg), etoposide (1200 mg/m2), carboplatin (1500 mg/m2), and melphalan (210 mg/m2). Non-MIBG-avid subgroup received etoposide (600 mg/m2), carboplatin (1200 mg/m2), and melphalan (150 mg/m2). Patients received CRA after ASCT. Mean age at diagnosis was 42.5 months (range, 17-65) in MIBG-avid and 38.9 months (range, 18-65) in non-MIBG-avid patients. Mean age at diagnosis and transplantation did not reveal significant difference between two subgroups. In MIBG-avid patients, the three-yr OS was 66 ± 21%. In MIBG-non-avid subgroup, the three-yr OS was 53 ± 20%. In MIBG-avid and non-MIBG-avid subgroups, the three-yr EFS were 66 ± 21% and 47 ± 19%, respectively. These findings may suggest an effective role in selecting the therapeutic strategy for pre-ASCT MIBG scintigraphy in high-risk neuroblastoma. MIBG-avid subset may benefit from the combination of therapeutic MIBG and high dose of chemotherapy.

For what endpoint does myocardial 123I-MIBG scintigraphy have the greatest prognostic value in patients with chronic heart failure? Results of a pooled individual patient data meta-analysis

The purpose of this study was to determine the most appropriate prognostic endpoint for myocardial (123)I-metaiodobenzylguanidine (MIBG) scintigraphy in patients with chronic heart failure (CHF) based on aggregate results from multiple studies published in the past decade. Original individual late (3-5 h) heart/mediastinum (H/M) ratio data of 636 CHF patients were retrieved from six studies from Europe and the USA. All-cause mortality, cardiac mortality, arrhythmic events, and heart transplantation were investigated to determine which provided the strongest prognostic significance for the MIBG imaging data. The majority of patients was male (78%), had a decreased left ventricular ejection fraction (31.1 ± 12.5%), and a mean late H/M of 1.67 ± 0.47. During follow-up (mean 36.9 ± 20.1 months), there were 83 deaths, 67 cardiac deaths, 33 arrhythmic events, and 56 heart transplants. In univariate regression analysis, late H/M was a significant predictor of all event categories, but lowest hazard ratios (HRs) were for the composite endpoint of any event (HR = 0.30, 95% CI 0.19-0.46), all-cause (HR = 0.29, 95% CI 0.16-0.53), and cardiac mortality (HR = 0.28, 95% CI 0.14-0.55). In multivariate analysis, late H/M was an independent predictor for all event categories, except for arrhythmias. This pooled individual patient data meta-analysis showed that, in CHF patients, the late H/M ratio is not only useful as a dichotomous predictor of events (high vs. low risk), but also has prognostic implication over the full range of the outcome value for all event categories except arrhythmias.

Cardiac 131I-MIBG scintigraphy in patients with multiple system atrophy

Background 131 I-metaiodobenzylguanidine ( 131 I-MIBG) can be intaked by cardiac sympathetic postganglionic fibre, thus becomes the imaging agent to evaluate cardiac sympathetic nerve function. The aim of this study is to investigate the autonomic nerve dysfunction of patients with multiple system atrophy (MSA) by using cardiac 131 I-MIBG scintigraphy. Methods Clinical data of 12 patients conforming to the secord consensus statement on the diagnosis of MSA was analyzed by Unified Multiple System Atrophy Rating Scale (UMSARS). 131 I-MIBG scintigraphy was performed in 12 patients and 7 age-matched controls. Planar images of the chest were obtained 15 min, 4 h and 24 h after the intravenous injection of 3 mCi 13 131 I-MIBG. Cardiac 131 I-MIBG uptake was quantified by comparing region of interest (ROI) over heart/mediastinum (H/M) ratio. Results Cardiac 131 131 I-MIBG uptake ratio in group was significantly less than that in control group in 15 min (1.90 ± 0.41 vs 2.38 ± 0.32, P = 0.017) and 4 h (1.96 ± 0.63 vs 2.60 ± 0.55, P = 0.039). There were significant difference ( P < 0.05) between group and control group. Conclusions Cardiac 131 I-MIBG uptake ratio in group was less than that in control group. This finding suggests cardiac sympathetic degeneration may occur in patients. doi: 10.3969/j.issn.1672-6731.2014.03.018

(18)F-FDG-PET/CT, (123)I-MIBG and (99m)Tc-MDP whole-body scans, in detecting recurrence of an adult adrenal neuroblastoma.

