Technetium-99m Sestamibi Research Articles

Ectopic pyriform sinus parathyroid adenoma

To describe the diagnosis and treatment of ectopic pyriform sinus parathyroid adenoma. A 44-year-old woman presented with persistent primary hyperparathyroidism after previous failed cervical exploratory surgery. Diagnosis of ectopic pyriform sinus parathyroid adenoma was suggested by computed tomography and technetium-99m sestamibi scintigraphy (99mTc-MIBI SPECT/CT). A submucosal tumor was identified under laryngoscopy and resected by endoscopic CO2 laser. Histopathology confirmed the diagnosis of parathyroid adenoma. Ectopic pyriform sinus locations are rare in parathyroid adenoma. 99mTc-MIBI SPECT/CT facilitates diagnosis, especially in case of previous failed neck exploration. Endoscopic CO2 laser resection is the treatment of choice.

Parathyroid Adenoma in a Sixteen Year Old Male Presenting with Long-standing Non-specific Gastrointestinal Symptoms

A sixteen year-old male presented with a six-month history of intermittent morning nausea and epigastric pain. There was a ten-day history of non-bilious vomiting, anorexia, and weight loss. He admitted to binge drinking on weekends. He had pancreatitis at ten years of age. Both father and paternal grandfather had a history of renal stones. Physical examination revealed epigastric tenderness. Investigations: lipase 1534 (23-300U/L), PTH 11.5 (1.1-6.8pmol/L), calcium 2.93 (2.10-2.60mmol/L), ionized calcium 1.29 (1.09-1.25mmol/L), phosphorus 0.63 (0.8-1.45mmol/L). A technetium-99m sestamibi scan combined with single photon emission computed tomography revealed an 8 mm parathyroid adenoma in the lower right parathyroid region. The patient underwent right superior and inferior parathyroidectomies. Intraoperative PTH dropped precipitously from 15 to 1.4pmol/L, ionized calcium dropped from 1.32 to 0.97mmol/L. The patient did not develop hypocalcemia postoperatively. The pathology report confirmed the diagnosis of spontaneous parathyroid adenoma.

Evaluation of coronary artery abnormalities in Williams syndrome patients using myocardial perfusion scintigraphy and CT angiography

Sudden death risk in Williams syndrome (WS) patients has been shown to be 25-100 times higher than in the general population. This study aims to detect coronary artery anomalies and myocardial perfusion defects in WS patients using noninvasive diagnostic methods. This study features 38 patients diagnosed with WS. In addition to physical examination, electrocardiography, and echocardiography, computed tomography (CT) angiography and rest/dipyridamole stress technetium-99m sestamibi ((99m)Tc-sestamibi) single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy (MPS) were performed. Twenty-one (55%) patients were male; 17 (45%) were female. The average patient age was 12 ± 5 years (2.5-26 years); the average follow-up period was 7.2 ± 4.2 years (6 months-18 years). Cardiovascular abnormalities were found in 89% of patients, the most common one being supravalvar aortic stenosis (SVAS). CT angiography revealed coronary anomalies in 10 (26%) patients, the most common ones being ectasia of the left main coronary artery and proximal right coronary artery as well as myocardial bridging. SVAS was present in 80% of patients with coronary artery anomalies. (99m)Tc-sestamibi SPECT MPS revealed findings possibly consistent with myocardial ischemia in 29% of patients, and ischemia in 7 out of 10 patients (70%) with coronary anomalies shown on CT angiography (p = 0.03). Coronary artery abnormalities are relatively common in WS patients and are often accompanied by SVAS. CT angiography and dipyridamole (99m)Tc-sestamibi SPECT MPS seem to be less invasive methods of detecting coronary artery anomalies and myocardial perfusion defects in WS patients.

