Journal of Nuclear Cardiology

, Volume 15, Issue 1, pp 127–136 | Cite as

Assessment of left ventricular mechanical dyssynchrony by phase analysis of ECG-gated SPECT myocardial perfusion imaging

  • Ji ChenEmail author
  • Maureen M. Henneman
  • Mark A. Trimble
  • Jeroen J. Bax
  • Salvador Borges-Neto
  • Ami E. Iskandrian
  • Kenneth J. Nichols
  • Ernest V. Garcia
Review Article


Cardiac resynchronization therapy (CRT) has shown benefits in patients with severe heart failure. However, at least 30% of patients selected for CRT by use of traditional criteria (New York Heart Association class III or IV, depressed left ventricular [LV] ejection fraction, and prolonged QRS duration) do not respond to CRT. Recent studies with tissue Doppler imaging have shown that the presence of LV dyssynchrony is an important predictor of response to CRT. Phase analysis has been developed to allow assessment of LV dyssynchrony by gated single photon emission computed tomography myocardial perfusion imaging. This technique uses Fourier harmonic functions to approximate regional wall thickness changes over the cardiac cycle and to calculate the regional onset-of-mechanical contraction phase. Once the onset-of-mechanical contraction phases are obtained 3-dimensionally over the left ventricle, a phase distribution map is formed that represents the degree of LV dyssynchrony. This technique has been compared with other methods of measuring LV dyssynchrony and shown promising results in clinical evaluations. In this review the phase analysis methodology is described, and its up-to-date validations are summarized.

Key words

Heart failure cardiac resynchronization therapy left ventricular dyssynchrony electrocardiography-gated single photon emission computed tomography myocardial perfusion imaging 


