How did the COVID-19 pandemic affect SPECT myocardial perfusion scans?

Objectives: The aim of this study is to evaluate the effect of the COVID-19 pandemic on myocardial perfusion scans (MPS) during the COVID-19 pandemic period. Method(s): We respectively reviewed single photon emission computed tomography myocardial perfusion scans (SPECT-MPS) performed between June and September 2020 during the COVID-19 pandemic at the Nuclear Medicine Research Center at Mashhad University of Medical Sciences. The findings of stress SPECT-MPS studies acquired in the corresponding months of 2019 were also evaluated for direct comparison. Result(s): In COVID-19 pandemic compared to period prior to the pandemic, no difference was observed in terms of age range of patients under study or their cardiovascular risk factors, except smoking which underwent a significant increase during the COVID-19 pandemic ( 19% vs. 13% , p = 0.009). While the number of patients with non-angina (19% vs. 31%, p = 0.000) or typical (11% vs. 19%, p = 0.000) chest pain significantly decreased during the COVID-19 pandemic, atypical (42% vs. 25%, p = 0.000) chest pain cases showed an increasing number. By considering pretest probability of the patients (high, intermediate and low/very low), during the COVID-19 period, cases of high pretest probability decreased (6% vs. 18%, p = 0.000) and intermediate pretest probability patients also increased (64% vs. 55%, p = 0.005) while low/very low pretest probability cases showed no changes between the two periods. All types of MPS stress tests in the COVID-19 period were pharmacological compared to exercise stress test. No statistically significant difference on the myocardial ischemia or cardiomyopathy between patients between the two periods was observed. Summed stress score (SSS) and summed rest score (SRS) was similar over the two periods,while summed difference score (SDS) significantly increased over the course of COVID-19, confirming a non- increasing pattern of myocardial ischemia. Conclusion(s): Previous research underscores the fact that the number of stress SPECT-MPS studies was significantly reduced during the COVID-19 pandemic compared to the corresponding months prior to the pandemic [1, 2]. Our study concluded that all types of MPS stress tests in the COVID-19 period were pharmacological. This is due to the fact that all related recommendations published in the literature [3] highlighted the avoidance of exercise stress tests during the COVID-19 pandemic to reduce the risk of droplet exposure. During the COVID-19 pandemic, patients in two ends of the spectrum (e.g., non-angina & typical chest pain) were referred less for MPS. However, patients in the middle of the spectrum (e.g., atypical chest pain) underwentMPS less frequently. Myocardial ischemia and cardiomyopathy were not decreased or increased in patients over the COVID-19 period.

Evaluation of cardiac involvement in patients with clinical post-COVID-19 syndrome

Introduction: The underlying pathophysiology of Post-COVID-19 syndrome remains unknown, but increased cardiometabolic demand and state of mitochondrial dysfunction have emerged as candidate mechanisms. Cardiovascular magnetic resonance (CMR) provides insight into pathophysiological mechanisms underlying cardiovascular disease and 31-phosphorus magnetic resonance spectroscopy (31P-MRS) allows noninvasive assessment of the myocardial energetic state. Purpose(s): We sought to assess whether Post-COVID-19 syndrome is associated with abnormalities of myocardial structure, function, perfusion and tissue characteristics or energetic derangement. Method(s): Prospective case-control study. A total of 20 patients with a clinical diagnosis of Post-COVID-19 syndrome (seropositive) and no prior underlying cardiovascular disease (CVD) and ten matching controls underwent 31P-MRS and CMR at 3T at a single time point. (Figure 1) All patients had been symptomatic with acute COVID-19, but none required hospital admission. Result(s): Between the Post-COVID-19 syndrome patients and matched contemporary controls there were no differences in myocardial energetics (phosphocreatine to ATP ratio), in cardiac structure (biventricular volumes, left ventricular mass), function (biventricular ejection fractions, global longitudinal strain), tissue characterization (T1 and extracellular volume [ECV] fraction mapping, late gadolinium enhancement) or perfusion (myocardial rest and stress blood flow, myocardial perfusion reserve). One patient with Post-COVID-19 syndrome showed subepicardial hyperenhancement on the late gadolinium enhancement imaging compatible with prior myocarditis, but no accompanying abnormality in cardiac size, function, perfusion, ECV, T1, T2 mapping or energetics. This patient was excluded from statistical analyses. (Table 1) Conclusion(s): In this study, the overwhelming majority of patients with a clinical Post-COVID-19 syndrome with no prior CVD did not exhibit any abnormalities in myocardial energetics, structure, function, blood flow or tissue characteristics.

