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The active papillary muscle sign in 18F-FDG PET/CT cardiac sarcoidosis exams and its relationship with myocardial suppression

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Abstract

Objective

Papillary muscle (PM) activity may demonstrate true active cardiac sarcoidosis (CS) or mimic CS in 18FDG-PET/CT if adequate myocardial suppression (MS) is not achieved. We aim to examine whether PM uptake can be used as a marker of failed MS and measure the rate of PM activity presence in active CS with different dietary preparations.

Materials and methods

We retrospectively reviewed PET/CTs obtained with three different dietary preparations. Diet-A: 24-h ketogenic diet with overnight fasting (n = 94); Diet-B: 18-h fasting (n = 44); and Diet-C: 72-h daytime ketogenic diet with 3-day overnight fasting (n = 98). Each case was evaluated regarding CS diagnosis (negative, positive, and indeterminant) and presence of PM activity. MaxSUV was measured from bloodpool, liver, and the most suppressed normal myocardium. Linear mixed-effects models were used to compare these factors between those with PM activity and those without.

Results

PM activity was markedly lower in the Diet-C group compared with others: Diet-C: 6 (6.1%), Diet-A: 36 (38.3%), and Diet-B: 26 (59.1%) (p < 0.001). MyocardiumMaxSUV was higher, and MyocardiummaxSUV/BloodpoolmaxSUV, MyocardiummaxSUV/LivermaxSUV ratios were significantly higher in the cases with PM activity (p < 0.001). Among cases that used Diet-C and had PM activity, 66.7% were positive and 16.7% were indeterminate. If Diet-A or Diet-B was used, those with PM activity had a higher proportion of indeterminate cases (Diet-A: 61.1%, Diet-B: 61.5%) than positive cases (Diet-A: 36.1%, Diet-B: 38.5%).

Conclusion

Lack of PM activity can be a sign of appropriate MS. PM activity is less common with a specific dietary preparation (72-h daytime ketogenic diet with 3-day overnight fasting), and if it is present with this particular preparation, the likelihood that the case being true active CS might be higher than the other traditional dietary preparations.

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References

  1. Blankstein R, Osborne M, Naya M, Waller A, Kim CK, Murthy VL, et al. Cardiac positron emission tomography enhances prognostic assessments of patients with suspected cardiac sarcoidosis. J Am Coll Cardiol. 2014;63(4):329–36.

    Article  PubMed  Google Scholar 

  2. Chareonthaitawee P, Beanlands RS, Chen W, Dorbala S, Miller EJ, Murthy VL, et al. Joint SNMMI-ASNC expert consensus document on the role of (18)F-FDG PET/CT in cardiac sarcoid detection and therapy monitoring. J Nucl Med. 2017;58(8):1341–53.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Hwang IC, Bang JI, Yoon YE, Lee WW. Myocardial positron emission tomography for evaluation of cardiac sarcoidosis: specialized protocols for better diagnosis. J Cardiovasc Imaging. 2020;28(2):79–93.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Lebasnier A, Legallois D, Bienvenu B, Bergot E, Desmonts C, Zalcman G, et al. Diagnostic value of quantitative assessment of cardiac (18)F-fluoro-2-deoxyglucose uptake in suspected cardiac sarcoidosis. Ann Nucl Med. 2018;32(5):319–27.

    Article  CAS  PubMed  Google Scholar 

  5. Sgard B, Brillet PY, Bouvry D, Djelbani S, Nunes H, Meune C, et al. Evaluation of FDG PET combined with cardiac MRI for the diagnosis and therapeutic monitoring of cardiac sarcoidosis. Clin Radiol. 2019;74(1):81 e9-e18.

    Article  PubMed  Google Scholar 

  6. Williams G, Kolodny GM. Suppression of myocardial 18F-FDG uptake by preparing patients with a high-fat, low-carbohydrate diet. AJR Am J Roentgenol. 2008;190(2):W151–6.

    Article  PubMed  Google Scholar 

  7. Clement A, Boutley H, Poussier S, Pierson J, Lhuillier M, Kolodziej A, et al. A 1-week extension of a ketogenic diet provides a further decrease in myocardial (18)F-FDG uptake and a high detectability of myocarditis with FDG-PET. J Nucl Cardiol. 2020;27(2):612–8.

    Article  PubMed  Google Scholar 

  8. Lu Y, Grant C, Xie K, Sweiss NJ. Suppression of myocardial 18F-FDG uptake through prolonged high-fat, high-protein, and very-low-carbohydrate diet before FDG-PET/CT for evaluation of patients with suspected cardiac sarcoidosis. Clin Nucl Med. 2017;42(2):88–94.

    Article  PubMed  Google Scholar 

  9. Ozutemiz C, Koksel Y, Froelich JW, Rubin N, Bhargava M, Roukuz H, et al. Comparison of the effect of three different dietary modifications on myocardial suppression in (18)F-Fdg Pet/Ct evaluation of patients for suspected cardiac sarcoidosis. J Nucl Med. 2021;62:1767.

