Applicability of the appropriate use criteria for SPECT myocardial perfusion imaging in Italy: preliminary results.

PURPOSE: Clinical applicability of the appropriate use criteria for SPECT myocardial perfusion imaging has not yet been evaluated in Italy. We investigated the applicability of the Appropriate Use Criteria (AUC) in Italy. METHODS: The indications for testing were prospectively recorded in three different nuclear cardiology laboratories: a general hospital, an academic hospital, and a tertiary centre. Indications were categorized as appropriate, uncertain or inappropriate according to the 2009 AUC; the specialty of the ordering physician was also noted. SPECT results were classified as: normal, probably normal, uncertain, probably abnormal, abnormal. The presence and severity of ischaemia were also noted. RESULTS: Over a 9-month period, 2,134 patients (age 67 ± 10 years, 68 % men) were evaluated (62 % exercise stress test). On average, there were 700 (84 %) appropriate, 73 (7 %) inappropriate and 93 (9 %) uncertain tests. The rates for the appropriateness of indications were comparable in men and women (84 % and 83 %, not significant). As expected, the rate of nonnormal studies was higher (58 %) for appropriate than for inappropriate (33 %) indications. Appropriateness was lower in the tertiary centre (74 %), and uncertain (16 %) and inappropriate (10 %) indications were more common; this was related to the higher rate of outpatients scheduled by nonhospital cardiologists (37 %). The most common indications associated with inappropriate testing were: chest pain, low likelihood of coronary artery disease, interpretable ECG and able to exercise (29 %), and asymptomatic <2 years after percutaneous coronary intervention (24 %). CONCLUSION: In this preliminary evaluation of the AUC in Italy, the majority of studies were classified as appropriate, but a consistent proportion of scheduled SPECT studies, particularly by nonhospital cardiologists, were still categorized as uncertain or inappropriate. Educational approaches should be implemented to reduce the rate of less appropriate examinations. However, a substantial proportion (33 %) of inappropriate studies were classified as nonnormal, with 26 % of these patients having ischaemia.

Temporal evolution of administered activity in cardiac gated SPECT and patients' effective dose: analysis of an historical series.

PURPOSE: Myocardial perfusion imaging contributes >20 % of the average medical radiation exposure to the population in the USA. Imaging protocols able to achieve a radiation exposure ≤9 mSv in 50 % of the studies by 2014 have been recommended. The aim of this study was to analyse the temporal evolution of administered activities in patients scheduled for dual-day (99m)Tc tracer gated single photon emission computed tomography (SPECT) and to compare different dose administration protocols in terms of patients' effective dose. METHODS: Patients evaluated from 1 July 2002 to 31 January 2012 were allocated according to the protocol adopted: group 1: fixed activity according to diagnostic reference level: 740 MBq up to 80 kg (adapted for weight <60 kg); 900 MBq 80-100 kg, 1,110 MBq >100 kg, standard filtered back-projection (FBP) reconstruction; group 2: weight-adjusted activity: 8 MBq/kg up to 1,110 MBq, standard FBP reconstruction; and group 3: 4 MBq/kg, UltraSPECT wide beam reconstruction (WBR) reconstruction. A dual-head Anger camera (GE Helix) was used. RESULTS: A total of 9,060 patients were allocated to different groups: 4,751 in group 1, 2,844 in group 2 and 1,465 in group 3. The stress + rest administered activity was 1,617 ± 180 in group 1, 1,136 ± 260 in group 2 and 682 ± 164 MBq in group 3 (all p < 0.001). Patients' effective dose was 13.7 ± 3 in group 1, 9.5 ± 2.8 in group 2 and 5.7 ± 1.6 mSv in group 3 (all p < 0.001). The 50th percentile was 12.6 in group 1, 9.1 in group 2 and 5.3 mSv in group 3. The effective dose received by the dedicated cardiologists was 2.1, 1.5 and 1.0 µSv/exam in group 1, group 2 and group 3 periods, respectively (all p < 0.001). CONCLUSION: A significant reduction over time in the administered activity for gated SPECT was achieved; accordingly, a significant reduction in patients' exposure was obtained. A simple weight-adjusted strategy with 8 MBq/kg immediately fulfils the recommendations to limit exposure. In selected group 3 patients, a stress-only strategy allows for studies with <3 mSv exposure. Thus, at least the adoption of a new reconstruction algorithm is strongly encouraged, and suggested tracer activities for cardiac gated SPECT are to be revised.