Influence of Attenuation Correction on Transient Left Ventricular Dilation in Dual Isotope Myocardial Perfusion Imaging in Patients With Known or Suspected Coronary Artery Disease

The aim of this study was to assess the effect of attenuation correction (AC) on left ventricular (LV) volumes and LV transient ischemic dilatation (TID) during dual-isotope single-photon emission computer tomographic (SPECT) myocardial perfusion imaging (MPI). Ninety-six patients (mean age 58 ± 11 years, 15% women, 38 patients completed exercise and 58 dipyridamole pharmacologic stress tests) assessed for known or suspected coronary artery disease underwent dual-isotope thallium-201 rest and technetium-99m sestamibi stress SPECT MPI with computed tomography-based AC. The TID ratio was calculated separately for non-AC and AC SPECT MPI studies as the ratio of the LV endocardial volume at stress divided by LV endocardial volume at rest. The mean and range of the gated LV ejection fraction during exercise and pharmacologic stress was 54 ± 12% (29% to 80%) and 58 ± 12% (27% to 80%), respectively. In the exercise stress group, the same mean LV endocardial volumes in non-AC and AC stress (76.4 ± 30 and 76.5 ± 28) and rest (66.3 ± 26 and 66.4 ± 24) studies were found (p = 0.90). There was no statistical difference between the mean exercise TID ratio in non-AC and AC studies (1.27 vs 1.31, respectively, p = 0.10). The same mean LV endocardial volumes in non-AC and AC in pharmacologic stress (79.9 ± 42 and 80 ± 41) and rest (71.4 ± 41 and 72.3 ± 37), respectively, were found (p = 0.50). There was no statistical difference between the mean dipyridamole TID ratio in non-AC and AC studies (1.20 vs 1.17, respectively, p = 0.10). In conclusion, LV volumes and TID indexes obtained on SPECT MPI with exercise or pharmacologic stress using dipyridamole are not affected by AC.

Technetium-99m sestamibi imaging: are the results dependent on the reviewer?

BackgroundMinimally invasive parathyroidectomy (MIP) is dependent upon accurate preoperative parathyroid localization. We hypothesized that surgeon recognition of subtle differences in radiotracer accumulation would increase the sensitivity of technetium-99m sestamibi imaging and result in more frequent use of MIP. MethodsTechnetium-99m sestamibi scans completed at our institution for patients who underwent resection of a solitary parathyroid adenoma were reviewed by a surgeon and a radiologist who were blinded to patient identifying information, prior scan interpretation, and results of the operation. For each scan, the reviewer determined whether there was abnormal radiotracer accumulation and documented its location. Results were correlated with outcome of operation and final pathology. Blinded interpretations of the surgeon and radiologist were compared to each other and to the original radiologic interpretation. ResultsFrom 1994 to 2009, 274 patients with primary hyperparathyroidism (HPT) had sestamibi imaging prior to parathyroidectomy; 149 patients with a single adenoma underwent curative parathyroidectomy and had scans available for review. Seventeen radiologists who reviewed an average of 11 ± 14 scans (range = 1–61) completed the original interpretations of the sestamibi imaging. Sensitivity of sestamibi imaging was 86% for the blinded surgeon compared to 75% for the blinded radiologist and 69% for the original radiologists (P < 0.05). There was no difference in the false positive rates (blinded surgeon = 5%, blinded radiologist = 5%, original radiologists = 5%, P > 0.05). ConclusionRadiologists were less likely to call a scan positive. Surgeon recognition of subtle anatomic asymmetry increases the sensitivity of sestamibi imaging and successful completion of MIP.

Randomized and double-blind controlled clinical trial of extracorporeal cardiac shock wave therapy for coronary heart disease

