EuropeanJournalof
Nuclear Medicine
Case report
A partial defect in technetium-99m pyrophosphate image suggesting cardiac rupture following acute myocardial infarction Motoyoshi T s u j i n o 1'2, M i c h i a k i Hiroe 2, Keiichi S u g i m o t o 1, Y a s u h i r o M i y a h a r a 1, Z e n j i r o u Ishii 1, K o i c h i T a n i g u c h i 2, and F u m i a k i M a r u m o 2 1 Department of Medicine and Pathology, Hokushin General Hospital, Nagano, 2 Division of Cardiology, Second Department of Internal Medicine, Tokyo Medical and Dental University, 1-5~45 Yushima Bunkyo-ku, Tokyo 113, Japan Received 5 October and in revised form 19 October 1991
Abstract. We p r e s e n t the case o f a 7 0 - y e a r - o l d w o m a n with a c u t e m y o c a r d i a l i n f a r c t i o n w h o d i e d o f c a r d i a c r u p t u r e o n the 2nd h o s p i t a l day. D u a l i s o t o p e single p h o t o n e m i s s i o n c o m p u t e d t o m o g r a p h y ( S P E C T ) using thallium-201 c h l o r i d e a n d t e c h n e t i u m - 9 9 m p y r o p h o s p h a t e ( P Y P ) p e r f o r m e d on the 2nd h o s p i t a l d a y s h o w e d a large p e r f u s i o n defect in the a n t e r o s e p t a l wall o n 2°1T1 i m a g e a n d a i n c r e a s e d a c c u m u l a t i o n on 99mTc-PYP image in the a n t e r i o r a r e a c o n s i s t e n t with a p a r t i a l defect. A u t o p s y p e r f o r m e d I h after d e a t h r e v e a l e d a t e a r in the left v e n t r i c u l a r a n t e r i o r wall c o n s i s t e n t with the defect o n the 99mTc-PYP image. We p r o p o s e t h a t the finding o f a p a r t i a l defect in 99mTc-PYP is a n interesting f i n d i n g w h i c h m a y be a s s o c i a t e d with c a r d i a c r u p t u r e f o l l o w i n g a c u t e m y o c a r d i a l infarction. Key words: D u a l i s o t o p e single p h o t o n emission c o m puted tomography - Acute myocardial infarction - Cardiac rupture
Eur J Nucl Med (1992) 19:219-221
Introduction C a r d i a c r u p t u r e is a c o m m o n cause o f d e a t h in the early stage o f a c u t e m y o c a r d i a l infarction. N u m e r o u s studies h a v e focussed on i d e n t i f y i n g factors t h a t w o u l d be useful in p r e d i c t i n g the c a r d i a c r u p t u r e . We r e p o r t c h a r a c t e r i s tic findings o f d u a l i s o t o p e single p h o t o n e m i s s i o n c o m p u t e d t o m o g r a p h y ( S P E C T ) using t e c h n e t i u m - 9 9 m p y r o p h o s p h a t e ( P Y P ) a n d t h a l l i u m 201 c h l o r i d e in a p a t i e n t w h o suffered a n a c u t e a n t e r i o r m y o c a r d i a l infarction and died of cardiac rupture.
Offprint requests to .' M. Hiroe
Case report A 70-year-old woman was hospitalized for precordial discomfort present for the past 5 days. She had received medication for hypertension for 2 years. There was no prior history of angina or myocardial infarction. On admission, her blood pressure was 102/ 70 mmHg, and the heart rate was 87 heats/min. Physical examination showed no murmur and no extra cardiac sound. An electrocardiogram on admission revealed Q-wave and ST-segment elevation in the precordial leads. Haemodynamic data were consistent with Forrester subset I (pulmonary capillary wedge pressure 5 mmHg, right atrial pressure 1 mmHg, cardiac index 2.3 1/min.m2). Twodimensional echocardiography was performed on admission and showed thinning of the wall of a left ventricular true aneurysm with a wide orifice and mural thrombus. Pericardial effusion was not observed. The patient received nitroglycerin intravenously and heparin, 10000 U per day. To evaluate the site and the extent of cardiac damage, dual isotope myocardial SPECT was performed in the afternoon of the 2nd day. She was intravenously injected with 740 MBq of 99mTCand 4 h later, with 111 MBq of 2°1T1. Imaging was begun 15 min after the second injection. Thirty projection images were acquired over 180° from 45 ° right anterior oblique to 45° left posterior oblique for a preset time of 30 s with a wide field-of-view gamma-camera (GCA-90B, Toshiba) with a low-energy, general-purpose, parallel-hole collimator. The 20% energy windows centered on 80 and 140 keV photopeaks for 2°1T1 and 99mTC, respectively, were used. Projection images were recorded as 64 x 64 matrices by a dedicated nuclear medicine computer system. Total imaging time for both SPECT studies was 20 rain. The threshold cut-off level was determined as 55% for 99mycand 35% for 2°1T1 according