Assessment of cardiac asynchrony by radionuclide phase analysis: correlation with ventricular function in patients with narrow or prolonged QRS interval.

BACKGROUND: Conflicting data exist on the relation between the synchronism of cardiac contraction and ventricular function. AIM AND METHODS: A resting radionuclide ventriculography (RNV) was performed in 380 consecutive patients to evaluate the relationship between the synchronism of cardiac contraction and ventricular function. RESULTS: A significant, non-linear, relation was found between LVEF and intra-ventricular asynchrony or QRS, but not between inter-ventricular asynchrony and LVEF. A linear correlation was observed between QRS and intra-ventricular or inter-ventricular asynchrony. Intra-ventricular asynchrony was identified as the major, independent, determinant of LV function. With the increase in QRS duration, a decrease in LVEF (p<0.001), and a worsening of either intra-ventricular (p<0.001) or inter-ventricular synchronism (p<0.05), was documented. However, 48% of patients with QRS 120-150 ms had abnormal inter-ventricular and 42% abnormal intra-ventricular synchronism, while 27% of patients with QRS>150 ms had normal inter-ventricular and 25% normal intra-ventricular synchronism. CONCLUSIONS: Intra-ventricular asynchrony was identified as the major determinant of ventricular dysfunction. A consistent proportion of patients had asynchrony despite preserved QRS duration or normal synchronism with a QRS>150 ms. Fourier phase analysis of RNV may detect asynchrony better than QRS. The role of RNV for detection of individual patients who may most benefit from resynchronization therapy requires additional investigations.

Differential systolic and diastolic effects of beta-adrenergic stimulation in patients with severe left ventricular dysfunction: a radionuclide ventriculographic study.

BACKGROUND: An attenuated inotropic response to beta-adrenergic stimulation has been documented in patients with severely depressed left ventricular (LV) function. Scant data exist regarding the effect of beta-adrenergic stimulation on LV diastolic function in human beings. Our objective was to evaluate the effect of dobutamine infusion on LV systolic and diastolic function in patients with severe ventricular dysfunction. METHODS AND RESULTS: We studied 26 patients (60 +/- 9 years) in stable condition with healed myocardial infarction and LV ejection fraction (EF) less than 35% by radionuclide ventriculography. LVEF, volumes, peak ejection rate (PER), peak filling rate (PFR), and peak systolic pressure-to-end-systolic volume ratio were calculated at the infusion rate of 5 and 10 gamma x kg(-1) x min(-1). At 5 gamma x kg(-1) x min(-1), no changes were observed in heart rate (75 +/- 16 beats/min vs 75 +/- 15 beats/min at rest), LVEF (23% +/- 8% vs 22% +/- 7%), and PER (1.40 +/- 0.48 end-diastolic volume per second [EDV/s] vs 1.30 +/- 0.48 EDV/s); however, a significant increase in PFR was observed (1.11 +/- 0.36 EDV/s vs 0.86 +/- 0.30 EDV/s, P < .01). At 10 gamma x kg(-1) x min(-1), an increase in LVEF (25% +/- 10%, P < .01) and PER (1.60 +/- 0.57 EDV/s, P < .01) was observed; PFR (1.25 +/- 0.36 EDV/s, P < .05) also increased, whereas heart rate (78 +/- 18 beats/min) was unchanged. No significant changes in LV volumes or in indices of LV contraction synchronicity were observed during infusion. Finally, the peak systolic pressure-to-end-systolic volume ratio was unchanged at 5 gamma x kg(-1) x min(-1) and significantly increased at 10 gamma x kg(-1) x min(-1). CONCLUSIONS: In stable patients with ischemic heart disease and severe LV dysfunction, beta-adrenergic stimulation may still induce a positive lusitropic response, despite attenuated inotropic and chronotropic responses; moreover, the effects on diastolic function occur earlier than those on systolic function.