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  1. 1.
    Hunt SA. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report from the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2005;46:e1–82.PubMedCrossRefGoogle Scholar
  2. 2.
    American Heart Association. Heart disease and stroke statistics: 2006 update. Dallas (TX): American Heart Association; 2006.Google Scholar
  3. 3.
    Leclercq C, Kass DA. Retiming the failing heart: principles and current clinical status of cardiac resynchronization. J Am Coll Cardiol 2002;39:194–201.PubMedCrossRefGoogle Scholar
  4. 4.
    Abraham WT, Hayes DL. Cardiac resynchronization therapy for heart failure. Circulation 2003;108:2596–603.PubMedCrossRefGoogle Scholar
  5. 5.
    Leclercq C, Hare JM. Ventricular resynchronization: current state of the art. Circulation 2004;109:296–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Auricchio A, Stellbrink C, Block M, Sack S, Vogt J, Bakker P, et al. Effect of pacing chamber and atrioventricular delay on acute systolic function of paced patients with congestive heart failure. The Pacing Therapies for Congestive Heart Failure Study Group. The Guidant Congestive Heart Failure Research Group. Circulation 1999;99:2993–3001.PubMedGoogle Scholar
  7. 7.
    Brecker SJ, Xiao HB, Sparrow J, Gibson DG. Effects of dualchamber pacing with short atrioventricular delay in dilated cardiomyopathy. Lancet 1992;340:1308–12.PubMedCrossRefGoogle Scholar
  8. 8.
    Leclercq C, Faris O, Tunin R, Johnson J, Kato R, Evans F, et al. Systolic Improvement and mechanical resynchronization does not require electrical synchrony in the dilated failing heart with left bundle-branch block. Circulation 2002;106:1760–3.PubMedCrossRefGoogle Scholar
  9. 9.
    Achilli A, Sassara M, Ficili S, Pontillo D, Achilli P, Alessi C, et al. Long-term effectiveness of cardiac resynchronization therapy in patients with refractory heart failure and “narrow” QRS. J Am Coll Cardiol 2003;42:2117–24.PubMedCrossRefGoogle Scholar
  10. 10.
    Bax JJ, Bleeker GB, Marwick TH, Molhoek SG, Boersma E, Steendijk P, et al. Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. J Am Coll Cardiol 2004;44:1834–40.PubMedCrossRefGoogle Scholar
  11. 11.
    Bax JJ, Marwick TH, Molhoek SG, Bleeker GB, van Erven L, Boersma E, et al. Left ventricular dyssynchrony predicts benefit of cardiac resynchronization therapy in patients with end-stage heart failure before pacemaker implantation. Am J Cardiol 2003;92: 1238–40.PubMedCrossRefGoogle Scholar
  12. 12.
    Bax JJ, Abraham T, Barold SS, Breithardt OA, Fung JW, Garrigue S, et al. Cardiac resynchronization therapy: part 1—issues before device implantation. J Am Coll Cardiol 2005;46:2153–67.PubMedCrossRefGoogle Scholar
  13. 13.
    Godoy IE, Mor-Avi V, Weinert L, Vignon P, Korcarz C, Spencer KT, et al. Use of color kinesis for evaluation of left ventricular filing in patients with dilated cardiomyopathy and mitral regurgitation. J Am Coll Cardiol 1998;31:1598–606.PubMedCrossRefGoogle Scholar
  14. 14.
    Suffoletto MS, Dohi K, Cannesson M, Saba S, Goresan J III. Novel speckle-tracking radial strain from routine black-and-white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy. Circulation 2006;113: 960–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Westenberg JJ, Lamb HJ, van der Geest RJ, Bleeker GB, Holman ER, Schalij MJ, et al. Assessment of left ventricular dyssynchrony in patients with conduction delay and idiopathic dilated cardiomyopathy: head-to-head comparison between tissue Doppler imaging and velocity-encoded magnetic resonance imaging. J Am Coll Cardiol 2006;47:2042–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Delfino JG, Bhasin M, Cole R, Eisner RL, Merlino J, Leon AR, et al. Comparison of myocardial velocities obtained with magnetic resonance phase velocity mapping and tissue Doppler imaging in normal subjects and patients with left ventricular dyssynchromy. J Magn Reson Imaging 2006;24:304–11.PubMedCrossRefGoogle Scholar
  17. 17.
    Somsen GA, Verberne HJ, Burri H, Ratib O, Righetti A. Ventricular mechanical dyssynchrony and resynchronization therapy in heart failure: a new indication for Fourier analysis of gated blood-pool radionuclide ventriculography. Nucl Med Commun 2006;27:105–12.PubMedCrossRefGoogle Scholar
  18. 18.
    Vilain D, Daou D, Casset-Senon D, Faraggi M, Le Guludec D. Optimal 3-dimensional method for right and left ventricular Fourier phase analysis in electrocardiography-gated blood-pool SPECT. J Nucl Cardiol 2001;8:371–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Botvinick EH, O'Connell JW, Kadkade PP, Glickman SL, Dae MW, Cohen TJ, et al. Potential added value of three-dimensional reconstruction and display of single photon emission computed tomographic gated blood pool images. J Nucl Cardiol 1998;5: 245–55.PubMedCrossRefGoogle Scholar