Last year challenge of Nuclear Medicine: medical radioisotopes supply

Aim/Introduction: 99mTc is used in about 80% of the convencional diagnostic nuclear imaging procedures and represent yearly approximately 30 million examinations/year worldwide a year in diagnostic tests in hospitals, among others by oncology, cardiology and neurology.The production of radiopharmaceuticals for use in Nuclear Medicine has a complex system. It involves carefully calculated production schedules that take into account supply, demand and many logistical operations.The aim of this study is to show how our nuclear medicine department manage the impact of the shortly 99Mo supply chain and consequently, in the 99mTc availability and other radiopharmaceuticals produced in nuclear reactora. Material(s) and Method(s): European nuclear medicine organizations had just pay attention to how the COVID-19 pandemic might affect different parts of the 99Mo supply chain when had to dealt again faced with a new problem;the shortness 99Mo production. There are only five nuclear reactors involved in the production of 99Mo on industrial scale. These aging reactors are subject to unscheduled shutdowns and longer maintenance periods making the 99Mo supply chain vulnerable. In the last few months at our nuclear medicine department we had to reinvent ourselves so as not to completely stop carrying out the previously scheduled exams and therapies. Result(s): The use of technetium generators in Europe represents about 17% - 25% of the worldwide consumption of 99Mo, representing 30,000 exams per day and about 1.1 million doses per month. The main consequences at the IPO-Porto was;Delays in diagnosis/staging, rescheduling exams, change of surgery dates (Sentinel Ganglion and Myocardial Perfusion Cardiacs), weeks of overbooking, delay in follow-up of Glomerular Filtration Rate in pre- or post-transplant patients, postponement of 131I Therapies, Scintigraphy and Whole Body Scintigraphy in patients who were already in hypothyroidism. we had to reinvent the use of 99mTc generators, change exams appointments times, reagroup exams types by defined days and other radiopharmaceutical management tools that were not commonly used. Conclusion(s): Approximately 2/3 of scheduled exams were postponed and we had to deal with weekly and daily stock updates. Our department suggest some measures and procedures that could help with future 99Mo shortages, in order to be ready in future situations and to avoid shortness of production: the creation of a centralized European radiopharmacy system, European policies to encourage long-term investment, homogenization of marketing specifications in the Member States, solid databases of radiopharmaceuticals used/ available in Europe and encouraging cooperation between other countries outside the European Union.