to cardiac phantom studies (Hiroe et al. 1988). Then, color tomograms were described on the red and green image for 99mTc-PYP and for 2°1T1, respectively, in identical slices and regions. The 2°1T1 image (presented in green) showed a large perfusion defect in the anteroseptal wall, and the 99mTc-PYP image (presented in red) showed increased accumulation in the anterior area consistent with a partial defect (Fig. I). During hospitalization, the patient's systolic pressure was controlled between 100 and 120 mmHg. In the evening of the second day, she suffered sudden cardiac arrest, and although cardiopulmonary resuscitation was immediately performed, she died. The autopsy 1 h later re-
© Springer-Verlag 1992
220
(apex)
Short Axis (base)
Long Axis (horizontal)
(vertical) Fig. 1. Dual isotope single photon emission computed tomography (SPECT) using thallium-201 chloride and technetium-99m pyrophosphate (PYP) on the 2nd day. The 2°lT1 (presented in green) image shows a large perfusion defect in the anteroseptal wall, and the 99mTc-PYP image (presented in red) shows increased accumulation in the anterior area concomitant with a partial defect (arrow) in myocardial infarction (M/)
Fig. 2. Short-axis slices of the heart show a rip in the anterior area of the left ventricle (arrows), which corresponds to the site of the partial defect on 99mTc-PYP tomograms vealed a pericardium filled with clotting blood. Short-axis slices of the ventricles showed a tear corresponding to the defect on the 99mTc-PYP image (Fig. 2).
Discussion The clinical findings usually associated with cardiac rupture include old age, female gender, history o f hypertension, no history o f prior m y o c a r d i a l infarction, restless-
ness and friction rub ( L o n d o n and L o n d o n 1965; Lewis et al. 1969). This patient showed all but one feature; i.e. there was no friction rub. A l t h o u g h some investigators report the finding o f ventricular p s e u d o a n e u r y s m in two-dimensional e c h o c a r d i o g r a p h y as a factor for predicting rupture ( C a t h e r w o o d et al. 1980), our patient showed a true a n e u r y s m with this investigation. The utility o f dual isotope S P E C T for diagnosing myocardial infarction has been previously reported (Adachi et al. 1991; H a s h i m o t o et al. 1988). O u r observations in this
221 case showed that the site of the partial defect on the 99mTc-PYP image corresponded to the site of rupture. While such a defect often suggests a previous or " o l d " myocardial infarction, our patient had no history or other evidence of previous myocardial infarction. Schuster and Bulkley (1979) emphasized the role of infarct expansion, including regional dilatation and thinning of the infarcted myocardium, as a mechanism for rupture. Two-dimensional echocardiography showed regional dilatation and thinning of the infarcted wall at the same site where the defect in the 99mTc-PYP image was noted. In conclusion we note that a partial defect in 99mTc-PYP uptake m a y be associated with cardiac rupture following acute myocardial infarction.
References Adaehi S, Hiroe M, Sugimoto K, Miyahara Y, Marumo F (1991) Color display of dual isotope SPECT imaging in right ventricular infarction associated with acute inferior myocardial infarction. Clin Nucl Med 16:876-877
Catherwood E, Mintz GS, Kotler MN, Parry WR, Segal BL (1980) Two-dimensional echocardiographic recognition of left ventricular pseudoaneurysm. Circulation 62: 294-303 Hashimoto T, Kambara H, Fudo T, Tamaki S, Takatsu Y, Hattori R, Tokunaga S, Kawai C (1988) Significance of technetium99m/thalllium 201 overlap on simultaneous dual emission computed tomography in acute myocardial infarction. Am J Cardio161:1181 1186 Hiroe M, Muramatsu Y, Sugimoto K, Tsujino M, Maejima M, Miyahara Y, Taniguchi K, Matsui S, Mizukawa K (1988) New application of myocardial infarct map using a dual isotope single photon emission computed tomography (SPECT) of Tc99m pyrophosphate and T1-201 chloride in patients with acute myocardial infarction (in Japanese with English abstract). Jpn J Nucl Med 25 : 1125-1129 Lewis AJ, Burchell HB, Titus JL (1969) Clinical and pathologic features of postinfarction cardiac rupture. Am J Cardiol 23:4353 London RE, London SB (1965) Rupture of the heart. A critical analysis of 47 consecutive autopsy cases. Circulation 31:202208 Schuster EH, Bulkley BH (1979) Expansion of transmural myocardial infarction. A pathophysiologic factor in cardiac rupture. Circulation 60:1532-1538
