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Radionuclide angiography is an area of nuclear medicine which specialises in imaging which shows the functionality of the right and left ventricles of the heart, thus allowing informed diagnostic intervention in heart failure. It involves use of a radiopharmaceutical, injected into a patient, and a gamma camera for acquisition. A MUGA scan (multigated acquisition) involves an acquisition triggered (gated) at different points of the cardiac cycle. MUGA scanning is also called equilibrium radionuclide angiocardiography, radionuclide ventriculography, or gated blood pool imaging, as well as SYMA scanning (synchronized multigated acquisition scanning).
This mode of imaging uniquely provides a cine type of image of the beating heart, and allows the interpreter to determine the efficiency of the individual heart valves and chambers. MUGA/Cine scanning represents a robust adjunct to the now more common echocardiogram. Mathematics regarding acquisition of cardiac output (Q) is well served by both of these methods as well as other inexpensive models supporting ejection fraction as a product of the heart/myocardium in systole. The advantage of a MUGA scan over an echocardiogram or an angiogram is its accuracy. An echocardiogram measures the shortening fraction of the ventricle and is limited by the user's ability. Furthermore, an angiogram is invasive and, often, more expensive. A MUGA scan provides a more accurate representation of cardiac ejection fraction.
The MUGA scan was first introduced in the early 1970s and quickly became accepted as the preferred technique for measurement of left ventricular ejection fraction (LVEF) with a high degree of accuracy. Several early studies demonstrated an excellent correlation of MUGA-derived LVEF with values obtained by cardiac catheterization contrast ventriculography.
MUGA is typically ordered for the following patients:
- With known or suspected coronary artery disease, to diagnose the disease and predict outcomes
- With lesions in their heart valves
- With congestive heart failure
- Who have undergone percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery, or medical therapy, to assess the efficacy of the treatment
- With low cardiac output after open-heart surgery
- Who are undergoing cardiotoxic drug agents such as in chemotherapy e.g., with doxorubicin or immunotherapy (herceptin)
- Who have had a cardiac transplant
The MUGA scan is performed by labeling the patient's red blood pool with a radioactive tracer, technetium-99m-pertechnetate (Tc-99m), and measuring radioactivity over the anterior chest as the radioactive blood flows through the large vessels and the heart chambers.
The introduction of the radioactive marker can either take place in vivo or in vitro. In the in vivo method, stannous (tin) ions are injected into the patient's bloodstream. A subsequent intravenous injection of the radioactive substance, technetium-99m-pertechnetate, labels the red blood cells in vivo. With an administered activity of about 800 MBq, the effective radiation dose is about 8 mSv to 12 mSv. In the in vitro method, some of the patient's blood is drawn and the stannous ions (in the form of stannous chloride) are injected into the drawn blood. The technetium is subsequently added to the mixture as in the in vivo method. In both cases, the stannous chloride reduces the technetium ion and prevents it from leaking out of the red blood cells during the procedure. The in vivo technique is more convenient for the majority of patients since it is less time-consuming and less costly and more than 80 percent of the injected radionuclide usually binds to red blood cells with this approach. Red blood cell binding of the radioactive tracer is generally more efficient with the in vitro labeling, and it is preferred in patients with indwelling intravenous catheters to decrease the adherence of Tc-99m to the catheter wall and increase the efficiency of blood pool labeling.
The patient is placed under a gamma camera, which detects the low-level 140 keV gamma radiation being given off by technetium-99m. As the gamma camera images are acquired, the patient's heart beat is used to 'gate' the acquisition. The final result is a series of images of the heart (usually sixteen), one at each stage of the cardiac cycle.
Depending on the objectives of the test, the doctor may decide to perform either a resting or a stress MUGA. During the resting MUGA, the patient lies stationary, whereas during a stress MUGA, the patient is asked to exercise during the scan. The stress MUGA measures the heart performance during exercise and is usually performed to assess the impact of a suspected coronary artery disease. In some rare cases, a nitroglycerin MUGA may be performed, where nitroglycerin (a vasodilator) is administered prior to the scan.
The resulting images show that the volumetrically derived blood pools in the chambers of the heart and timed images may be computationally interpreted to calculate the ejection fraction and injection fraction of the heart. This nuclear medicine scan yields an accurate, inexpensive and easily reproducible means of measuring and monitoring the ejection and injection fractions of the ventricles, which are one of many of the important clinical metrics in assessing global heart performance.
In normal subjects, the left ventricular ejection fraction (LVEF) should be about 50%(range, 50-80%). There should be no area of abnormal wall motion (hypokinesis, akinesis or dyskinesis). Abnormalities in cardiac function may be manifested as a decrease in LVEF and/or the presence of abnormalities in global and regional wall motion. For normal subjects, peak filling rates should be between 2.4 and 3.6 end diastolic volume (EDV) per second, and the time to peak filling rate should be 135-212 ms. (source?)
An uneven distribution of technetium in the heart indicates that the patient has coronary artery disease, a cardiomyopathy, or blood shunting within the heart. Abnormalities in a resting MUGA usually indicate a heart attack, while those that occur during exercise usually indicate ischemia. In a stress MUGA, patients with coronary artery disease may exhibit a decrease in ejection fraction. For a patient that has had a heart attack, or is suspected of having another disease that affects the heart muscle, this scan can help pinpoint the position in the heart that has sustained damage as well as assess the degree of damage. MUGA scans are also used to evaluate heart function prior to and while receiving certain chemotherapies (e.g. doxorubicin (Adriamycin)) or immunotherapy (specifically, herceptin) that have a known effect on heart function.
- Gillam, Linda D.; Otto, Catherine M. (2011). Advanced Approaches in Echocardiography. Elsevier Health Sciences. p. 224. ISBN 1437726976.
- Folland, ED; Hamilton GW; Larson SM; Kennedy JW; Williams DL; Ritchie JL (1977). "The radionuclide ejection fraction: a comparison of three radionuclide techniques with contrast angiography". J Nucl Med. 18 (12): 1159.
- "MUGA Scan". Cancer.Net.