Electrocardiographic evolution after Q-wave anterior myocardial infarction: correlations between QRS score and changes in left ventricular perfusion and function.

BACKGROUND: In the thrombolytic era, conflicting data have been reported on the usefulness of the QRS score in estimating the amount of left ventricular (LV) damage after acute myocardial infarction (MI). METHODS AND RESULTS: We correlated the QRS score with the extent of LV hypoperfusion and ejection fraction (EF) in 95 consecutive male patients with a first anterior Q-wave MI; the 6-month evolution of QRS score and changes in LV perfusion and function were also compared. The Selvester-Wagner QRS score was computed from the digitized 12-lead electrocardiogram, both at predischarge and 6 months later; at the same time, resting sestamibi first-pass ventriculography and single photon emission computed tomography imaging were performed. A reduction in QRS score occurred at 6 months (6.7 +/- 3.4 vs 7.8 +/- 2.9 at predischarge; P <.001); the perfusion defect extent also decreased (P <.01), and LV EF improved (P <.05). At predischarge, no correlation was found between QRS score and hypoperfusion extent or EF; in contrast, a weak correlation was observed 6 months later (r = 0.55; P <.001; and r = 0.48; P <.01, respectively). QRS score changes from predischarge to 6 months showed limited accuracy in predicting clinically meaningful changes of perfusion or EF (receiver operating characteristic area under the curve, 0.58 and 0.61, respectively). Thrombolytic therapy did not influence the relationship between QRS score and scintigraphic findings. CONCLUSIONS: In patients with recent anterior Q-wave MI, QRS scoring showed a weak, delayed correlation with the amount of LV damage, as estimated by radionuclide techniques. Spontaneous changes in QRS score from predischarge to 6 months seem to be of limited value in identifying patients with late improvement in LV perfusion and function.

Independent and incremental prognostic value of (201)Tl lung uptake at rest in patients with severe postischemic left ventricular dysfunction.

BACKGROUND: An elevated (201)Tl lung uptake after stress is related to an adverse prognosis. METHODS AND RESULTS: The functional and prognostic significance of resting (201)Tl lung uptake was assessed in 124 consecutive patients with ischemic heart disease and ejection fraction 0.61 best separated patients with and without events (ROC area under curve 0.82). Event-free survival was significantly lower in patients with L/H >0.61 (P:<0. 001); L/H >0.61 (chi(2)=10.8; P:<0.001) and a restrictive filling pattern (chi(2)=3.6; P:<0.05) were independent predictors of events. The prognostic value of L/H was incremental over that obtained by clinical, echographic and Doppler data (global chi(2)=20.8). CONCLUSIONS: In patients with severe postischemic left ventricular dysfunction undergoing rest-redistribution (201)Tl imaging, an increased lung tracer uptake showed incremental prognostic value over clinical and other imaging findings, providing clinically useful risk assessment.

Transient left ventricular dilation at quantitative stress-rest sestamibi tomography: clinical, electrocardiographic, and angiographic correlates.

BACKGROUND: Few data are available regarding the incidence and significance of transient left ventricular (LV) dilation on stress sestamibi single photon emission computed tomography (SPECT), which is different from thallium-201 studies because images are acquired late after tracer injection. METHODS: We studied 234 patients with ischemic heart disease and interpretable electrocardiograms undergoing stress-rest sestamibi SPECT on separate days. Sestamibi uptake defect extent was quantified on SPECT polar maps. Epicardial and endocardial transient dilation indexes (TDI) were also calculated. RESULTS: According to our normal TDI values, 148 patients (63%) had no dilation and 86 patients (37%) had abnormal endocardial TDI; a global LV dilation (abnormal endocardial and epicardial TDI) was observed in 19 patients (8%). ST-segment depression was more frequent in patients with transient LV dilation (55%) than in those without (36%; P < .01), as were the extent of stress hypoperfusion (13% +/- 12% vs 6% +/- 7% in patients with no dilation; P < .001) and the angiographic severity score (11.4 +/- 5.9 vs 9.2 +/- 3.7; P < .05). At multivariate analysis, stress hypoperfusion was the sole predictor of transient LV dilation. CONCLUSIONS: Transient LV cavity dilation is frequent on stress sestamibi SPECT. Ventricular cavity dilation is more common than global dilation and suggests subendocardial ischemia. It is related to a greater amount of jeopardized myocardium and is strongly associated with electro-cardiographic signs of ischemia.