Neuroblastoma is the most common extracranial solid malignancy in children, but is rare in adults. We report the case of a 33 year old man with recurrence of neuroblastoma, 2 years after the excision of the primary tumor in the right adrenal gland. The iodine-123-radioiodinated metaiodobenzylguanidine ((123)I-MIBG) and (99m)Tc-methylene diphosphonate ((99m)Tc-MDP) bone scans and the fluorine-18-fluorodeoxyglucose-positron computed tomography ((18)F-FDG PET/CT) findings in this patient are presented. First, we applied (123)I-MIBG scintigraphy that detected increased uptake at the right adrenal gland region and probably at liver lesions and in several bones. Then, the (99m)Tc-MDP bone scan revealed also increased uptake of the radiopharmaceutical in bones, but there was a discrepancy between these two studies concerning the number and location of the lesions. Then, (18)F-FDG PET/CT scan was performed, which showed increased uptake of (18)F-FDG at the right adrenal gland region with extension to the liver and also in multiple bones. Additionally, an aortocaval lymph node was detected. In conclusion, this case indicated that (18)F-FDG PET/CT has defined the extent of the recurrence of neuroblastoma in a better way than (123)I-MIBG and (99m)Tc-MDP together.

Impairment of cardiac metabolism and sympathetic innervation after aneurysmal subarachnoid hemorrhage: a nuclear medicine imaging study.

IntroductionAlthough aneurysmal subarachnoid hemorrhage (SAH) is often complicated by myocardial injury, whether this neurogenic cardiomyopathy is associated with the modification of cardiac metabolism is unknown. This study sought to explore, by positron emission tomography/computed tomography, the presence of altered cardiac glucose metabolism after SAH.MethodsDuring a 16-month period, 30 SAH acute phase patients underwent myocardial 18 F- fluorodesoxyglucose positron emission tomography (18F-FDGPET), 99mTc-tetrofosmin and 123I-meta-iodobenzylguanidine (123I-mIBG) scintigraphy, respectively, assessing glucose metabolism, cardiac perfusion, and sympathetic innervation. Patients with initial abnormalities were followed monthly for two months for 18F-FDG, and six months later for 123I-mIBG.ResultsIn this SAH population, acute cardiac metabolic disturbance was observed in 83% of patients (n = 25), and sympathetic innervation disturbance affected 90% (n = 27). Myocardial perfusion was normal for all patients. The topography and extent of metabolic defects and innervation abnormalities largely overlapped. Follow-up showed rapid improvement of glucose metabolism in one or two months. Normalization of sympathetic innervation was slower; only 27% of patients (n = 8) exhibited normal 123I-mIBG scintigraphy after six months. Presence of initial altered cardiac metabolism was not associated with more unfavorable cardiac or neurological outcomes.ConclusionsThese findings support the hypothesis of neurogenic myocardial stunning after SAH. In hemodynamically stable acute phase SAH patients, cardiomyopathy is characterized by diffuse and heterogeneous 18F-FDG and 123I-mIBG uptake defect.Trial registrationClinicaltrials.gov NCT01218191. Registered 6 October 2010.

Peripheral Autonomic Nervous System Involvement in Gaucher-Related Parkinsonism

The pathological process affects the peripheral autonomic nervous system in the vast majority of sporadic PD patients. Recent reports have shown that patients with a familial form of the disease caused by mutation of the gene encoding LRRK2 and alpha-synuclein also display autonomic abnormalities, especially cardiac sympathetic denervation. In the present report, we have studied the involvement of the peripheral autonomic system in a patient with Gaucher disease-associated parkinsonism. Using colonic biopsies and quantitative 123I-MIBG scintigraphy respectively, we show that both Lewy pathology and cardiac denervation were present in this case of Gaucher-associated Parkinsonism. We discuss the consequence of these findings on the pathophysiology of the disease.

