SIGNIFICANCE OF PERFUSION DEFECTS ON DIPYRIDAMOLE THALLIUM CARDIAC SPECT IN PATIENTS WITH LEFT BUNDLE BRANCH BLOCK
Abstract
Background: Left Bundle Branch Block (LBBB) is a known cause of false positive results inmyocardial perfusion studies. We aimed at investigation of correlation between degree of severityof perfusion defect on cardiac Single Photon Emission Computed Tomography (SPECT) andpresence of coronary artery disease on angiography in patients with LBBB. Study Design: Thiswas an analytical study and was carried out at Department of Nuclear Cardiology and Departmentof Cardiac Catheterisation of Punjab Institute of Cardiology, Lahore from January 2007 to April2007. Methods: In this study patients having LBBB without known coronary artery disease(CAD) referred for myocardial perfusion studies to the Nuclear Cardiology Department fromoutpatient, indoor and emergency departments were included. Thallium201 stress/rest SinglePhoton Emission Tomography (SPECT) acquisition scanning was performed. The myocardialperfusion pattern was classified as normal, fixed defect and reversible defect. Coronaryangiography was used to confirm CAD only in patients with abnormal scan. Results: Thirtyconsecutive patients having LBBB were studied. All patients underwent myocardial perfusionimaging using dipyridamole pharmacologic stress. Fourteen patients (47%) revealed normalThallium201 uptake and distribution at the septum. Reversible defects were noted in 13 (43%)patients. Fixed defects were noted in 3 (10%) patients. Among four patients with mild perfusiondefects only 1 (25%) had significant coronary artery disease. In patients with moderate perfusiondefects, coronary angiogram was positive for significant coronary artery disease in 1 (33%)patient. In six patients having severe perfusion defects significant coronary artery disease wasnoted in 5 (83%) patients. All patients with fixed defects had significant coronary artery disease.False positive studies were found to be significantly greater in patients with reversible defectsparticularly with mild to moderate defects. Conclusions: Patients with left bundle branch blockshowing moderate to severe reversible perfusion defects on dipyridamole thallium cardiac SPECThave high likelihood of coronary artery disease.Keywords: Left bundle branch block, Coronary artery disease, Thallium201 stress test, Myocardialperfusion imaging, Single-photon emission computed tomography (SPECT).References
Hansen CL. The conundrum of left bundle branch block. J
Nucl Cardiol 2004;11:90–2.
Shah AA, De Puey EG, Kamran M, Kasai T. Base line septal
perfusion disparity in patients with LBBB. J Nucl Med
;43:175–6.
Gracia E, Berman DS, Port SC. American society of nuclear
cardiology. Imaging guidelines for nuclear cardiology
procedures. Part 2. J Nucl Cardiol 1999;6:53–8.
Klocke FJ, Baird MG, Bateman TM. A report of the
American College of Cardiology/American Heart
Association Task Force on practice guideline
(ACC/AHA/ASNC Committee to Revise the 1995 Guidelines
for clinical use of Radionuclide Imaging) 2003.
Moller J. Myocardial Perfusion Scintigraphy with Tc-99m
MIBI in patients with LBBB: Visual quantitation of the
anteroseptal perfusion imaging for the diagnosis of LAD
stenosis. Cardiovasc J S Afr 2005;16(2):95–101.
Beller GA. First annual Mario S, Verani, Memorial lecture:
Clinical value of myocardial perfusion imaging in coronary
artery disease. J Nucl Cardiol 2003;10:529–36.
Nigam A, Auman DP. Prognostic value of myocardial
perfusion imaging with exercise/dipyridamole hyperemia in
patients with pre existing LBBB. J Nucl Med 1998;39:579–81.
Beller GA, Zaret BL. Contributions of nuclear cardiology to
diagnosis and prognosis of patients with coronary artery
disease. Circulation 2000;101:1465–74.
Hirzel HO, Senn M, Nuesh K , Buettner C, Pfeiffer A , Hess
OM , et al. Thallium-201 scintigraphy in complete left
bundle branch block . Am J Cardiol 1984;53:764–9.
O'Keefe JH, Bateman TM, Barnhart CS. Adenosine thallium-
is superior to exercise thalium-201 for detecting coronary
artery disease in patients with left bundle branch block. J Am
Coll Cardiol 1993;21:1332–8.
Burns RJ, Galligan L, Wright LM, Lawand L, Burke RJ,
Gladstone PJ. Improved specificity of myocardial thallium-
single-photon emission computed tomography in patients
with left bundle branch block by dipyridamole. Am J Cardiol
;68:504–8.
Miller DD. Pharmacologic stressor in coronary artery
J Ayub Med Coll Abbottabad 2007;19(4)
disease. In Dilsizian V, Narula J, Braunwald E (eds.); Atlas
of Nuclear Cardiology. Philadelphia, Current Medicine,
: pp47–62.