Heterogeneous fate of perfusion and contraction after anterior wall acute myocardial infarction and effects on left ventricular remodeling.

After acute myocardial infarction, patency of infarct vessel and extent of left venticular (LV) dysfunction are major determinants of ventricular remodeling. Spontaneous, delayed reperfusion in the infarct zone occurs in a sizeable number of patients well after the subacute phase. The aim of this study was to determine the relation between the occurrence of this spontaneous, delayed reperfusion and LV remodeling. In 84 patients, resting LV volumes, topography, regional function, and perfusion were quantitatively evaluated by 2-dimensional echocardiography and sestamibi tomography 5 weeks (study 1) and 7 months (study 2) after anterior Q-wave infarction. At study 2, LV end-diastolic volume increased by > 15% in 17 patients (20%, LV remodeling); they had already had at study 1 significantly larger LV volumes, more severe hypoperfusion and wall motion abnormalities, and greater regional dilation than patients with stable LV volumes. Delayed reperfusion occurred in 8 of 17 patients with and in 42 of 67 patients without LV remodeling (47% vs 63%; p=NS). At study 2, LV regional dilation and end-diastolic volumes were stable in patients with, but increased in patients without, spontaneous reperfusion (from 25+/-24% to 29+/-26% at study 2 [p<0.05] and from 65+/-14 to 68+/-18 ml/m2 [p <0.05]). At multivariate analysis, however, regional ventricular dilation at study 1 was the sole predictor of further LV remodeling. Thus, after acute myocardial infarction, spontaneous reperfusion occurring after 5 weeks plays only a minor role in influencing LV remodeling. Benefits from delayed reperfusion seem limited to patients with preserved LV volumes; patients with an enlarged left ventricle 5 weeks after acute infarction are prone to further LV remodeling, irrespective of delayed reperfusion.

Ischemic burden in silent and painful myocardial ischemia: a quantitative exercise sestamibi tomographic study.

OBJECTIVES: We sought to determine whether the amount of myocardial ischemic burden differs in patients with painful or silent myocardial hypoperfusion during exercise testing. BACKGROUND: Whether a lack of symptoms during ischemia reflects an alteration in pain perception or less myocardium in jeopardy remains a controversial issue. METHODS: We studied 300 consecutive patients with a well established history of ischemic heart disease and reversible hypoperfusion on exercise sestamibi tomography. Rest and stress sestamibi defects were quantitatively assessed and indexes of exercise left ventricular dilation derived. RESULTS: Painful and silent reversible ischemia was observed in 97 (32%) and 203 (68%) patients, respectively. Patients with painful ischemia had lower values for work load, exercise time and peak rate-pressure product (p < 0.01) and more frequently showed significant ST segment depression during exercise than did patients with silent ischemia (69% vs. 40%, p < 0.001). On sestamibi tomography, patients with painful ischemia had more reversible hypoperfusion than did patients with silent ischemia (mean +/- SD 16 +/- 10% vs. 11 +/- 7%, p < 0.001), despite a comparable extent of stress hypoperfusion (22 +/- 12% vs. 22 +/- 13%); they also had a higher endocardial dilation index (1.32 +/- 0.32 vs. 1.10 +/- 0.26, p < 0.001). By multivariate logistic analysis, the most powerful correlate of painful ischemia was a history of effort angina; the extent of reversible perfusion defect was the sole independent scintigraphic correlate of painful ischemia. CONCLUSIONS: To our knowledge, this is the largest study comparing the degree of hypoperfusion and the presence of symptoms during exercise stress testing in a consecutive cohort of patients with ischemic heart disease and reversible hypoperfusion. The results suggest that the ischemic burden is greater in painful than in silent ischemia.

