Myocardial Perfusion Studies in Abnormal Ventricular Activation

184 Pages·2009·4.31 MB·English

Myocardial Perfusion Studies
in
Abnormal Ventricular Activation
T.J.F. ten Cate
Myocardial Perfusion Studies in Abnormal Ventricular Activation
Thesis, Utrecht University, The Netherlands
Cover: Split Apple Rock, Marahau, Abel Tasman National Park, New Zealand.
Foto: © C.J. ten Cate - van den Ochtend
Lay-out: Legatron Electronic Publishing, Rotterdam, The Netherlands
Printed by: Ipskamp Drukkers, Enschede, The Netherlands
ISBN/EAN: 978-90-393-5273-1
© 2010 by T.J.F. ten Cate, IJsselstein, The Netherlands
All rights reserved. No part of this publication may be reproduced, stored
in a retrieval system or transmitted in any form or by any other means,
mechanically, by photocopy, recording or otherwise, without prior written
permission of the author.
Financial support by the J.H.W. Pasman Foundation, The Hague, The
Netherlands and Medtronic Trading BV, Heerlen, The Nederlands for the
production of this thesis is gratefully acknowledged.
Additional financial support was generously provided by Astellas Pharma,
AstraZeneca, Biotronik, Boehringer Ingelheim, Cordis Benelux, Covidien
Nederland, GlaxoSmithKline, Hermes Medical Solutions, MEDA Farma,
Menarini Farma, MSD, ScheringPlough, Servier Farma, St. Antonius Ziekenhuis
Nieuwegein, Sorin Group and St. Jude Medical.
Myocardial Perfusion Studies
in Abnormal Ventricular Activation
Onderzoek naar de effecten van abnormale linker kamer
activatie op de perfusie van het hart en risico
stratificatie van patiënten met pijn op de borst.
(met een samenvatting in het Nederlands)
Proefschrift
ter verkrijging van de graad van doctor
aan de Universiteit Utrecht
op gezag van de Rector Magnificus
Prof.dr. J.C. Stoof
ingevolge het besluit van het college voor promoties
in het openbaar te verdedigen
op dinsdag 2 februari 2010 des middags te 12.45 uur
door
Tim Jan Frederik ten Cate
geboren op 6 februari 1977 te Rotterdam
Promotor
Prof. Dr. N.M. van Hemel
Co-promotor
Dr. J.F. Verzijlbergen
Een vriend is iemand die alles van je weet en toch van je houdt. (Augustinus)
Voor Nienke en Xavier

Table of Contents
Chapter 1 General Introduction 9
Chapter 2 Pacemaker-related myocardial perfusion defects worsen 25
during higher pacing rate and coronary flow augmentation
Heart Rhythm 2005, 2:1058-1063
Chapter 2a Editorial Commentary. Myocardial perfusion defects 41
during right ventricular pacing: Artifact versus adaptation
Heart Rhythm 2005, 2:1064–1065
Chapter 3 Right ventricular outflow and apical pacing comparably 47
worsen the echocardioghraphic normal left ventricle
European Journal of Echocardiography 2008, 9:672-677
Chapter 4 PACFLOW: a study into the effects of different pacing 61
modes and paced heart rates on myocardial blood-flow
distribution
Submitted
Chapter 5 Myocardial perfusion defects in right ventricular apical 75
pacing are caused by partial volume effects due to wall
motion abnormalities. A new model to study gated
myocardial SPECT with the pacemaker on and off
Nuclear Medicine Communications 2009, 30:480–484
Chapter 6 The prognostic significance of typical perfusion defects 87
on vasodilator stress myocardial perfusion SPECT in
patients with left bundle branch block or right ventricular apical
pacing
Nuclear Medicine Communications 2009, 30:232–239
Chapter 7 Myocardial perfusion SPECT identifies patients with left 105
bundle branch block patterns at high risk for future
coronary events
Accepted for publication in the Journal of Nuclear Cardiology
Chapter 8 High cardiac risk after myocardial SPECT warrants invasive 123
strategies. A review and systematic analysis of a specific
patient population
Submitted
Chapter 9 General Discussion 139
Chapter 10 Summary 155
Samenvatting in het Nederlands 163
Appendix Examples of myocardial perfusion SPECT 170
Abbreviations 183
Chapter 1
General Introduction
Chapter 1
Background
Despite improved medical treatment and more emphasis on primary prevention,
death from cardiac causes remains one of the leading causes of death in the
Western world [1,2]. With the improved prognosis of coronary artery disease,
patients get older with more extensive coronary artery disease and more co-
morbidity. Since invasive diagnostic approaches require admission into the
hospital and subsequent recovery from the procedure, are expensive [3,4] and
carry a certain risk for complications [5], non-invasive diagnostic and prognostic
approaches of the patients with chest pain suspected of coronary origin, are
important [6]. Despite the development of new and more sophisticated non-
invasive techniques like cardiac MRI [7-9] and CT coronary angiography [10-
13] myocardial perfusion SPECT is still a powerful tool for diagnostic and
prognostic purposes of patients with chest-pain suspected of coronary origin
for a wide variety of patients [6,14-23].
Consideration of specific patient populations with left bundle
branch block and right ventricular apical pacing
The left bundle branch block (LBBB) induces an abnormal left ventricular
electrical activation pattern frequently associated with abnormal wall motion
[24,25]. LBBB is associated with hypertension and thought to result in a worse
cardiac prognosis compared with patients with right bundle branch block and
normal left ventricular activation [26]. Especially heart failure [27] was more
frequently observed in patients with LBBB compared with non-LBBB activation
patterns, but also cardiac events from coronary artery disease (CAD) related
causes [26,28-32].
Pacing from the right ventricular apex (RVA) results in an LBBB like pattern on
the surface ECG. The long-term effects of chronic pacing are less well established
than that of intrinsic LBBB. RVA pacing is thought to result in a worsening of
left ventricular function [33-35] and is associated with a higher burden of atrial
fibrillation [36-38]. Left ventricular function impairment is thought to be caused
by the abnormal electrical activation pattern with possible subsequent heart
failure as result [39]. In order to avoid these deleterious effects other pacing
sites in the right ventricle have been proposed with a more physiological left
10