How do neurological and psychiatric signs and symptoms which are indicative of lewy body disease appear in apparent idiopathic rem sleep behavior disorder? – A descriptive study in the clinical setting

Introduction There has been accumulating evidence that idiopathic RBD (iRBD) could be pre-motor or pre-dementing state of Levy body disease (LBD) (Parkinson’s disease (PD) and dementia with Lewy bodies). Since the transition from apparent iRBD to full-blown LBD is considered gradual development, various symptoms and signs could appear in this process. This observational study outlines when and how neurological and psychiatric signs and symptoms appeared in our patients with apparent iRBD. Materials and methods We retrospectively reviewed the sleep clinic records of consecutive 19 polysomnographically confirmed iRBD patients who made the first consultation from December 2005 to December 2009 with successful continual follow-up period (once per 1–3 months) up to June 2013. One patient who had end-stage renal disease under hemodialysis was excluded. 18 patients (15 men and 3 women, 66.4 ± 6.5 years of age at the first clinic visit, 71.7 ± 6.6 at the last clinic visit) were analyzed. 16 out of the18 patients underwent myocardial 123I-MIBG scintigraphy within two months from the first clinic visit, the result of which was taken into consideration whether it helps to predict the later development into LBD. Results The follow-up duration was 5.2 ± 1.2 years (range 3.5–7.5). The onset age of iRBD was 59.8 ± 6.9 years old and the duration from the onset to the first clinic visit was 6.6 ± 4.7 years (range 2–19), therefore, our patients have been suffering from RBD for 11.8 ± 5.3 years (range 6.5–26). Seven out of 18 patients (38.9%) showed muscle rigidity at the 7.8 ± 4.6 years from the onset of iRBD, and 2 of them fulfilled the British Brain Bank Criteria of PD at 4.2 years and 1 year respectively after the appearance of rigidity. About the remaining 5 patients with muscle rigidity, 4 of them also showed other symptoms (temporary depressive episodes in 2, mild cognitive impairment in 1, and episodic decreased activity [bedridden all day] continuing a few weeks in 1. All of the 7 patients with rigidity had showed decreased 123I-MIBG uptake. One patient is overall anxious with the past depressive episode (after the onset of RBD), and one started to experience visual hallucination at night which was clearly differentiated from RBD behaviors. Eight out of 18 patients (44.4%) still remained as apparent iRBD at 12.0 ± 4.0 years after the onset of iRBD, however, 7 patients of this group had 123I-MIBG scintigraphy and all but one had showed decreased uptake. The last one patient revealed to be possible multiple system atrophy, of whom 123I-MIBG uptake was within normal limits. In this woman, mild cerebellar signs appeared at the 3.6 years from the onset of iRBD and it took another 2.3 years to have this diagnosis. Conclusion Our results strongly support that iRBD is a predictor of LBD, but neurological and psychiatric signs and symptoms in iRBD which are indicative of LBD seem to appear in a long time span with various severities and combinations. It is still difficult to expect when and what will be overt in the daily clinical settings. Acknowledgement We thank Keiichi Marumoto and Youko Uozumi for their technical support for performing PSG.

Spotlight on the November 12 Issue

The authors examined 94 patients with possible dementia with Lewy bodies based on established consensus criteria. 123I-MIBG myocardial scintigraphy was a good predictor of the future conversion of possible to probable dementia with Lewy bodies. See p. 1741 From editorialists Ballard & Grimmer: “Independent validation, including blinding of diagnosing clinicians with regards to the 123 I-MIBG results, is needed for a potential diagnostic test; optimal cutoffs may overestimate the magnitude of diagnostic discrimination.” See p. 1730 The authors investigated blood glucose markers, memory, and …

Milnacipran influences the indexes of I-metaiodobenzylguanidine scintigraphy in elderly depressed patients.

