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Background. Myocardial stunning has recently been demonstrated by use of stress gated technetium 99m sestamibi single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy. However, its prognostic value is less well determined. The aim of this study was to investigate the prognostic value of reversible regional wall motion abnormalities (RWMAs). Methods and Results. We studied 303 consecutive subjects with known or suspected coronary artery disease who underwent 2-day stress-rest gated Tc-99m sestamibi SPECT and were followed up for 19 ± 16 months. Clinical and test-derived variables were evaluated to predict cardiac death, nonfatal myocardial infarction (MI), unstable angina, and early or late coronary revascularization. Reversible RWMAs were identified in 102 patients. On Cox analysis, the presence, site, degree, and extent of reversible RWMAs did not identify an adverse outcome, except in patients without prior ML After adjustment for prescan data, the strongest predictors of hard events and all cardiac events were poststress RWMAs and the amount of ischemia. The addition of poststress RWMAs to the combined model of prescan and perfusion data yielded incremental prognostic value. Conclusion. Poststress RWMAs and ischemia by perfusion were the most powerful predictive parameters of cardiac events. However, myocardial stunning should always be considered, particularly in patients without prior MI and in the referral of patients for early revascularization. (J Nucl Cardiol 2005;12:20-31.)

The simultaneous assessment of perfusion and function with the use of technetium 99m sestamibi gated single photon emission computed tomography (SPECT) is helpful for the detection of myocardial viability, but its value in comparison with more established methods is not yet defined. This study compared low-dose dobutamine (LDD) nitrate-enhanced gated SPECT with LDD echocardiography for predicting recovery of regional ventricular function after revascularization in 25 patients with ischemic cardiomyopathy. In both studies, regional function (wall motion and thickening) at rest, during inotropic stimulation, and after revascularization was scored by a 4-point scale. In LDD echocardiography, the prediction of reversible dysfunction was based on the recognition of contractile reserve in asynergic (hypokinetic or a-dyskinetic) segments. In LDD gated sestamibi SPECT, reversible dysfunction was predicted on the basis of perfusion quantification (sestamibi uptake > 50%) in a-dyskinetic segments and on the basis of contractile reserve in hypokinetic segments. LDD echocardiography predicted reversible dysfunction with sensitivity, specificity, and global accuracy of 57%, 85%, and 75%, respectively. The sensitivity and specificity of LDD gated SPECT for identifying dysfunctional segments capable of functional recovery were 77% and 88%, respectively, with a diagnostic accuracy of 84% (P < .02 vs LDD echocardiography). The combined use of 2 different markers of viability, such as cellular integrity in a-dyskinetic segments and contractile reserve in hypokinetic segments, as permitted by LDD gated sestamibi SPECT, showed higher predictive accuracy for reversible dysfunction than the assessment of contractile reserve in all asynergic segments with LDD echocardiography. (J Nucl Cardiol 2002;9:402-6.)

The value of gated single photon emission computed tomography (SPECT) in the assessment of wall motion (WM) in patients with severe perfusion defects and in the evaluation of low-dose dobutamine (LDD)-induced changes is not yet established. In patients with chronic coronary artery disease who have left ventricular (LV) dysfunction, the results of nitrate-enhanced technetium 99m sestamibi (sestamibi) gated SPECT for the evaluation of resting and LDD WM were compared with those of baseline and LDD echocardiography (LDDE).Thirty-seven patients underwent echocardiography and nitrate-enhanced sestamibi gated SPECT within 1 week at rest and during LDD infusion. WM was scored from 1 (normal) to 4 (dyskinetic) by using a 16-segment model. Segments with sestamibi uptake less than 30% were considered unsuitable for WM analysis (36 of 592 segments). Echocardiography was technically unreliable in 10 of 592 segments. The precise agreement between echocardiography and gated SPECT for baseline regional WM was 68.4% (kappa = 0.54), without significant differences for the involved coronary artery territory. The agreement for +/- 1 WM scoring was 96.5% (kappa = 0.94). Contractile reserve during LDD was detected by means of echocardiography in 36% and by means of sestamibi gated SPECT in 33% of baseline asynergic segments. Agreement for detection of WM improvement in response to LDD was 74% (kappa = 0.41). The overall and +/-1 WM score agreement for LDD WM was 67.5% (kappa = 0.50) and 94.7% (kappa = 0.91), respectively. A significant correlation between echocardiography and gated SPECT was observed for both baseline (p = 0.78) and LDD (p = 0.74) WM score index.In patients with coronary artery disease who have LV dysfunction, nitrate-enhanced sestamibi gated SPECT allows a reliable WM evaluation, both at rest and during LDD infusion, in almost all segments and provides results in agreement with LDDE.