  20. 20.
    Chen J, Garcia EV, Folks RD, Cooke CD, Faber TL, Tauxe EL, et al. Onset of left ventricular mechanical contraction as determined hy phase analysis of ECG-gated myocardial perfusion SPECT imaging: development of a diagnostic tool for assessment of cardiac mechanical dyssynchrony. J Nucl Cardiol 2005;12:687–95.PubMedCrossRefGoogle Scholar
  21. 21.
    Gheorghiade M, Bonow RO. Chronic heart failure in the United States: a manifestation of coronary artery disease. Circulation 1998;97:282–9.PubMedGoogle Scholar
  22. 22.
    Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE, et al. Effect of vasodilator therapy on mortality in chronic congestive heart failure: results of a Veterans Administration Cooperative Study. N Engl J Med 1986;314:1547–52.PubMedGoogle Scholar
  23. 23.
    Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991;325:303–10.PubMedGoogle Scholar
  24. 24.
    The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failur: results of the Cooperative North Scandinavian Enalapril Survival Study. N Engl J Med 1987;316:1429–35.Google Scholar
  25. 25.
    DiBianco R, Shabetai R, Kostuk W, Moran J, Schlant RC, Wright R. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med 1989;320:677–83.PubMedGoogle Scholar
  26. 26.
    The effect of digoxin on mortality and morbidity in patients with heart failure. The Digitalis Investigation Group. N Engl J Med 1997;336:525–33.CrossRefGoogle Scholar
  27. 27.
    Feldman AM, Bristow MR, Parmley WW, Carson PE, Pepine CJ, Gilbert EM, et al., Effects of vesnarinone on morbidity and mortality in patients with heart failure. Vesnarinone Study Group. N Engl J Med 1993;329:149–55.PubMedCrossRefGoogle Scholar
  28. 28.
    Packer M, Carver JR, Rodeheffer RJ, Ivanhoe RJ, DiBianco R, Zeldis SM, et al. Effect of oral milrinone on mortality in severe chronic heart failure. The PROMISE Study Research Group. N Engl J Med 1991;325:1468–75.PubMedGoogle Scholar
  29. 29.
    Packer M, Gheorghiade M, Young JB, Costantini PJ, Adams KF, Cody RJ, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. RADIANCE Study. N Engl J Med 1993;329:1–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB, Gilbert EM, et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. N Engl J Med 1996;334:1349–55.PubMedCrossRefGoogle Scholar
  31. 31.
    Packer M, O'Connor CM, Ghali JK, Pressler ML, Carson PE, Belkin RN, et al. Effect of amlodipine on morbidity and mortality in severe chronic heart failure. Prospective Randomized Amlodipine Survival Evaluation Study Group. N Engl J Med 1996;335: 1107–14.PubMedCrossRefGoogle Scholar
  32. 32.
    Singh SN, Fletcher RD, Fisher SG, Singh BN, Lewis HD, Deedwania PC, et al. Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. N Engl J Med 1995;333:77–82.PubMedCrossRefGoogle Scholar
  33. 33.
    Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators. N Engl J Med 1991;325:293–302.Google Scholar
  34. 34.
    Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. The SOLVD Investigators. N Engl J Med 1992;327:685–91.Google Scholar
  35. 35.
    Bart BA, Shaw LK, McCants CB Jr, Fortin DF, Lee KL, Califf RM, et al. Clinical determinants of mortality in patients with angiographically diagnosed ischemic or nonischemic cardiomyopathy. J Am Coll Cardiol 1997;30:1002–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Bleeker GB, Kaandorp TA, Lamb HJ, Boersma E, Steendijk P, de Roos A, et al. Effect of posterolateral scar tissue on clinical and echocardiographic improvement after cardiac resynchronization therapy. Circulation 2006;113:969–76.PubMedCrossRefGoogle Scholar
  37. 37.
    Champeney DC. Fourier transform and their physical applications. New York, Academic Press, 1973. p. 8–21.Google Scholar
  38. 38.
    Hoffman EJ, Huang SC, Phelps ME. Quantitation in positron emission computed tomography: 1. Effect of object size. Comput Assist Tomogr 1979;3:299–308.CrossRefGoogle Scholar
  39. 39.
    Galt JR, Garcia EV, Robbins WL. Effects of myocardial wall thickness on SPECT quantification. IEEE Trans Med Imaging 1990;9:144–50.PubMedCrossRefGoogle Scholar
  40. 40.
    Cooke CD, Garcia EV, Cullom SJ, Faber TL, Pettigrew RI. Determining the accuracy of calculating systolic wall thickening using a fast Fourier transform approximation: a simulation study based on canine and patient data. J Nucl Med 1994;35:1185–92.PubMedGoogle Scholar
  41. 41.
    Garcia E, DePuey EG, Sonnemaker RE, Neely HR, DePasquale EE, Robbins WL, et al. Quantification of the reversibility of stress induced SPECT thallium-201 myocardial perfusion defects: a multicenter trial using bull’s-eye polar maps and standard normal limits. J Nucl Med 1990;31:1761–5.PubMedGoogle Scholar
