Impact of revascularization and myocardial viability determined by nitrate-enhanced Tc-99m sestamibi and Tl-201 imaging on mortality and functional outcome in ischemic cardiomyopathy

Background. Nitrate-enhanced perfusion imaging has been shown to detect viability in dysfunctional myocardium, but nitrate-enhanced technetium 99m sestamibi has not been compared with nitrate-enhanced thallium 201. Methods and Results. Fifty-six patients with ischemic cardiomyopathy and heart failure (New York Heart Association classes II-IV) were scheduled for revascularization. Through use of a matching 12-segment model, nitrate-enhanced Tl-201 and Tc-99m sestamibi uptake at rest was assessed by 2 sets of blinded investigators. All single photon emission computed tomography data sets were read separately. Additional exercise Tc-99m sestamibi single photon emission computed tomography was performed on a separate day. Myocardial viability was thought to be present when the tracer uptake score was less than 3 (normal, 0; absent, 4). Of the 56 patients scheduled to undergo revascularization, only 23 (41 %) underwent the procedure and the remainder continued medical therapy. Functional assessment by rest echocardiography was performed at 21 ± 8 months, and survival was determined at 40 ± 18 months. The baseline clinical and hemodynamic parameters were similar in the revascularization (n = 23) and medical therapy (n = 33) groups. Perfusion scores with nitrate-enhanced Tl-201 and Tc-99m sestamibi were similar in dysfunctional segments. Stress Tc-99m sestamibi reversible defects predicted significant improvement in left ventricular function compared with those without defects (P < .01) after revascularization. Cox regression model showed that when at least 5 reversible segments were viable, revascularization produced greater improvements in New York Heart Association class, a better trend toward survival (P = .07 for Tl-201 and P = .06 for Tc-99m), and a significantly greater impact on reverse remodeling. Conclusions. Myocardial viability determined by nitrate-enhanced Tl-201 and myocardial viability determined by Tc-99m sestamibi are equivalent for predicting functional improvements, remodeling, and survival after revascularization in patients with ischemic cardiomyopathy.