Residual exertional ischemia and unfavorable left ventricular remodeling in patients with systolic dysfunction after anterior myocardial infarction.

OBJECTIVES: This study investigated whether exercise-induced myocardial ischemia influences left ventricular remodeling after anterior myocardial infarction. BACKGROUND: The effects of acute and recurrent ischemia on ventricular function are well established. However, to our knowledge the role of exertional ischemia in the remodeling response after infarction has not been investigated. METHODS: Ninety-one patients with a first anterior Q wave myocardial infarction were studied at 5 weeks by rest echocardiography and exercise scintigraphy. The echocardiographic examination was repeated 6 months later. On the basis of the presence and extent of reversible perfusion defects on exercise scintigraphy, patients were assigned to groups with no exertional ischemia (group 1, n = 20 [22%], mild to moderate ischemia (group 2, n = 45 [49%]) and severe exertional ischemia (group 3, n = 26 [29%]). RESULTS: Initial left ventricular volumes were similar, and no differences were found among the three groups in the remodeling response over the 6-month period of the study. However, patients in groups 2 and 3 with an ejection fraction < or = 40% showed significant (p < 0.01) ventricular enlargement over time, which was similar between the two groups (end-diastolic volume [mean +/- SD] from 74 +/- 13 to 80 +/- 17 ml/m2 in group 2 and from 72 +/- 11 to 81 +/- 19 ml/m2 in group 3; regional dilation from 42 +/- 16% to 52 +/- 22% in group 2 and from 38 +/- 18% to 46 +/- 27% in group 3). In contrast, ventricular dimensions did not change in group 1 patients with an ejection fraction < or = 40% as well as in patients in all three groups with an ejection fraction > 40%. CONCLUSIONS: Exercise-induced myocardial ischemia may contribute to progressive ventricular enlargement in patients with poor left ventricular function after a large anterior myocardial infarction.

Technetium-99m sestamibi tomographic evaluation of residual ischemia after anterior myocardial infarction.

OBJECTIVES: This study investigated the value of sestamibi scintigraphy in assessing residual ischemia after anterior myocardial infarction. BACKGROUND: Serial imaging with sestamibi, the uptake and retention of which correlate with regional myocardial blood flow and viability, has been used to estimate salvaged myocardium and risk area after acute infarction. We recently documented that recovery of perfusion and contraction in the infarcted area may continue well after the subacute phase, suggesting myocardial hibernation. Some underestimation of viability in the setting of hibernating myocardium by sestamibi imaging has been reported. METHODS: We studied 58 patients in stable condition after Q wave anterior infarction. Regional perfusion and function were quantitatively assessed by sestamibi tomography and two-dimensional echocardiography at 4 to 6 weeks and at 7 months after infarction. In sestamibi polar maps, abnormal areas with tracer uptake > 2.5 SD below our reference values were computed at rest and after symptom-limited exercise. On two-dimensional echocardiography the ejection fraction and extent of rest wall motion abnormalities were assessed by a computerized system. All patients had coronary angiography between the two studies. RESULTS: At 7 months the extent of rest sestamibi defect was significantly reduced in 40 patients (69%, group 1) and unchanged in 18 (31%, group 2). Rest wall motion abnormalities and ventricular ejection fraction significantly improved in group 1 but not in group 2. Underlying coronary disease, patency of the infarct-related vessel and rest sestamibi defect extent at 5 weeks were comparable between the two groups. At 7 months, an increase in the reversible (stress-rest defect) tracer defect was observed in group 1 (p < 0.05) despite a smaller stress-induced hypoperfusion (p < 0.05). Reversible sestamibi defects and stress hypoperfusion were unchanged in group 2. In 38 (95%) of 40 group 1 patients, the area showing reversible sestamibi defects at 7 months matched the area showing fixed hypoperfusion at 5 weeks. CONCLUSIONS: The reduction in the rest tracer uptake defect that can occur late after infarction may affect the assessment of ischemic burden by sestamibi imaging early after anterior myocardial infarction.