  42. 42.
    Faber TL, Cooke CD, Folks RD, Vansant JP, Nichols KJ, DePuey EG, et al. Left ventricular function and perfusion from gated SPECT perfusion images: an integrated method. J Nucl Med 1999;40:650–9.PubMedGoogle Scholar
  43. 43.
    Yu CM, Chau E, Sanderson JE, Fan K, Tang MO, Fung WH, et al. Tissue Doppler echocardiographie evidence of reverse remodeling and improved synchronicity by simultaneously delaying regional contraction after biventricular pacing therapy in heart failure. Circulation 2002;105:438–45.PubMedCrossRefGoogle Scholar
  44. 44.
    Sogaard P, Egeblad H, Kim WY, Jensen HK, Pedersen AK, Kristensen BØ, et al. Tissue Doppler imaging predicts improved systolic performance and reversed left ventricular remodeling during long-term cardiac resynchronization therapy. J Am Coll Cardiol 2002;40:723–30.PubMedCrossRefGoogle Scholar
  45. 45.
    Henneman MM, Chen J, Ypenburg C, Dibbets P, Bleeker GB, Boersma E, et al. Phase analysis of gated myocardial perfusion SPECT compared to tissue Doppler imaging for the assessment of left ventricular dyssynchrony. J Am Coll Cardiol 2007;49: 1708–14.PubMedCrossRefGoogle Scholar
  46. 46.
    Yu CM, Zhang Q, Fung JW, Chang HC, Chan YS, Yip GW, et al. A novel tool to assess systolic asynchrony and identify responders of cardiac resynchronization therapy by tissue synchronization imaging. J Am Coll Cardiol 2005;45:677–84.PubMedCrossRefGoogle Scholar
  47. 47.
    Yu CM, Fung WH, Lin H, Zhang Q, Sanderson JE, Lau CP. Predictors of left ventricular reverse remodeling after cardiac resynchronization therapy for heart failure secondary to idiopathic dilated or ischemic cardiomyopathy. Am J Cardiol 2003;91:684–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Ajmone Marsan N, Henneman MM, Chen J, Ypenburg C, Dibbets P, Ghio S, et al. Left ventricular dyssynchrony assessed by two 3-dimensional imaging modalities: phase analysis of gated myocardial perfusion SPECT and tri-plane tissue Doppler imaging. Eur J Nucl Med Mol Imaging 2008;35:166–73.PubMedCrossRefGoogle Scholar
  49. 49.
    Muramatsu T, Matsumoto K, Nishimura S. Efficacy of the phase images in Fourier analysis using gated cardiac pool-SPECT for determining the indication for cardiac resynchronization therapy. Circ J 2005;69:1521–6.PubMedCrossRefGoogle Scholar
  50. 50.
    Nichols K, Saouaf R, Ababneh AA, Barst RJ, Rosenbaum MS, Groch MW, et al. Validation of SPECT equilibrium radionuclide angiographic right ventricular parameters by cardiac magnetic resonance imaging. J Nucl Cardiol 2002;9:153–60.PubMedCrossRefGoogle Scholar
  51. 51.
    Nichols KJ, Van Tosh A, Siddiqi S, Chen J, Garcia EV. Comparison between myocardial perfusion and blood pool gated SPECT measurements of LV dyssynchrony [abstract]. J Nucl Cardiol 2007;14:S102–3.CrossRefGoogle Scholar
  52. 52.
    Trimble MA, Borges-Neto S, Smallheiser S, Chen J, Honeycutt EF, Shaw LK, et al. Evaluation of left ventricular mechanical dyssynchrony as determined by phase analysis of ECG-gated myocardial perfusion SPECT imaging in patients with left ventricular dysfunction and conduction disturbances. J Nucl Cardiol 2007;14:298–307.PubMedCrossRefGoogle Scholar
  53. 53.
    Henneman MM, Chen J, Dibbets-Schneider P, Stokkel MP, Bleeker GB, Ypenburg C, et al. Can LV dyssynchrony as assessed with phase analysis on gated myocardial perfusion SPECT predict response to CRT? J Nucl Med 2007;48:1104–11.PubMedCrossRefGoogle Scholar
  54. 54.
    Trimble MA, Velazquez EJ, Adams GL, et al. Repeatability and reproducibility of phase analysis of gated SPECT myocardial perfusion imaging used to quantify cardiac dyssynchrony. Nucl Med Commun. In press 2008.Google Scholar
  55. 55.
    Chen J, Faber TL, Cooke CD, Garcia EV. Technical aspects in multi-harmonic phase analysis of LV dyssynchrony from gated myocardial perfusion SPECT [abstract]. J Nucl Cardiol 2007;14: S98.CrossRefGoogle Scholar

Copyright information

© American Society of Nuclear Cardiology 2008

Authors and Affiliations

  • Ji Chen
    • 1
    Email author
  • Maureen M. Henneman
    • 2
  • Mark A. Trimble
    • 3
  • Jeroen J. Bax
    • 2
  • Salvador Borges-Neto
    • 3
  • Ami E. Iskandrian
    • 4
  • Kenneth J. Nichols
    • 5
  • Ernest V. Garcia
    • 1
  1. 1.Department of RadiologyEmory University School of MedicineAtlanta
  2. 2.Department of CardiologyLeiden UniversityLeidenThe Netherlands
  3. 3.Division of Cardiovascular DiseaseDuke UniversityDurham
  4. 4.Division of CardiologyUniversity of Alabama at BirminghamBirmingham
  5. 5.Division of Nuclear Medicine and Molecular ImagingNorth Shore Long Island Jewish Health SystemNew Hyde Park

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