Last year challenge of Nuclear Medicine: medical radioisotopes supply

Aim/Introduction: 99mTc is used in about 80% of the convencional diagnostic nuclear imaging procedures and represent yearly approximately 30 million examinations/year worldwide a year in diagnostic tests in hospitals, among others by oncology, cardiology and neurology.The production of radiopharmaceuticals for use in Nuclear Medicine has a complex system. It involves carefully calculated production schedules that take into account supply, demand and many logistical operations.The aim of this study is to show how our nuclear medicine department manage the impact of the shortly 99Mo supply chain and consequently, in the 99mTc availability and other radiopharmaceuticals produced in nuclear reactora. Material(s) and Method(s): European nuclear medicine organizations had just pay attention to how the COVID-19 pandemic might affect different parts of the 99Mo supply chain when had to dealt again faced with a new problem;the shortness 99Mo production. There are only five nuclear reactors involved in the production of 99Mo on industrial scale. These aging reactors are subject to unscheduled shutdowns and longer maintenance periods making the 99Mo supply chain vulnerable. In the last few months at our nuclear medicine department we had to reinvent ourselves so as not to completely stop carrying out the previously scheduled exams and therapies. Result(s): The use of technetium generators in Europe represents about 17% - 25% of the worldwide consumption of 99Mo, representing 30,000 exams per day and about 1.1 million doses per month. The main consequences at the IPO-Porto was;Delays in diagnosis/staging, rescheduling exams, change of surgery dates (Sentinel Ganglion and Myocardial Perfusion Cardiacs), weeks of overbooking, delay in follow-up of Glomerular Filtration Rate in pre- or post-transplant patients, postponement of 131I Therapies, Scintigraphy and Whole Body Scintigraphy in patients who were already in hypothyroidism. we had to reinvent the use of 99mTc generators, change exams appointments times, reagroup exams types by defined days and other radiopharmaceutical management tools that were not commonly used. Conclusion(s): Approximately 2/3 of scheduled exams were postponed and we had to deal with weekly and daily stock updates. Our department suggest some measures and procedures that could help with future 99Mo shortages, in order to be ready in future situations and to avoid shortness of production: the creation of a centralized European radiopharmacy system, European policies to encourage long-term investment, homogenization of marketing specifications in the Member States, solid databases of radiopharmaceuticals used/ available in Europe and encouraging cooperation between other countries outside the European Union.

Myocardial perfusion imaging findings of patients with history of COVID-19 infection: a single-center one-year experience

Aim/Introduction: COVID-19 pandemic has introduced significant new challenges in everyday medical practice, as history of COVID-19 infection becomes increasingly prevalent and its potential long-term effects and interactions with other known or unknown health problems have not been fully clarified. Here, we aimed to characterize patients with a history of COVID-19 infection who underwent myocardial perfusion imaging at the department of nuclear medicine of a tertiary cardiovascular medicine center. Material(s) and Method(s): Records of all patients with a history of COVID-19 infection with/without need for hospitalization who underwent scintigraphy from April, 1, 2021 to March, 31, 2022 at our department were obtained. Patients undergoing scintigraphy for indications other than myocardial ischemia/viability detection (for example lung perfusion scans, bone scans) were excluded. Regarding myocardial perfusion studies, the presence of scar or ischemia was determined, together with basic hemodynamic parameters (blood pressure, systolic-SBP, diastolic-DBP, pulse-PP) and the respective changes from rest to maximal stress, according to stress test applied. Result(s): In total, 152 patients undergoing myocardial perfusion imaging reported previous COVID-19 infection. For 3 patients, data were incomplete, so the remaining 149 formed our study group (94 male, 55 female, age 67>10years, 5>4 months after COVID-19 infection). In 48 of them (32.2%), treadmill stress test according to Bruce protocol was applied. Another 60 received intravenous adenosine infusion (40.3%), the remaining 41 undergoing regadenoson test (27.5%). Patient age differed significantly according to stress test type (treadmill: 63>10 years, adenosine 70>8 years, regadenoson: 66>10 years, p=0.0001). Forty five patients (30.2%) had reversible perfusion defects compatible with ischemia, while 21 (14.1%) showed permanent perfusion defects (myocardial scar). Both ischemia and scar were more common among patients who needed hospitalization due to COVID-19 compared to those with milder symptoms (ischemia: 17/40 among patients with history of hospitalization, 28/109 among those with no hospitalization due to COVID-19, p=0.048;scar: 11/40 among patients with history of hospitalization, 10/109 among those with no hospitalization, p=0.004). Among those undergoing treadmill test, the ones with history of COVID-19 hospitalization showed higher SBP and PP increase during exercise (86>17 versus 60>24mmHg for SBP, 65>18 versus 45>24mmHg for PP, p=0.009 and p=0.048 respectively), while DBP differences were insignificant. Conclusion(s): Abnormal myocardial perfusion findings in the form of both fixed and reversible perfusion defects are more common among patients needing hospitalization for COVID-19 infection. Altered hemodynamic response to exercise is also present in this patient population.