Nuclear Medicine
Case report
A partial defect in technetium-99m pyrophosphate image suggesting cardiac rupture following acute myocardial infarction Motoyoshi T s u j i n o 1'2, M i c h i a k i Hiroe 2, Keiichi S u g i m o t o 1, Y a s u h i r o M i y a h a r a 1, Z e n j i r o u Ishii 1, K o i c h i T a n i g u c h i 2, and F u m i a k i M a r u m o 2 1 Department of Medicine and Pathology, Hokushin General Hospital, Nagano, 2 Division of Cardiology, Second Department of Internal Medicine, Tokyo Medical and Dental University, 1-5~45 Yushima Bunkyo-ku, Tokyo 113, Japan Received 5 October and in revised form 19 October 1991
Abstract. We p r e s e n t the case o f a 7 0 - y e a r - o l d w o m a n with a c u t e m y o c a r d i a l i n f a r c t i o n w h o d i e d o f c a r d i a c r u p t u r e o n the 2nd h o s p i t a l day. D u a l i s o t o p e single p h o t o n e m i s s i o n c o m p u t e d t o m o g r a p h y ( S P E C T ) using thallium-201 c h l o r i d e a n d t e c h n e t i u m - 9 9 m p y r o p h o s p h a t e ( P Y P ) p e r f o r m e d on the 2nd h o s p i t a l d a y s h o w e d a large p e r f u s i o n defect in the a n t e r o s e p t a l wall o n 2°1T1 i m a g e a n d a i n c r e a s e d a c c u m u l a t i o n on 99mTc-PYP image in the a n t e r i o r a r e a c o n s i s t e n t with a p a r t i a l defect. A u t o p s y p e r f o r m e d I h after d e a t h r e v e a l e d a t e a r in the left v e n t r i c u l a r a n t e r i o r wall c o n s i s t e n t with the defect o n the 99mTc-PYP image. We p r o p o s e t h a t the finding o f a p a r t i a l defect in 99mTc-PYP is a n interesting f i n d i n g w h i c h m a y be a s s o c i a t e d with c a r d i a c r u p t u r e f o l l o w i n g a c u t e m y o c a r d i a l infarction. Key words: D u a l i s o t o p e single p h o t o n emission c o m puted tomography - Acute myocardial infarction - Cardiac rupture
Eur J Nucl Med (1992) 19:219-221
Introduction C a r d i a c r u p t u r e is a c o m m o n cause o f d e a t h in the early stage o f a c u t e m y o c a r d i a l infarction. N u m e r o u s studies h a v e focussed on i d e n t i f y i n g factors t h a t w o u l d be useful in p r e d i c t i n g the c a r d i a c r u p t u r e . We r e p o r t c h a r a c t e r i s tic findings o f d u a l i s o t o p e single p h o t o n e m i s s i o n c o m p u t e d t o m o g r a p h y ( S P E C T ) using t e c h n e t i u m - 9 9 m p y r o p h o s p h a t e ( P Y P ) a n d t h a l l i u m 201 c h l o r i d e in a p a t i e n t w h o suffered a n a c u t e a n t e r i o r m y o c a r d i a l infarction and died of cardiac rupture.
Offprint requests to .' M. Hiroe
Case report A 70-year-old woman was hospitalized for precordial discomfort present for the past 5 days. She had received medication for hypertension for 2 years. There was no prior history of angina or myocardial infarction. On admission, her blood pressure was 102/ 70 mmHg, and the heart rate was 87 heats/min. Physical examination showed no murmur and no extra cardiac sound. An electrocardiogram on admission revealed Q-wave and ST-segment elevation in the precordial leads. Haemodynamic data were consistent with Forrester subset I (pulmonary capillary wedge pressure 5 mmHg, right atrial pressure 1 mmHg, cardiac index 2.3 1/min.m2). Twodimensional echocardiography was performed on admission and showed thinning of the wall of a left ventricular true aneurysm with a wide orifice and mural thrombus. Pericardial effusion was not observed. The patient received nitroglycerin intravenously and heparin, 10000 U per day. To evaluate the site and the extent of cardiac damage, dual isotope myocardial SPECT was performed in the afternoon of the 2nd day. She was intravenously injected with 740 MBq of 99mTCand 4 h later, with 111 MBq of 2°1T1. Imaging was begun 15 min after the second injection. Thirty projection images were acquired over 180° from 45 ° right anterior oblique to 45° left posterior oblique for a preset time of 30 s with a wide field-of-view gamma-camera (GCA-90B, Toshiba) with a low-energy, general-purpose, parallel-hole collimator. The 20% energy windows centered on 80 and 140 keV photopeaks for 2°1T1 and 99mTC, respectively, were used. Projection images were recorded as 64 x 64 matrices by a dedicated nuclear medicine computer system. Total imaging time for both SPECT studies was 20 rain. The threshold cut-off level was determined as 55% for 99mycand 35% for 2°1T1 according to cardiac