This study investigated whether or not and how much milnacipran influences the indexes of I-metaiodobenzylguanidine (I-MIBG) scintigraphy, early heart-to-mediastinum (H/M) ratio, delayed H/M ratio, and wash-out rate. Six elderly depressed patients participated in the study. All six patients met the diagnostic criteria for a major depressive disorder. They were taking milnacipran for their depression. They needed differential diagnosis for Lewy body diseases due to their symptomatology. I-MIBG scintigraphy was performed twice for each subject, once under prescription of milnacipran and the other without prescription of milnacipran. Both early and delayed phase H/M ratio were significantly lower when taking milnacipran (early phase H/M ratio, P < 0.01, Cohen's d 1.62; delayed phase H/M ratio, P < 0.005, Cohen's d 1.98) than when not taking the drug. Wash-out rate (%) was significantly higher when taking milnacipran (P < 0.05, Cohen's d 2.31) than when off the drug. Taking milnacipran substantially influences the indexes of I-MIBG scintigraphy, indicating that taking the drug possibly causes a false-positive result for Lewy body diseases diagnosis.

Letter by Minutoli et al Regarding Article, “Reduced Myocardial 123-Iodine Meta-Iodobenzylguanidine Uptake: A Prognostic Marker in Familial Amyloid Polyneuropathy”

We read with great interest the study of Azevedo Coutinho et al1 evaluating the prognostic value of 123Iodine Meta-iodobenzylguanidine (123I-MIBG) scintigraphy in patients with transthyretin (TTR) familial amyloid polyneuropathy (FAP). The authors evaluated 143 patients with TTR-FAP comparing time to all-cause death with late heart-to-mediastinum MIBG uptake ratio (H/M). Median follow-up was 5.5 years. Of 143 patients, 32 (22%) patients died. Five-year mortality rate was 42% and 7.4% for patients with late H/M <1.60 (the estimated lower limit of normal) and H/M ≥1.60, respectively, reaching a high statistical significance (hazard ratio, 7.19; P <0.001). Late …

Impact diagnostique de l’imagerie hybride TEMP/TDM dans la prise en charge des neuroblastomes. Expérience du service de médecine nucléaire du CHU Mohammed VI de Marrakech