Evaluation of technetium-99m-sestamibi lung uptake: correlation with left ventricular function.

UNLABELLED: Lung uptake of 201Tl is a reliable marker of left ventricular dysfunction. The goal of our study was to establish whether the evaluation of lung-to-heart uptake ratios (LHR) with 99mTc-sestamibi imaging may provide valuable information. METHODS: We studied 72 male subjects with recent anterior myocardial infarction undergoing 99mTc-sestamibi first-pass ventriculography and SPECT perfusion imaging. A group of 46 gender-matched subjects with low pre-test likelihood of CAD and normal exercise and rest 99mTc-sestamibi perfusion images was used as a control. The lung-to-heart count ratios (LHR) were calculated on planar projections from the sets of SPECT images. RESULTS: Both groups were studied at rest and after a symptom-limited exercise tolerance test. In the control group a significant decrease in LHR was observed during stress (p < 0.001). The infarcted group showed significantly higher LHR values both at rest and at stress. Exercise and rest LHR values did not differ significantly. A positive correlation was observed between LHR values and left ventricular ejection fraction at rest and stress. CONCLUSION: LHR, measured by 99mTc-sestamibi imaging, gives clinically useful information. Both resting and postexercise values are correlated with ejection fraction and should predict left ventricular dysfunction.

Effects of nitroglycerin by technetium-99m sestamibi tomoscintigraphy on resting regional myocardial hypoperfusion in stable patients with healed myocardial infarction.

Myocardial sestamibi uptake reflects regional flow distribution and cellular integrity; however, some segments showing reduced tracer uptake at rest may consist of viable, although hypoperfused, myocardium. It is speculated that the administration of nitroglycerin (NTG) before the sestamibi injection would improve the tracer uptake in resting hypoperfused regions. Thirty-six stable patients with previous myocardial infarction (56 +/- 2 years; mean ejection fraction 42 +/- 2%), in whom perfusion defects could be seen at resting sestamibi tomography, repeated the scintigraphic study 2 to 6 days later, receiving NTG (0.3 to 0.6 mg sublingually) before the tracer injection. The size of the tracer uptake defect was quantified from circumferential profiles in 3 short-axis slices by integrating the area below the lower normal limit (mean -2 SD). After NTG, the mean perfusion defect significantly decreased (from 6,324 +/- 619 to 5,365 +/- 516, p < 0.01). The defect was reduced beyond the reproducibility limits in 20 patients (56%, group 1) and was unchanged or increased in 16 (44%, group 2). The resting sestamibi defect size was comparable between the 2 groups. The average percent reduction of the perfusion defect after NTG was 29 +/- 4% (range 7 to 74).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of mental stress on myocardial perfusion in patients with ischemic heart disease.

The purpose of the present study was to determine whether and to what extent mental stress can reproduce the perfusion defects that are known to be induced by exercise. Twenty-four patients with recent myocardial infarction (New York Heart Association functional class I) and evidence of ischemic response were evaluated by means of SESTAMIBI scintigraphy performed once after exercise and then again within 2 days after mental arithmetic. Baseline, exercise, and mental stress planar scintigrams were divided into 15 segments, and each segment was reviewed and scored on a scale of 0 to 3 by experienced observers using circumferential profile analysis. Conflicting scores were resolved by consensus. Electrocardiographic abnormalities were found in 15 of 24 patients during exercise and in none during mental arithmetic. Chest pain was experienced by five patients during exercise and by none during mental stress. Twenty patients showed reversible perfusion defects during mental stress. Of the 360 pooled scintigram segments, 99 evidenced uptake defects during exercise, and 48 of these showed the same defects during mental stress. Twenty of the remaining 51 of 99 segments were adjacent to segments showing reversible hypoperfusion, suggesting milder hypoperfusion in these segments during mental arithmetic than during exercise. Furthermore, 10 segments showed reversible defects only during mental stress such that seven of these occurred in areas adjacent to those that had shown exercise-induced reversible perfusion defects, two occurred in areas that had shown fixed SESTAMIBI defects during exercise, and one occurred in a segment that had shown completely normal uptake during exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative lymphoscintigraphy.

