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Society of Nuclear Medicine Procedure Guideline for

Gated Equilibrium Radionuclide Ventriculography
version 3.0, approved June 15, 2002

Authors: Jac Scheiner, MD (Brown Medical School, Providence, RI); Albert Sinusas, MD (Yale University School of
Medicine, New Haven, CT); Mark D. Wittry, MD (Saint Louis University, St. Louis, MO); Henry D. Royal, MD (Mallinck-
rodt Institute of Radiology, St. Louis, MO); Josef Machac, MD (Mount Sinai School of Medicine of New York University,
NY); Helena R. Balon, MD (William Beaumont Hospital, Royal Oak, MI); and Otto Lang, MD (Third Medical School,
Charles University, Prague, Czech Republic).

I. Purpose 6. Stroke volume ratios
B. Common clinical settings in which RVG may
The purpose of this guideline is to assist nuclear
be useful include:
medicine practioners in recommending, perform-
1. Known or suspected coronary artery disease
ing, interpreting, and reporting the results of gated
(CAD)
equilibrium radionuclide ventriculography.
a. CAD without myocardial infarction (MI)
b. Remote MI
II. Background Information and Definitions c. Acute MI (however, these patients usu-
ally should not undergo exercise stress in
Gated equilibrium radionuclide ventriculography
the first 48 hours after acute MI)
(RVG) is a procedure in which the patient’s red
2. To help distinguish systolic from diastolic
blood cells (RBCs) are radiolabeled and electrocar-
diograph (ECG)-gated cardiac scintigraphy is ob- causes of congestive heart failure (CHF) in
tained. Single or multiple measurements of left patients with known or suspected CHF
and/or right ventricular function are obtained. Al- 3. Evaluation of cardiac function in patients
ternative terminologies for this technique include undergoing chemotherapy
gated cardiac blood-pool imaging, multigated ac- 4. Assessment of ventricular function in pa-
quisition (MUGA), and gated equilibrium ra- tients with valvular heart disease
dionuclide angiography (RNA). An RVG may be used in the conditions listed
Data are collected from several hundred cardiac above for (a) determining long-term progno-
cycles to generate an image set of the beating heart sis; (b) assessing short-term risk (e.g., preop-
that is presented as a single, composite cardiac cy- erative evaluation); and (c) monitoring re-
cle. The method can be used to assess (a) regional sponse to surgery or other therapeutic
and global wall motion; (b) cardiac chamber size interventions.
and morphology; and (c) ventricular systolic and
diastolic function, including left and right ventric-
IV. Procedure
ular ejection fractions (LVEF and RVEF, respec-
tively). An RVG may be acquired at rest, during A. Patient Preparation
exercise, or after either pharmacologic or mechan- 1. Rest
ical interventions. No special preparation is required for a rest-
ing RVG. A fasting state is generally pre-
ferred. It is not necessary to withhold any
III. Common Indications
medications. The electrodes used for cardiac
A. Parameters obtained from RVG include the fol- gating must be placed securely on the skin to
lowing: ensure an optimal ECG signal.
1. Global ventricular systolic function 2. Exercise
2. Regional wall motion The patient should be fasting for at least 3–4
3. Ventricular volumes (qualitative or quanti- hours before the study and should be both
tative) hemodynamically and clinically stable. Ex-
4. Responses of above parameters to exercise ercise stress, in the form of supine or upright
or other interventions ergometry, is generally preferred. Patients
5. Systolic and diastolic function indices who are unable to exercise for noncardiac
2 • RADIONUCLIDE VENTRICULOGRAPHY

reasons may undergo pharmacologic stress preclude the performance of a study requiring
with a positive inotropic agent. It is recom- physical exercise. A resting 12-lead ECG
mended that medications that may alter the should be reviewed before an exercise study.
heart rate response be withheld unless medi- C. Precautions
cally contraindicated or the efficacy of the 1. It is mandatory that Occupational Safety
medication is being tested by the exercise test. and Health Administration guidelines for
Life support instrumentation and cardiac safe handling of human blood products be
resuscitative drugs must be available in the followed at all times when techniques label-
immediate vicinity of the stress laboratory. ing autologous RBCs are used.
A physician or other personnel trained in 2. When an in vitro method is used for radiola-
advanced cardiac life support (ACLS) must beling autologous RBCs, a fail-safe policy
be immediately available during the stress and procedure must be in place and imple-
and recovery phases. Continuous, prefer- mented to assure that administration of la-
ably 12-lead ECG monitoring must also be beled cells to the wrong patient is prevented.
performed throughout all phases of the 3. Patients with potentially unstable cardiac
stress study. Intermittent blood pressure rhythms (e.g., paroxysmal supraventricular
measurement and ECG tracings should be or ventricular tachycardia) or implanted de-
performed before, during, and in the recov- vices (e.g., implantable defibrillators) may
ery phases of the stress study. The patient require special precautions, because heart
should be clinically observed during and rate response to exercise may be unpre-
immediately after the stress test. Any abnor- dictable.
malities in symptomatology, hemodynam- D. Radiopharmaceuticals
ics, or the ECG should be monitored until re- For the adult, the usual administered activity is
solved. 555–1110 MBq (15–30 mCi) autologous RBCs
B. Information Pertinent to Performing the Proce- labeled with Tc-99m using the in vivo, modi-
dure fied in vivo, or in vitro techniques. The usual
An adequate history and cardiovascular exam- administered activity in children is 7–15
ination should be obtained before diagnostic MBq/kg (0.2–0.4 mCi/kg), with a minimum
evaluation. Specific areas to be reviewed in- dose of 70–150 MBq (2–4 mCi). The largest ab-
clude the indication(s) for testing, medications, sorbed radiation dose to an organ is that to the
symptomatology, cardiac risk factors, and heart (about 0.02 mSv/MBq). Tc-99m–labeled
prior cardiac procedures (diagnostic or thera- RBCs distribute within the blood-pool with an
peutic). The patient’s cardiac rhythm should be estimated volume of distribution of approxi-
noted, because marked heart rate variability mately 4%–7% of body weight. The estimated
may limit the ability to both perform and inter- biological half-life is approximately 24–30
pret the RVG. Physical limitations may limit or hours. Approximately 25% of the administered