IntroductionThe neuroblastoma is a malignant pediatric tumor of the peripheral sympathetic nervous system. This is the pediatric solid extracranial tumor most common and accounts for approximately 8 to 10% of childhood cancers. The diagnosis is based on imaging showing a tumor developed at the expense of the sympathetic nervous system, increased urinary catecholamines, increased uptake of meta-iodo-benzylguanidine (MIBG) and histology who finds a malignant proliferation of small round cells. An assessment of the tumor mass and its extension are required to assess the prognosis and adapt the treatment. The MIBG scintigraphy is a non-invasive imaging technique that can evaluate with a single review the totality of the tumor extension. The single-photon emission computed tomography/computed tomography (SPECT/CT) improves the sensitivity of the examination, it allows an anatomical and functional study and improves the anatomical localization of scintigraphic uptake observed. The purpose of our work is to illustrate the contribution of the SPECT/CT in addition to the planar MIBG scintigraphy in the diagnosis and staging of neuroblastoma about four cases. Case reportClinical case 1: a 4-year old child, presented for 2months abdominal pain. In the clinical examination, he presented a hard abdominal mass, painless and right paramedian. Abdominal ultrasound showed a right retroperitoneal mass with lymph nodes. The dosage of urinary catecholamines was increased. The 131I-MIBG scintigraphy showed an image for a right adrenal neuroblastoma measuring 8.6×4.5cm. Surgical excision of the adrenal mass revealed in the anatomopathologic study a malignant tumoral proliferation with round cells compatible with a neuroblastoma. Clinical case 2: a 10-month old infant, presented since 15 days an exophtalmia with poor general status. The clinical examination showed a right abdominal mass and a bilateral periorbital ecchymosis. The radiography of the thorax showed a widening mediastinal. Abdominal echography showed a tissular mass of the right adrenal gland with retroperitoneal lymph nodes and an ascites. The dosage of urinary catecholamines was increased. The 131I-MIBG scintigraphy showed a right adrenal neuroblastoma measuring 6.4×2.7cm with orbital bone metastases in favor of a Hutchinson syndrome. Clinical case 3: a 2-month old infant, followed since 1month for bilateral adrenal neuroblastoma. The clinical examination showed an important abdominal distension with bluish nodules under skin. The abdominal echography and the abdomino-pelvic TDM showed two adrenal masses corresponding to a bilateral neuroblastoma with liver metastases. The 131I-MIBG scintigraphy showed two adrenal masses measuring respectively 6.5×3.4cm and 8×6cm, with liver and skin metastases in favor of 4S neuroblastoma with bilateral adrenal tumors. Clinical case 4: a 3-year old child, followed for left adrenal neuroblastoma with multiple bone metastases. The clinical examination showed a left abdominal mass with exophtalmia and right palpebral ecchymosis. The radiography of the thorax showed a widening of the mediastin with repression of the paravertebral right line. Abdominal echography showed a left retroperitoneal tissular mass measuring 9.2×5.2cm. The abdomino-pelvic TDM showed a left adrenal tumor with lumbar vertebral bone metastases. A first 131I-MIBG scan showed a left neuroblastoma with multiple bone metastases in the right orbit, the right humerus, the occipital bone, the right scapula and spine (D10, D11, L1, L3, S1). The child was treated by 5 courses of chemotherapy (protocol HRNLB/10). The 131I-MIBG scan control showed a regression of neuroblastoma size (1.4×1.2cm) with loss of bone metastases of the occipital bone, the right scapula and spine. DiscussionThe MIBG scintigraphy is a simple, non-invasive examination that has excellent sensitivity and specificity in detection of neuroblastoma and especially in invasion bone marrow and in evaluation of the therapeutic response. The hybrid SPECT/CT imaging improve the performance of the scintigraphy as well in sensibility, toward the deep localization, as in specificity for images poorly defined in planar imaging.

Effects of oral nicorandil therapy on sympathetic nerve activity and cardiac events in patients with chronic heart failure: subanalysis of our previous report using propensity score matching

Nicorandil, an adenosine triphosphate-sensitive potassium channel opener, improves cardiac sympathetic nerve activity (CSNA) in patients with ischaemic heart disease. However, the long-term effects on both CSNA, as evaluated by (123)I-metaiodobenzylguanidine (MIBG) scintigraphy, and prognosis have not been determined in patients with chronic heart failure (CHF). This study was a subanalysis of our previous results that serial (123)I-MIBG scintigraphic studies are the most useful prognostic indicator in CHF patients. The study group comprised 208 patients with CHF (left ventricular ejection fraction <45 %) but no cardiac events for at least 5 months identified on the basis of a history of decompensated acute heart failure requiring hospitalization. These patients underwent (123)I-MIBG scintigraphy and echocardiography just before leaving the hospital and again 6 months later. We selected 170 patients and used propensity propensity score matching to compare patients who received oral nicorandil (85 patients) and those who did not (85 patients). The patients were followed up for a median of 5.03 years, with the primary and secondary study end-points defined as the occurrence of a fatal cardiac event and a major adverse cardiac event (MACE), respectively. After treatment, the extent of changes in (123)I-MIBG scintigraphic and echocardiographic parameters in the nicorandil group were more favourable than in those not receiving nicorandil. Of the 170 patients, a fatal cardiac event occurred in 42, and a MACE in 68 during the study. Multivariate Cox regression analyses revealed that no nicorandil treatment was a significant predictor of both cardiac death and MACE in our patients with CHF. On Kaplan-Meier analysis, the rates of freedom from cardiac death or from MACE in the nicorandil group were significantly higher than in those not receiving nicorandil (all p<0.05). Long-term nicorandil treatment improves CSNA and left ventricular parameters in patients with CHF. Furthermore, this agent is potentially effective for reducing the incidence of cardiac events in patients with CHF.