Our aim was to evaluate the safety and effectiveness of extracorporeal cardiac shock wave therapy (CSWT) for the patients with coronary heart disease (CHD) using a randomized, double-blind, controlled clinical trial design. Twenty-five patients with CHD were enrolled in this study. Fourteen of the patients were randomized into the CSWT group and 11 into the control group. We applied the CSWT procedure to each patient by using nine shock treatments during 3 months, but the shock wave (SW) energy was only applied to the patients in the CSWT group and not to the patients in the control group. Technetium-99m sestamibi myocardial perfusion, fluorine-18 fluorodeoxyglucose myocardial metabolism single-photon emission computed tomography (SPECT), and two-dimensional echocardiography were performed to identify segments of myocardial ischemia, myocardial viability, and ejection fraction before and after CSWT. We also followed the patients to evaluate adverse effects. After CSWT, the New York Heart Association class, the Canadian Cardiovascular Society angina scale, nitroglycerin dosage, myocardial perfusion and myocardial metabolic imaging scores of dual-isotope SPECT in the CSWT group were reduced significantly (P = 0.019, 0.027, 0.039, 0.000, 0.001, respectively), and the Seattle Angina Questionnaire scale, 6-min walking test, and left ventricular ejection fraction were increased significantly (P = 0.021, 0.024, 0.016, respectively) compared with those before the SW treatment. All of the parameters in the control group did not change significantly after the treatment (all P > 0.05). No serious adverse effects of CSWT were observed. Cardiac shock wave therapy is a safe and effective treatment for CHD patients.

Prognostic Value of Late Heart Rate Recovery After Treadmill Exercise

Recovery from exercise can be divided into an early, rapid period and a late, slower period. Although early heart rate (HR) recovery 1 minute after treadmill exercise independently predicts survival, the prognostic value of late HR recovery has not been well studied. The aim of this study was to evaluate the independent prognostic value of late HR recovery for all-cause mortality. A total of 2,082 patients referred to the nuclear cardiology laboratory of an urban academic medical center for treadmill exercise with imaging from August 1998 to December 2003 were followed for all-cause mortality. During 9.9 ± 1.5 years of follow-up, 196 deaths (9%) occurred. To avoid overlap with early HR recovery or the baseline HR, late HR recovery was defined as the percentage of the cycle length change between rest and peak exercise that had been recovered after 5 minutes. Lower values represent impaired recovery, by analogy with 1-minute HR recovery. Impaired late HR recovery was a significant univariate predictor of all-cause mortality (hazard ratio 0.28 per percentage, 95% confidence interval 0.17 to 0.46, p <0.001). It significantly improved a nested, multivariate model (change in chi-square 8.66, p = 0.003), including 1-minute HR recovery, with independent prognostic value (adjusted hazard ratio 0.58, 95% confidence interval 0.41 to 0.84, p = 0.004). In conclusion, late HR recovery after treadmill exercise stress adds prognostic value for all-cause mortality to a multivariate model including early, 1-minute HR recovery.

Modern Approach to Surgical Intervention of the Thyroid and Parathyroid Glands

Operative intervention on the parathyroid and thyroid glands has become more minimally invasive and selective over the past decade. This requires high-quality preoperative imaging evaluation for better knowledge of the relevant anatomical considerations and potential localization. Minimally invasive parathyroidectomy has become the operation of choice for most patients presenting with sporadic primary hyperparathyroidism (when the suspected parathyroid tumor is localized preoperatively). Preoperative imaging helps guide the surgeon as to which patients with thyroid pathology require intervention and the extent of resection. The imaging modalities reviewed include ultrasonography, technetium-99m sestamibi imaging, and four-dimensional computed tomography. Imaging modalities are discussed within the categories of benign and neoplastic parathyroid and thyroid pathology.

Intraoperative 3-D mapping of parathyroid adenoma using freehand SPECT

BackgroundFreehand single photon emission computed tomography (fSPECT) is a three-dimensional (3-D) tomographic imaging modality based on data acquisition with a handheld detector that is moved freely, in contrast to conventional, gantry-mounted gamma camera systems. In this pilot study, we evaluated the feasibility of fSPECT for intraoperative 3-D mapping in patients with parathyroid adenomas.MethodsThree patients (range 30 to 45 years) diagnosed with hyperparathyroidism (one primary and two tertiary) underwent parathyroid scintigraphy with technetium-99m sestamibi (99mTc-MIBI) to localize parathyroid adenomas. Two patients were referred with persistent hyperparathyroidism after conventional parathyroidectomy. In all three patients, a planar scintigraphy of the neck was performed 10 min after injection (p.i.) followed by SPECT/CT (Symbia T2, Siemens Healthcare) and a correlative ultrasound 2 h p.i. 99mTc-MIBI scan was performed the day before surgery in two patients and at the same day in one patient. fSPECT images were acquired intraoperatively using declipse SPECT (SurgicEyeTM).ResultsA total of five parathyroid adenomas were successfully located with SPECT/CT. fSPECT allowed intraoperative detection of all adenomas, and successful parathyroidectomy was accomplished. Parathyroid hormone level decreased intraoperatively in all three patients, on average, by 79% (range 72% to 91%).ConclusionIn this preliminary study, we could demonstrate that intraoperative localization of parathyroid adenomas is feasible using the freehand SPECT technology, thus allowing an image-guided parathyroidectomy.