A radioisotopic method was used to evaluate the state and dynamics of the lymphatic system in 92 patients affected by chronic oedema of the limbs and in 12 control subjects. After interstitial injections of 99mTc-sulphur microcolloid, scans were obtained using a LFOV camera linked to a data processor. The quantitative indices of clearance and lymph node uptake obtained showed good correlation with lymphoedema etiology, controls and ostensibly healthy limbs of patients affected by monolateral disease. In conclusion, quantitative lymphoscintigraphy appears to be a feasible indicator of early changes in the lymph pathophysiology and supports the hypothesis that lymphoedema generally arises from a predisposing congenital pathology.

[Lymphoscintigraphy in the study of lymphedema of the arms]. / La linfoscintigrafia nello studio dei linfedemi degli arti superiori.

The aim of this work has been the study of the mechanism of lymph formation and drainage in the upper limb in patients with monolateral lymphoedema (15 limbs, L) in comparison with the apparently healthy limb (S) as well as with a control group (8 limbs, C). After interstitial injection of 99mTc sulphur micro-colloid, scans were obtained employing a LFOV camera linked to a data processor. Results were expressed as percentage of the id removed from the injection site 1 and 6 hr pi, mean T6%/h it is (T6-T1)/5 and percentage lymph nodes uptake at the same times. Mean T6%/h is significantly different between C and L, but not between L and S, while lymph node uptake at 6 hr shows a significant difference even between C and S. Quantitative lymphoscintigraphy appears to be a feasible indicator of early changes in the lymph pathophysiology and supports the hypothesis that lymphoedema generally arises from a predisposing congenital pathology.

[Prognostic value of echocardiography in acute myocardial infarct: comparison, by multivariate analysis, between mono- and bidimensional parameters]. / Validità prognostica dell'ecocardiografia nell'infarto miocardico acuto: confronto, mediante analisi multivariata, tra reperti mono e bidimensionali.

A multivariate step-wise analysis with death or heart failure as prognostic end-points was utilized in 62 patients with an acute myocardial infarction (AMI), to evaluate the age related short-term prognostic significance of selected M-Mode and two dimensional echocardiographic parameters, and to identify, among them, the best predictors of the clinical outcome. The echocardiographic examination was performed within 24 hours from the occurrence of cardiac chest pain. After a three months follow-up study, the patients were divided into groups: 9 patients who died (Group A), 53 patients who survived (Group B), subdivided into 41 asymptomatic patients (Group B1) and 12 patients with clinical signs of heart failure (Group B2). The selected parameters were: age, left ventricular end-diastolic and end-systolic diameters (LVEDD, LVESD), left atrial diameter (LAD), the electrocardiographic PR interval minus AC interval from the mitral echogram (PR-AC), the distance between the mitral E point and the septum (EPSS), total aortic excursion (TAE), and two dimensional wall motion score. From the step-wise analysis of groups A and B we classified the parameters as follows, the relative prognostic significance being highest on the left side: score greater than TAE greater than AGE greater than PR-AC greater than LVEDD (LAD, LVESD, EPSS). For groups B1 and B2 the following results were obtained: score greater than PR-AC greater than AGE greater than LVESD greater than EPSS (TAE, LVESD, LAD). In parenthesis are indicated the variables whose prognostic value did not reach any significant level. When a discriminant function was applied to the 5 most significant variables, we could identify 78% of the patients of group A, and 77% of those of the group B; of groups B1 and B2 we identified correctly 83% and 92% of the patients respectively.(ABSTRACT TRUNCATED AT 250 WORDS)