Preserved thrombolysis in myocardial infarction (TIMI) flow before percutaneous coronary intervention (PCI) in acute myocardial infarction is related to improved outcome. Gated single-photon emission computed tomography (SPECT) allows the simultaneous assessment of left ventricular perfusion and function. We evaluated the initial risk area and subsequent evolution of perfusion and function according to TIMI flow before successful primary PCI.In 36 patients, treated with abciximab, primary PCI and stenting, 99mTc-sestamibi was injected before PCI and gated SPECT acquired thereafter. Gated SPECT was repeated 7 and 30 days later. Perfusion defect, wall motion score index, left ventricular ejection fraction and volumes were examined.Before PCI, 14 patients (group A) showed TIMI flow 2-3 and 22 (group B) TIMI flow 0-1, but no differences in clinical variables, initial risk area, wall motion score, ejection fraction or volumes. Perfusion defect was smaller in group A at 7 (9%+/-11% vs 19%+/-14%, p0.02) and 30 days (7%+/-7% vs 16%+/-12%, p0.02) and the salvage index was higher at 30 days (77%+/-22% vs 55%+/-28%, p0.02). Wall motion score was lower in group A at 30 days (p0.05). Ejection fraction significantly improved in both groups at 7 and 30 days. End-diastolic volume showed a trend towards a reduction in group A, whilst it was significantly increased in group B. Conversely, end-systolic volume was significantly decreased in group A but remained unchanged in group B.In the setting of optimal myocardial reperfusion for myocardial infarction, preserved TIMI flow before PCI does not limit the initial risk area but it does improve myocardial salvage and functional recovery.

The objective of this study is to determine if the increase in frequency of cesarean section (C/S) is associated with a decreased incidence of major birth trauma. A retrospective cohort study was performed looking at all neonatal cases of major birth trauma occurring from 1/89 to 12/94. Major birth trauma was defined as peripheral plexus or nerve injuries, fractures, and inadvertent surgical as well as traumatic lacerations. Neonates with minor birth trauma such as scalp clip injuries, cephalohematomas, bruises, and forceps marks were excluded. Charts of newborns and mothers were reviewed. Data was grouped into two mutually exclusive time periods (1/89 to 12/90 vs. 1/91 to 12/94) in which a significant difference in the C/S rate was suspected. The incidence of overall major birth trauma as well as the relative risk and 95% confidence interval (CI) of specific subtypes of birth trauma were calculated and compared between the time periods using the Chi-square test. To evaluate the role of changing delivery patterns on overall birth trauma, a stratified analysis and Mantel-Haenszel test were performed. The results showed that of 17,957 deliveries during the study period, 141 cases of birth trauma occurred. 137 of the 141 records were available for review, and 116 were classified as major trauma and are included in this analysis. The overall incidence of major birth trauma was 6.5 cases/1000 deliveries. During the two year time period(1/89 to 12/90), 18.3% of deliveries were by C/S, and the major birth trauma rate was 8.4 cases/1000 deliveries. During the following 4 year period, the C/S rate was 22.3% with the major birth trauma rate of 5.3 cases/1000 deliveries. A statistically significant difference in the birth trauma(χ2=6.12, p=.013) and C/S (χ2=40.80, p

We report on a woman with a balanced complex chromosomal rearrangement (CCR) involving chromosomes 7, 10, and 21. She is the third individual with an apparently de novo CCR to be ascertained by repeated fetal wastage. Both familial and de novo CCRs are associated with recurrent spontaneous abortions.

Three approaches to the prenatal diagnosis of the severe, early onset form of hypophosphatasia, a rare inborn error of metabolism, were investigated in 2 pregnancies of a family with a previous history of the disease. Two of these approaches, ultrasonography and the determination of the bone and liver isozyme activity of alkaline phosphatase (ALP) in cultured amniotic fluid cells have proven useful diagnostically. The third approach, assay of the bone and liver isozyme activity or total activity in supernatant amniotic fluid was not found to be informative. In 1 pregnancy, the failure of ultrasonography at 16, 18, and 19 weeks gestation to reveal a well defined fetal skull, when the level. of alpha-fetoprotein in the amniotic fluid was normal, suggested hypophosphatasia. This diagnosis was supported by the finding that cultured amniotic fluid cells from this fetus had an ALP specific activity which was 4% of the mean of 68 control cultures and much less than the lowest control value. A subsequent normal sibling who has heterozygous serum levels of ALP had normal ultrasound findings and normal cultured amniotic fluid cell enzyme activities. The study has emphasized the differences in tissue specific ALP isozyme composition of amnio-otic fluid supernatant and cultured cells. These differences are crucial in the diagnosis of this defect of bone and liver ALP.