    Article  Google Scholar 

  10. Atterton-Evans V, Turner J, Vivanti A, Robertson T. Variances of dietary preparation for suppression of physiological (18)F-FDG myocardial uptake in the presence of cardiac sarcoidosis: a systematic review. J Nucl Cardiol. 2020;27(2):481–9.

    Article  PubMed  Google Scholar 

  11. Soussan M, Brillet PY, Nunes H, Pop G, Ouvrier MJ, Naggara N, et al. Clinical value of a high-fat and low-carbohydrate diet before FDG-PET/CT for evaluation of patients with suspected cardiac sarcoidosis. J Nucl Cardiol. 2013;20(1):120–7.

    Article  PubMed  Google Scholar 

  12. Kobayashi Y, Kumita S, Fukushima Y, Ishihara K, Suda M, Sakurai M. Significant suppression of myocardial (18)F-fluorodeoxyglucose uptake using 24-h carbohydrate restriction and a low-carbohydrate, high-fat diet. J Cardiol. 2013;62(5):314–9.

    Article  PubMed  Google Scholar 

  13. Lin EC. Isolated papillary muscle uptake on FDG PET/CT. Clin Nucl Med. 2007;32(1):76–8.

    Article  PubMed  Google Scholar 

  14. Maurer AH, Burshteyn M, Adler LP, Steiner RM. How to differentiate benign versus malignant cardiac and paracardiac 18F FDG uptake at oncologic PET/CT. Radiographics. 2011;31(5):1287–305.

    Article  PubMed  Google Scholar 

  15. Roberts WC, McAllister HA Jr, Ferrans VJ. Sarcoidosis of the heart. A clinicopathologic study of 35 necropsy patients (group 1) and review of 78 previously described necropsy patients (group 11). Am J Med. 1977;63(1):86–108.

    Article  CAS  PubMed  Google Scholar 

  16. Lagana SM, Parwani AV, Nichols LC. Cardiac sarcoidosis: a pathology-focused review. Arch Pathol Lab Med. 2010;134(7):1039–46.

    Article  PubMed  Google Scholar 

  17. Tavora F, Cresswell N, Li L, Ripple M, Solomon C, Burke A. Comparison of necropsy findings in patients with sarcoidosis dying suddenly from cardiac sarcoidosis versus dying suddenly from other causes. Am J Cardiol. 2009;104(4):571–7.

    Article  PubMed  Google Scholar 

  18. Bhambhvani P. Challenges of cardiac inflammation imaging with F-18 FDG positron emission tomography. J Nucl Cardiol. 2017;24(1):100–2.

    Article  PubMed  Google Scholar 

  19. Osborne MT, Hulten EA, Murthy VL, Skali H, Taqueti VR, Dorbala S, et al. Patient preparation for cardiac fluorine-18 fluorodeoxyglucose positron emission tomography imaging of inflammation. J Nucl Cardiol. 2017;24(1):86–99.

    Article  PubMed  Google Scholar 

  20. Nakao R, Nagao M, Yamamoto A, Fukushima K, Watanabe E, Sakai S, Hagiwara N. Papillary muscle ischemia on high-resolution cine imaging of nitrogen-13 ammonia positron emission tomography: association with myocardial flow reserve and prognosis in coronary artery disease. J Nucl Cardiol. 2022;29(1):293–303.

    Article  PubMed  Google Scholar 

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Acknowledgements

We would like to thank to our PET/CT technicians; Todd Kes and Cassandra Koldenhoven for their excellent coaching of patients during these preparations and the high quality of these PET/CT exams. The preliminary data on this manuscript was presented as an electronic poster during RSNA 2020, Chicago.

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Correspondence to Can Özütemiz.

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Conflict of interest

Jerry Froelich: Receives grant support from Siemens Healthineers for a project unrelated to the present article. Nathan Rubin: Research reported in this publication was supported by NIH grant P30 CA77598 utilizing the Biostatistics and Bioinformatics Core shared resource of the Masonic Cancer Center, University of Minnesota and by the National Center for Advancing Translational Sciences of the National Institutes of Health Award Number UL1-TR002494. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Rebecca Cogswell: Serves in the advisory board of Abbott lab hearmate-3, and husband is employed in Medtronic, unrelated to the present article. Henri Roukuz: Consultant for Boston Scientific, receiving grants from Medtronic unrelated to the present article. Other authors have nothing to declare.

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Özütemiz, C., Koksel, Y., Froelich, J.W. et al. The active papillary muscle sign in 18F-FDG PET/CT cardiac sarcoidosis exams and its relationship with myocardial suppression. Ann Nucl Med 38, 391–399 (2024). https://doi.org/10.1007/s12149-024-01910-y

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