Cardiac Involvement is the Reason for Persistent Dyspnea in Post COVID-19 Patients without Pulmonary Sequelae: A Retrospective Study

Objective: Several forms of cardiovascular involvement have been described in acute coronavirus disease-2019 (COVID-19) infection and also it has been shown that acute infection is responsible for cardiac symptoms. However, the data on cardiac involvement and associated symptoms in chronic phase remains unclear. Recent evidence have shown that the reason for persistent dyspnea can be persistent cardiac dysfunction in post COVID-19 infection. The aim of our study was to investigate the relationship between persistent dyspnea and cardiac involvement in post COVID-19 patients without pulmonary sequelae. Material(s) and Method(s): In our study, we recruited 30 post COVID-19 patients with dyspnea between January 2021 and July 2021. In all patients, the absence of pulmonary sequelae was detected with PFT and chest- CT. 2D-TTE, 2D-STE and MPS were performed for each case. Result(s): Left ventricular dysfunction was detected in 63.3% of patients and also 93.3% of patients had extensive abnormal GLS at 3 month follow-up. Of the patients, 33.3% had myocardial perfusion defect (MPD) and all MPDs were observed to be reversible defects. MPD was obviously seen in anterior wall (60%) and mid (20%) to apical (70%) segments. As compared with patients without MPD, patients with MPD had higher CK-MB (p: 0.016) and troponin I (p: 0.011), lesser PW thickness (p:0.020) and lower peak systolic strain rate at A2C view (p:0.031). Patients with NYHA III had more impaired GLS than patients with NYHA II (p:0.035). Conclusion(s): Our study suggests ischemic or non-ischemic cardiac dysfunction may be associated with persistent dyspnea in post- COVID- 19 patients without lung sequelae. Copyright © 2022 by Turkiye Klinikleri.

A 51-YEAR-OLD MAN WITH WEIGHT LOSS AND CARDIOGENIC SHOCK

CASE: A 51-year-old man without significant past medical history presented to our hospital with dyspnea on exertion. SARS-CoV-2 was detected on routine occupational screening 2 months prior to admission. He subsequently reported a 100lb weight loss, during which time he experienced dysgeusia and ate primarily cereal, sandwiches, and potatoes and consumed nearly no fruits or vegetables. Three weeks prior to admission he developed postprandial nausea and vomiting and anorexia. A week later he developed progressive epigastric pain, lower extremity edema, and dyspnea while walking around the college campus where he worked as a security guard, and sought medical attention. He did not have fever, chills, night sweats, cough, orthopnea, paroxysmal nocturnal dyspnea, rash, or diarrhea. He had not seen a doctor in 20 years and took no medications. He did not drink alcohol, smoke cigarettes, or use illicit substances. Vital signs were T 36.6°F HR 104 BP 149/111 RR 20 and SpO2 97%. Physical examination revealed a cachectic man with bitemporal wasting, sunken orbits, poor dentition, and severe periodontal disease. JVP was 14cm of H2O at 45°. An S3 was present. The abdomen was tender to palpation in the mid epigastrium. The extremities were cool with 3+ pitting edema. Pancreatitis was diagnosed after discovery of markedly elevated lipase levels and peripancreatic fat stranding on abdominal CT. TTE showed biventricular systolic dysfunction with LVEF 15%. He developed cardiogenic shock complicated by oliguric renal failure, congestive hepatopathy and obtundation, requiring ICU transfer for diuresis and inotropic support. Further workup revealed deficiencies of thiamine, zinc, and vitamins A, C, and D. A regadenoson myocardial perfusion PET/CT showed no flow-limiting coronary artery disease, and workup for inflammatory, infectious, and toxic-metabolic causes of heart failure was unrevealing. While COVID myocarditis and multisystem inflammatory syndrome in adults (MIS-A) were considered, ultimately, a diagnosis of wet beriberi was made. After 5 months of aggressive nutritional supplementation via percutaneous gastrostomy tube and initiation of guideline-directed medical therapy, LVEF improved to 53% and weight increased by 35lbs. IMPACT/DISCUSSION: Wet beriberi is a potentially underrecognized cause of dilated cardiomyopathy in resource-rich areas. Within 3 months, thiamine deficiency can cause high-output heart failure due to impaired myocardial energy metabolism and dysautonomia. Risk factors include alcohol use disorder, prolonged vomiting, and history of bariatric surgery. CONCLUSION: The laboratory evaluation of non-ischemic dilated cardiomyopathy should include measurement of serum thiamine, carnitine, and selenium levels in select patients, alongside iron studies, ANA, screening for HIV, Chagas disease, and viral myocarditis, and genetic testing in patients with a suggestive family history. Empiric thiamine repletion should be considered in all critically ill patients with evidence of malnutrition.