Clinical analysis for 51 cases of primary hyperparathyroidism

Objective To study clinical characteristics,causes of misdignosis and diagnostic and therapeutic methods for primary hyperparathyroidism (PHPT).Methods Retrospective analysis was done for 51 patients of PHPT,47 confirmed by biopsy after surgical operation and 4 without operation diagnosed based on their serum levels of calcium,alkaline phosphatase ( ALP),intact parathyroid hormone ( iPTH ),and computed tomography (CT) or 99mtechnetium sestamibi (99mTcMIB1) imaging at the First Affiliated Hospital of Sun Yat-sen University,Guangzhou during June 1997 to November 2010.Results Bone-related complications were the most common clinical manifestation,accounting for 51％ (26/51 ) of the cases,and adenoma,a benign,enlarged and hyperactive parathyroid gland,in 34 of 47 cases ( 72％ ).In orthotopic lesions,the right inferior was affected in 19 of 46 cases (41％),followed by the left inferior in 13 cases (28％),while 5 of 51 cases (10％) with ectopic parathyroid gland.PHPT was easily misdiagnosed as urolithiasis,rheumatic disease,primary osteoporosis,etc,accounting for 92％ of the cases in our study.Preoperative serum levels of calcium,ALP and iPTH in the patients varied with their clinical type and pathological classification,the highest in patients with urolithiasis-bone-related complications [ (3.22 ±0.35) mmol/L,(1455 ± 1091 ) U/L and (1669 ± 515 ) ng/L,respectively ] and in patients with parathyroid carcinoma [ (3.46 ± 0.40) mmol/L,( 1410 ± 426) U/L and ( 1861 ± 768) ng/L,respectively ].Sensibility of preoperative localization diagnosis using ultrasonography,CT and 99mTcMIBI was 88％ (35/40),97％ (30/31) and 97％ (31/32),respectively.Conclusions PHPT is frequently misdiagnosed as other diseases.Measurement of serum calcium should be included in routine physical examinations,supplemented with measurement of serum ALP and iPTH,as well as medical imaging,which can help avoid misdiagnosis.CT combined with 99mTcMIBI imaging can improve accuracy of preoperative localization diagnosis. Key words: Hyperparathyroidism, primary ( PHPT ) ; Diagnostic technique; Endocrine disease; Diagnosis, differential; Treatment

A 32-Year-Old Man With Recurrent Kidney Stones and an Abnormal Chest Radiograph

A 32-Year-Old Man With Recurrent Kidney Stones and an Abnormal Chest Radiograph

Single‐Photon‐Emission Computed Tomography (SPECT) with Technetium‐99m Sestamibi in the Diagnosis of Small Breast Cancer and Axillary Lymph Node Involvement

In a prospective study we evaluated the accuracy, sensitivity, and specificity of single-photon-emission computed tomography (SPECT) technetium-99m (99Tcm) sestamibi scintimammography to differentiate between benign and malignant small solid lesions of the breast, and to diagnose axillary node involvement in patients with small breast tumors. We prospectively evaluated 172 women with a solid lesion of the breast less than 3 cm in diameter and no evidence of axillary lymph node involvement on physical examination, ultrasound, and mammography. Thereafter, all patients underwent excision of the lesion, and, if pathology was positive for cancer, quadrantectomy and axillary lymph node dissection independently by the results of scintimammography. There were 92 patients with a benign lesion and 80 patients with cancer. SPECT scintimammography correctly identified all 80 patients with cancer; there were six false-positive cases and no false-negative cases for a test efficacy of 96.5%, sensitivity of 100%, and specificity of 93.5%. Forty-five of the 80 patients with cancer had axillary lymph node involvement and scintimammography correctly identified 39 of the 45 patients. There was one false-positive case and six false-negative cases for a test efficacy of 90%, sensitivity of 86.4%, and specificity of 97.5%. SPECT scintimammography should be considered selectively in the preoperative evaluation of patients with small solid lesions of the breast. It allows correct identification of patients with cancer and identification of a significant number of patients with axillary lymph node involvement.