phantom studies (Hiroe et al. 1988). Then, color tomograms were described on the red and green image for 99mTc-PYP and for 2°1T1, respectively, in identical slices and regions. The 2°1T1 image (presented in green) showed a large perfusion defect in the anteroseptal wall, and the 99mTc-PYP image (presented in red) showed increased accumulation in the anterior area consistent with a partial defect (Fig. I). During hospitalization, the patient's systolic pressure was controlled between 100 and 120 mmHg. In the evening of the second day, she suffered sudden cardiac arrest, and although cardiopulmonary resuscitation was immediately performed, she died. The autopsy 1 h later re-
© Springer-Verlag 1992
220
(apex)
Short Axis (base)
Long Axis (horizontal)
(vertical) Fig. 1. Dual isotope single photon emission computed tomography (SPECT) using thallium-201 chloride and technetium-99m pyrophosphate (PYP) on the 2nd day. The 2°lT1 (presented in green) image shows a large perfusion defect in the anteroseptal wall, and the 99mTc-PYP image (presented in red) shows increased accumulation in the anterior area concomitant with a partial defect (arrow) in myocardial infarction (M/)
Fig. 2. Short-axis slices of the heart show a rip in the anterior area of the left ventricle (arrows), which corresponds to the site of the partial defect on 99mTc-PYP tomograms vealed a pericardium filled with clotting blood. Short-axis slices of the ventricles showed a tear corresponding to the defect on the 99mTc-PYP image (Fig. 2).
Discussion The clinical findings usually associated with cardiac rupture include old age, female gender, history o f hypertension, no history o f prior m y o c a r d i a l infarction, restless-
ness and friction rub ( L o n d o n and L o n d o n 1965; Lewis et al. 1969). This patient showed all but one feature; i.e. there was no friction rub. A l t h o u g h some investigators report the finding o f ventricular p s e u d o a n e u r y s m in two-dimensional e c h o c a r d i o g r a p h y as a factor for predicting rupture ( C a t h e r w o o d et al. 1980), our patient showed a true a n e u r y s m with this investigation. The utility o f dual isotope S P E C T for diagnosing myocardial infarction has been previously reported (Adachi et al. 1991; H a s h i m o t o et al. 1988). O u r observations in this
221 case showed that the site of the partial defect on the 99mTc-PYP image corresponded to the site of rupture. While such a defect often suggests a previous or " o l d " myocardial infarction, our patient had no history or other evidence of previous myocardial infarction. Schuster and Bulkley (1979) emphasized the role of infarct expansion, including regional dilatation and thinning of the infarcted myocardium, as a mechanism for rupture. Two-dimensional echocardiography showed regional dilatation and thinning of the infarcted wall at the same site where the defect in the 99mTc-PYP image was noted. In conclusion we note that a partial defect in 99mTc-PYP uptake m a y be associated with cardiac rupture following acute myocardial infarction.
References Adaehi S, Hiroe M, Sugimoto K, Miyahara Y, Marumo F (1991) Color display of dual isotope SPECT imaging in right ventricular infarction associated with acute inferior myocardial infarction. Clin Nucl Med 16:876-877
Catherwood E, Mintz GS, Kotler MN, Parry WR, Segal BL (1980) Two-dimensional echocardiographic recognition of left ventricular pseudoaneurysm. Circulation 62: 294-303 Hashimoto T, Kambara H, Fudo T, Tamaki S, Takatsu Y, Hattori R, Tokunaga S, Kawai C (1988) Significance of technetium99m/thalllium 201 overlap on simultaneous dual emission computed tomography in acute myocardial infarction. Am J Cardio161:1181 1186 Hiroe M, Muramatsu Y, Sugimoto K, Tsujino M, Maejima M, Miyahara Y, Taniguchi K, Matsui S, Mizukawa K (1988) New application of myocardial infarct map using a dual isotope single photon emission computed tomography (SPECT) of Tc99m pyrophosphate and T1-201 chloride in patients with acute myocardial infarction (in Japanese with English abstract). Jpn J Nucl Med 25 : 1125-1129 Lewis AJ, Burchell HB, Titus JL (1969) Clinical and pathologic features of postinfarction cardiac rupture. Am J Cardiol 23:4353 London RE, London SB (1965) Rupture of the heart. A critical analysis of 47 consecutive autopsy cases. Circulation 31:202208 Schuster EH, Bulkley BH (1979) Expansion of transmural myocardial infarction. A pathophysiologic factor in cardiac rupture. Circulation 60:1532-1538