Can 123 I-MIBG cardiac scintigraphy predict functional recovery in heart failure after cardiac resynchronization?

Background: Cardiac heart failure patients may benefit from cardiac resynchronization, but around 30% do not respond. Several parameters have been studied to evaluate possible positive predictive factors. Aim: To evaluate if baseline 123 I-MIBG cardiac scintigraphy parameters can predict functional capacity modification after cardiac resynchronization (CRT), assessed by cardiopulmonary testing, in patients (P) with chronic heart failure (CHF). Methods: We prospectively assessed 49 consecutive CHF P referred to CRT, mean age 68±14 (34-82 years old), 68% male, LVEF<35%; 28% ischemic cardiomyopathy P and 72% nonischemic cardiomyopathy P; 37% diabetic P; 43% P class III and 57%≤ class II (NYHA). All patients underwent, before CRT and 6 months post-CRT, echocardiogram for left ventricular ejection fraction (LVEF), cardiopulmonary testing, CPT, for peak oxygen consumption (VO2p), and 123 I-MIBG cardiac scintigraphy, for early heart-mediastinum rate (HMR), late HMR and washout (WO). Results: Our preliminary results showed, mean LVEF 27±8%; VO2p mean value 14.8±5.5 ml/kg/min. Regarding 123 I-MIBG scintigraphy parameters, we found early HMR mean value 1.5±0.17 (75% P with early HMR < 1.6); late HMR mean value 1.4+/0.16, (94% P with late HMR<1.6); washout (WO) mean value 41±27. VO2 change after CRT at 6 months was positive in 68% of the P (mean variation +4.3+/2.7 ml/kg/min), group A, and negative in 32% of the P (mean variation -3.4+/2.3), group B. There was a very significant difference between VO2 variation in group A and B (p 1.6 (100%) had a positive VO2 variation (group A); P with baseline early HMR <1.6, had negative VO2 variation in 60% (group B) and positive in 40% (group A).Considering early HMR<1.5, 88% P had negative VO2 variation (group B). No significant differences were found in the late HMR, WO and LVEF. Conclusion: In this heart failure patients group, ischemic and nonischemic, baseline MIBG early heart-mediastinum rate was predictive of functional capacity modification: early HMR superior to 1.6 was always associated to VO2 increase after CRT (100% P); contrarly, early HMR inferior to 1.5 was mostly associated to VO2 decrease (88% P).

Catecholamine-induced stress cardiomyopathies: More similarities than differences

We read with great interest the recent paper by Mikail et al. [1] reporting the case of a 52-year-old man with pheochromocytoma who presented to the emergency room with a clinical picture mimicking Non-ST Elevation Acute Myocardial Infarction. Diagnostic work-up had revealed normal coronary arteries and a right adrenal mass with intense tracer uptake at metaiodobenzylguanidine (131I-MIBG) scintigraphy. The final diagnosis was Takotsubo-like (TTL) syndrome, with a cardiac scintigraphic pattern of severe defects at 131I-MIBG and normal perfusion at 99mTc-tetrofosmin.

123I-MIBG, 18F-DOPA y 18F-FDG en una paciente con síndrome de neoplasia endocrina múltiple tipo 2 y recidiva de feocromocitoma

Pheochromocytoma is a rare tumor located in the medulla of the adrenal gland that is characterized by high catecholamine synthesis. Surgery is the treatment of choice and is usually curative if appropriately diagnosed and excised. Imaging methods, both morphological and functional, are of great importance in presurgical evaluation. We report the case of a female patient with multiple endocrine neoplasia syndrome type 2, with bilateral adrenalectomy due to two pheochromocytomas and progressive elevation of urinary metanephrine. Magnetic resonance imaging showed a nodular image in the right adrenal fossa. The patient was referred to our unit in order to confirm suspicion of recurrence. Due to the absence of pathological findings in the (123)I-MIBG scintigraphy and high suspicion of recurrence, PET/CT imaging with (18)F-DOPA and (18)F-FDG were performed, and the diagnosis was confirmed.