Characterization of mechanical dyssynchrony measured by gated single photon emission computed tomography phase analysis after acute ST-elevation myocardial infarction

BackgroundLeft ventricular dyssynchrony is an adverse consequence of ST-elevation myocardial infarction (STEMI) and bears an unfavorable prognosis. Mechanical dyssynchrony as measured by phase analysis from gated single photon emission computed tomography (GSPECT) correlates well with other imaging methods of assessing dyssynchrony but has not been studied in STEMI. We hypothesized that systolic dyssynchrony as measured by GSPECT would correlate with adverse remodeling after STEMI. MethodsIn 28 subjects suffering STEMI, GSPECT with technetium-99m sestamibi was performed immediately after presentation (day 5) and remotely (6 months). Parameters of left ventricular dyssynchrony (QRS width, histogram bandwidth (HBW) and phase standard deviation (PSD)) were measured from GSPECT using the Emory Cardiac Toolbox. Left ventricular volumes, ejection fraction (LVEF) and infarct size were also assessed. ResultsAfter successful primary percutaneous coronary intervention to the infarct-related artery, subjects had an LVEF of 46.4% ± 11% and a resting perfusion defect of 27.4% ± 16% at baseline. Baseline QRS width was normal (91.5 ± 17.5 ms). Subjects with STEMI had dyssynchrony compared with a cohort of 22 normal subjects (age 57.2 ± 10.6 years, <5% perfusion defect) by both HBW (100.3° ± 70.7° vs 26.5° ± 5.3°, P < .0001) and PSD (35.3° ± 16.9° vs 7.9° ± 2.1°, P < .0001). Baseline HBW correlated with resting perfusion defect size (r = 0.67, P < .001), end-systolic volume (r = 0.72, P < .001), end-diastolic volume (r = 0.63, P = .001), and inversely with LVEF (r = −0.74, P < .001). HBW and PSD improved over the follow-up period (−24.1 ± 35.9 degrees, P = .003 and −8.7° ± 14.6°, P = .006, respectively), and improvement in HBW correlated with reduction in LV end-systolic volumes (r = 0.43, P = .034). Baseline HBW and PSD, however, did not independently predict LVEF at 6 months follow-up. ConclusionsAfter STEMI, subjects exhibit mechanical dyssynchrony as measured by GSPECT phase analysis without evidence of electrical dyssynchrony. Improvement in mechanical dyssynchrony correlates with beneficial ventricular remodeling. The full predictive value of this measure in post-infarct patients warrants further study.

Tc-99m SPECT Sestamibi for the Measurement of Infarct Size

There are a variety of approaches to assess the efficacy of reperfusion therapy, and myocardial protection, in acute myocardial infarction. This review summarizes the available evidence validating the use of technetium-99m sestamibi single-photon emission computed tomography (SPECT) for this purpose. Multiple lines of evidence have validated its clinical utility. SPECT sestamibi infarct size has been used as an endpoint in multiple randomized clinical trials. A smaller number of clinical trials have used both early and later imaging with SPECT sestamibi to assess myocardium at risk and myocardial salvage. SPECT sestamibi has a number of limitations which must be recognized. Nevertheless, SPECT sestamibi infarct size is a well-validated measurement with a long track record of performance as an endpoint in multicenter, randomized clinical trials.