Afzal MS, Imran MB, Aslam N, Khurshid SJ, Khan MA,
Irfan J, et al. Gated SPECT myocardial perfusion
scintigraphy for identifying septal perfusion artifacts in left
bundle branch block. JCPSP 2006;16(8):504–8.
Port S. Imaging Guidelines for Nuclear Cardiology. J Nucl
Cardiol 1999; 6: G49–G84.
Merlano S, Rodriguez E, Murguetio R. Pattern of Myocardial
Perfusion abnormalities in patients with pre-existing Left
Bundle Branch Block using Tc-99m Sestamibni Myocardial
Perfusion imaging. World Nucl Med 2006;5:142–6.
Sugihara H, Tamaki N, Nozawa M. Septal perfusion and wall
thickening in patients with left bundle branch block assessed
by technetium-99m Sestamibi gated tomography. J Nucl Med
;38:545–7.
Kipper MS, Grosshans C, Ashburn WL. False positive Tl-
SPECT studies in patients with left bundle branch block.
Frequency and clinical significance. Clin Nucl Med
;16:890–3.
Depuey EG, Guertler-Krawczynska E, Robbins WL.
Thallium-201 SPECT in coronary artery disease patients with
left bundle branch block. J Nucl Med 1988; 29: 1479–85.
Jazmati B, Sadaniantz A, Emaus SP, Heller GV. Exercise
thallium-201 imaging in complete left bundle branch block
and the prevalence of septal perfusion defects. Am J Cardiol
; 67: 46–9.
Vigna C, Stanislao M, De Rito V. Dipyridamole stress
Echocardiography Vs Dipyridamole Sestamibi Scintigraphy
for diagnosing Coronary Artery Disease in left BundleBranch Block. Chest 2001;120: 1534–39.
Wagdy HM, Godge D, Christian TF, Miller TD, Gibbons RJ.
Prognostic value of vasodilator myocardial perfusion imaging
in patients with left bundle-branch block. Circulation
;97:1563–70.
Fahy GJ, Pinski SL, Miller DP. Natural History of isolated
bundle branch block. Am J Cardiol 1996;77:1185–90.
Freedman RA, Alderman EL, Sheffield LT, Saporito M,
Fisher LD. Bundle branch block in patients with chronic
coronary artery disease:angiographic correlates and
prognostic significance. J Am Coll Cardiol 1987;10:73–82.
Gil VM, Almeida M, Ventosa A. Prognosis in patients with
left bundle branch block and normal dipyridamole Thallium-
scintigraphy. J Nucl Cardiol 1998; 5: 414–7.
Inanir S, Caymaz O, Okay T, Dede F, Oktay A, Deger M. Tc-
m Sestamibi Gated SPECT in patients with left Bundle
Branch Block. Clin Nucl Med 2001; 26:840–6.
Knapp W, Bentrup A. Myocardial Scintigraphy with Tl-201
and Tc-99m in LBBB. Eur J Nucl Med 1993;20:219–24.
Skowerski M, Mandecki T, Nowak S. Myocardial
Scintigraphy with technetium 99m MIBI in patients with Left
bundle branch block. Pol Arch Med Wewn 1999;102:877–83.
Ono S, Nohara R, Kambara H, Okuda K, Kawai C. Regional
myocardial perfusion and glucose metabolism in
experimental left bundle branch block. Circulation
;85:1125–31.
Watson D, Glover D. Overview of kinetics and modelling. In
Zaret B (Ed) Nuclear Cardiology. State of the art and future
directions. St Louis, Mosby, 1999:3–12.
Soares A, Puig J, Pereira N, Oliveira C, Oliveira J, Cunha D.
Prognostic value of normal perfusion scintigraphy in patients
with chest pain and left bundle branch block. Rev Port
Cardiol 2002;21:1241–55.
Issue
Section
License
Journal of Ayub Medical College, Abbottabad is an OPEN ACCESS JOURNAL which means that all content is FREELY available without charge to all users whether registered with the journal or not. The work published by J Ayub Med Coll Abbottabad is licensed and distributed under the creative commons License CC BY ND Attribution-NoDerivs. Material printed in this journal is OPEN to access, and are FREE for use in academic and research work with proper citation. J Ayub Med Coll Abbottabad accepts only original material for publication with the understanding that except for abstracts, no part of the data has been published or will be submitted for publication elsewhere before appearing in J Ayub Med Coll Abbottabad. The Editorial Board of J Ayub Med Coll Abbottabad makes every effort to ensure the accuracy and authenticity of material printed in J Ayub Med Coll Abbottabad. However, conclusions and statements expressed are views of the authors and do not reflect the opinion/policy of J Ayub Med Coll Abbottabad or the Editorial Board.
USERS are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles, or use them for any other lawful purpose, without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open access.
AUTHORS retain the rights of free downloading/unlimited e-print of full text and sharing/disseminating the article without any restriction, by any means including twitter, scholarly collaboration networks such as ResearchGate, Academia.eu, and social media sites such as Twitter, LinkedIn, Google Scholar and any other professional or academic networking site.