Step-by-step surveillance in children with multisystem inflammatory syndrome associated with COVID-19 infection: proposal of a cardiologic follow-up

Introduction: Multisystem Inflammatory Syndrome Associated with COVID-19 Infection (MIS-C) shows many matches with children with Kawasaki disease (KD) and most children with MIS-C have incomplete or complete KD-like phenotype. In these patients cardiologic involvement mimics KD, showing, however, a higher incidence of severe acute manifestations. Objectives: In children with MIS-C and clinical findings related to heart disease, ECG and echocardiography are the first-line imaging. Until now, there are no international guidelines on the management of these patients. We suggest to take inspiration from the recommendations for KD for the significant phenotypic overlap between MIS-C and KD. Methods: We propose a step-by-step cardiologic imaging follow-up: - in all the patients, we recommend ECG and echocardiography at the diagnosis, at the worsening of the clinical and/or blood chemist parameters (CRP, ESR, ferritin;proBNP, troponin, D-Dimer), at any change of treatment supported by clinical worsening, at 8, 30, 45, 60, 90, 180 days since the diagnosis. The time-table may be changed in consideration of the outcome of the patient. -In patients with coronary artery dilatation (CAL), documented by echocardiography, it is advisable to follow-up them, since the diagnosis, with ECG, echocardiography, D-dimer, pro-BNP, troponin. -If CAL are oversized with z-score >- 2,5, according to age and body surface or increase during the follow-up: -it is recommended to perform Coronary Computed Tomography (CT) (CCA) or Cardiac Magnetic Resonance Angiography (CMRA). In fact, echocardiography cannot visualize the whole coronary artery vessels. Results: Both allow visualization of coronary artery aneurysms, vessels thickening, myocardial perfusion defects, permitting risk stratification and handing treatment decisions. CMRA is the first choice, because it is a radiation-free imaging method. It can evaluate the entire coronary artery system and provides details on myocardial function ischemia (detecting areas of inducible myocardial ischemia with pharmacological stress), infarction, inflammation, fibrosis. However, the new generation Multidetector Single -Source CT scanners and Dual Source Ct scanner allow a fast heart CT study with low radiation dose and reduce the need for sedation. CMR is less suitable because it is a lengthy examination and very often requires general anesthesia. If echocardiography demonstrates myocardial dysfunction or valve regurgitation at admission or during hospitalization, we suggest performing CMR. There is no consensus on the right timing. Conclusion: We suggest performing CMR during the acute or subacute phase: it is a step of the relieve in the cardiologic diagnosis to assess ventricular function and myocardial active injuries (oedema, hyperemia, ischemia, necrosis) and to repeat the imaging at the discharge in patients with the first pathological CMR, to evaluate fibrosis by myocardial delayed enhancement. CMR at the discharge is suggested also in cases with the first CMR normal, who showed a worsening of the echocardiographic parameters, the relieve of newinsurance valvulitis, persistent arrhythmia. At 3-6 months since the patient showed the remission, the CMR must be repeated to avoid any fibrotic lesions.