Anatomical and functional localization of ectopic parathyroid adenomas

Localization of ectopic parathyroid adenoma is highly important to guide surgery, thus reducing morbidity and rate of recurrent hyperparathyroidism. The aim of this study was to establish the incidence of ectopic parathyroid adenoma and evaluate the role of multimodality imaging in diagnosis. We reviewed 656 imaging studies of patients referred for investigations of primary hyperparathyroidism. All patients suspected of having an ectopic adenoma had technetium-99m (99mTc) sestamibi (MIBI) and ultrasound of the neck. In addition, patients had cross-sectional imaging, either computed tomography (CT) or magnetic resonance imaging (MRI), in cases of suspected ectopic adenoma. Some patients also underwent angiography. Results were correlated with postoperative findings and histopathology to calculate sensitivity, specificity, positive and negative predictive values. The incidence of ectopic adenoma was also determined. In our series, the incidence of ectopic adenoma was 1.4%, which is lower than earlier published reports in the literature. Eleven patients showed ectopic uptake suspicious of a parathyroid adenoma on 99mTc MIBI. CT confirmed the diagnosis of ectopic adenoma in seven patients and MRI showed adenoma in two patients. Surgical and histopathological findings confirmed the diagnosis of ectopic parathyroid adenoma in nine patients. Sensitivity and specificity for ultrasound were 11 and 100%, respectively. 99mTc MIBI had sensitivity, specificity, positive and negative predictive values of 100, 86, 98 and 65%, respectively. The combination of 99mTc-MIBI with CT or MRI yielded the correct diagnosis in all cases, giving a sensitivity and specificity of 100%. The incidence of ectopic parathyroid adenoma is much lower than previously reported. Multimodality imaging in a tertiary referral centre is the ideal approach for accurate diagnosis.

Predictive and prognostic values of transient ischemic dilatation of left ventricular cavity for coronary artery disease and impact of various managements on clinical outcome using technetium-99m sestamibi gated myocardial perfusion imaging

Transient ischemic dilatation (TID) of LV cavity during stress gated myocardial perfusion imaging (GMPI) is known as a predictor of severe CAD and signifies worse prognosis. To assess predictive and prognostic value of TID of LV cavity using GMPI and clinical outcome in patients treated conservatively or with revascularization. 189 patients out of 2689 were recruited (M:F 127/62, mean age 56 ± 9 years) whose same-day stress GMPI revealed TID ratio (> 1.22) with no (sum stress score, SSS < 2) or reversible perfusion defects (sum difference score, SDS > 2). Coronary angiography (CA) was performed within 3 months in 125/189 cases who were followed for mean period of 18 ± 4 months for fatal or non-fatal MI. CA was positive in 121/125 patients with TID for significant CAD (LAD = 11, multi vessel disease = 110 patients, positive predictive value 95%) and negative for obstructive disease in 4/125 (false-positive cases). 41/121 underwent revascularization within 2 months of CA (Intervention group), and remaining 80/121 were managed conservatively (Non-Intervention group). Overall event rate was 20% (4/16%: fatal/non-fatal MIs). Kaplan-Meier survival curves revealed event-free survival in Intervention and Non-Intervention groups for fatal MI 98/96% (P = 0.758), and for non-fatal MI, it was 97/58%, respectively (P = 0.042). We conclude that TID is a reliable predictor of multi vessel CAD and is associated with high incidence of non-fatal MIs than fatal MIs. Revascularization (PCI/CABG) rather than medical treatment should be considered in patients with TID for better clinical outcome.

Postreperfusion myocardial technetium-99m–sestamibi defect corresponds to area at risk

Technetium-99m-sestamibi (MIBI) is the most frequently used myocardial perfusion tracer in patients with ischemic heart disease. In patients with acute ST-elevation myocardial infarction, we previously found that the defect in myocardial MIBI uptake was the same in patients injected with MIBI before primary angioplasty and in patients injected immediately after successful treatment. Thus, reperfusion may not be followed by increased uptake of MIBI. Instead, the MIBI defect after reperfusion may reflect the area at risk (AAR) defined by MIBI injected before treatment. We intended to investigate whether myocardial imaging with MIBI administered after reperfusion reflects myocardial perfusion or rather the ischemic AAR. In 12 pigs, left anterior descending coronary artery was totally occluded for 45 min with an angioplasty balloon. After a 2-h reperfusion, MIBI was injected intravenously, and (153)Gd-microspheres were injected in left atrium. AAR and infarct size (IS) were determined by histochemical staining. MIBI and microsphere distribution were evaluated by counting the sliced left ventricle on a gamma camera. Defects were defined as uptake less than 45% of maximum uptake. The mean±S.D. defect size as a fraction of left ventricle was for MIBI 21%±5.5%, AAR 25%±6.3%, IS 13%±3.9% and microspheres defect size 7.3%±5.5%. MIBI defect size overestimated IS (P=.0005) and microspheres defect size (P=.0001), but it was not significantly different from AAR (P=.30). In a porcine model of myocardial infarction after 45 min of ischemia, MIBI administered 120 min after reperfusion delineates AAR.

Differentiating suspected nasopharyngeal infection from carcinoma using dual-tracer and multiple time-point technetium-99m sestamibi and white blood cell SPECT/CT imaging

The role of molecular and functional imaging lies in its capability to more accurately define and characterize pathologies, with a host of varied radiotracers and techniques being available to the clinician for use. We present a case in which dual-tracer and multiple time-point single photon emission computed tomography/computed tomography imaging using technetium-99m sestamibi and white blood cell radiotracers was used to characterize an indeterminate base of skull lesion.

The Occluded Artery Trial (OAT) Viability Ancillary Study (OAT-NUC): Influence of infarct zone viability on left ventricular remodeling after percutaneous coronary intervention versus optimal medical therapy alone

The Occluded Artery Trial (OAT) showed no difference in outcomes between percutaneous coronary intervention (PCI) versus optimal medical therapy (MED) in patients with persistent total occlusion of the infarct-related artery 3 to 28 days post-myocardial infarction. Whether PCI may benefit a subset of patients with preservation of infarct zone (IZ) viability is unknown. The OAT nuclear ancillary study hypothesized that (1) IZ viability influences left ventricular (LV) remodeling and that (2) PCI as compared with MED attenuates adverse remodeling in post-myocardial infarction patients with preserved viability. Enrolled were 124 OAT patients who underwent resting nitroglycerin-enhanced technetium-99m sestamibi single-photon emission computed tomography (SPECT) before OAT randomization, with repeat imaging at 1 year. All images were quantitatively analyzed for infarct size, IZ viability, LV volumes, and function in a core laboratory. At baseline, mean infarct size was 26% ± 18 of the LV, mean IZ viability was 43% ± 8 of peak uptake, and most patients (70%) had at least moderately retained IZ viability. There were no significant differences in 1-year end-diastolic or end-systolic volume change between those with severely reduced versus moderately retained IZ viability, or when compared by treatment assignment PCI versus MED. In multivariable models, increasing baseline viability independently predicted improvement in ejection fraction (P = .005). There was no interaction between IZ viability and treatment assignment for any measure of LV remodeling. In the contemporary era of MED, PCI of the infarct-related artery compared with MED alone does not impact LV remodeling irrespective of IZ viability.

A Case of Reoperative Parathyroidectomy in Tandem with Coronary Artery Bypass Surgery

Surgery remains the only curative therapy for primary hyperparathyroidism (PHPT). Successful localization of the hyperfunctioning parathyroid lesion(s) prior to surgery allows for a more focused surgical approach, especially important in reoperative patients. Surgery is recommended for most symptomatic patients and a subset of asymptomatic patients who meet specific criteria in terms of laboratory testing or who are osteoporotic. Situations may arise where hypercalcemia would pose significant morbidity in the postoperative periods of other major surgeries. Here, we report a case of tandem reoperative parathyroidectomy followed by coronary artery bypass surgery under one session of general anesthesia in a 60-year-old man with PHPT. Preoperatively, magnetic resonance imaging localized the lesion after multiple ultrasounds, technetium-99m sestamibi parathyroid scans and one bilateral internal jugular venous sampling failed to identify the hyperfunctioning lesion.