Radiation Dosimetry for Adults

Radiopharmaceutical Administered Organ Receiving the Effective
activity largest radiation dose dose
MBq mGy per MBq mSv per MBq
(mCi) (rad per mCi) (rem per mCi)

Tc-99m labeled 555 – 1110 i.v. 0.023 0.0085
red blood cells1 Heart
(15 – 30) (0.085) (0.031)

Tc-99m albumin2 370 – 740 i.v. 0.020 0.0079
Heart
(10 – 20) (0.074) (0.029)

1ICRP 53, p. 210
2ICRP 53, p. 173
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL JUNE 2002 • 3

Radiation Dosimetry for Children
(5 year old)

Radiopharmaceutical Administered Organ receiving the Effective
activity largest radiation dose dose
MBq mGy per MBq mSv per MBq
(mCi) (rad per mCi) (rem per mCi)
Tc-99m labeled 7 – 15 i.v. 0.062 0.025
red blood cells1 Heart
(0.2 – 0.4) (0.23) (0.093)
Tc-99m albumin2 5 – 10 i.v. 0.054 0.023
Heart
(0.1 – 0.3) (0.23) (0.085)
1ICRP 53, p. 210
2ICRP 53, p. 173

dose is excreted in the urine in the first 24 diac cycle from a heterogenous popula-
hours. A stannous pyrophosphate preparation tion of beats and for retrograde gating for
is typically used in most red cell labeling tech- diastolic parameters.
niques. The dosage of this preparation may b. Acquisition parameters
need to be increased in patients receiving “full- A minimum of 16 frames per R-R interval
dose” heparin and in patients in renal failure. are required for an accurate assessment of
Labeling is least consistent with the in vivo ventricular wall motion and assessment
method, intermediate with the modified in of ejection fraction. A higher framing rate
vivo method, and most consistent with the in (32–64 frames per R-R) is preferred for
vitro method. Tc-99m–radiolabeled human detailed measurement of diastolic filling
serum albumin (HSA) is an alternative to radi- parameters and is required for absolute
olabeled RBCs. However, images are usually of volume measurements. Acceptable in-
lower quality because of the escape of tracer dices of diastolic function are achievable
from the intravascular space and breakdown of at 16 frames per cardiac cycle, if Fourier
the albumin, resulting in decreased contrast. curve fitting is employed.
E. Image Acquisition Images should be acquired so that the
1. Rest study heart occupies ~50% of the usable field of
a. Instrumentation view. Typical acquisitions are for a total
Acquisition is performed by a gamma of 3–7 million counts. Supine imaging is
camera interfaced to a dedicated com- performed in a minimum of 3 views to vi-
puter. Images may be acquired with ei- sualize all wall segments of the left ven-
ther a low-energy all-purpose (LEAP) or tricle. The left anterior oblique (LAO) ac-
high-resolution parallel-hole collimator. quisition is obtained at 45° or at an angle
An appropriate ECG gating device that allows the best separation of the right
should interface with the acquisition and left ventricles (best septal or best sep-
computer. The simultaneity of the gating aration view). An anterior acquisition is
device’s R-wave trigger and the patient’s obtained in a straight (0°) anterior projec-
QRS complex should be verified before tion or at an angle ~45° less than the “best
initiation of the study. An appropriate R- septal” view. The lateral acquisition is ob-
R interval beat acceptance window tained as a left cross-table lateral or at an
should be selected to account for heart angle that is approximately 45° greater
rate variability and ectopy. Systolic func- than the best septal view. The lateral view
tion determinations are less susceptible to may also be acquired in the right-side-
heart rate variability than diastolic func- down left lateral decubitus position. This
tion measurements. “List” mode acquisi- altered positioning may improve visual-
tion is useful for making a composite car- ization of the true posterobasal segment.
4 • RADIONUCLIDE VENTRICULOGRAPHY

A 70° LAO acquisition may be used in- should be performed before calculation of
stead of a left cross-table lateral view. Left LVEF. ROIs should be created, either manually
posterior oblique (LPO) or right anterior by the operator or automatically by the com-
oblique (RAO) acquisitions may be of ad- puter, so that all activity from the left ventricle
ditional benefit. These angles often need is encompassed by the ROI. The ROI used for
to be altered in patients with congenital background correction should be free of activ-
heart or lung anomalies or right-sided ity from the spleen or descending aorta. Other
overload. A slant-hole collimator may be ventricular systolic and diastolic parameters
used for angulation in the may be generated. Discrepancies between the
caudal–cephalic plane to help separate calculated LVEF and qualitative left ventricular
the ventricles from the atria. systolic function should be resolved by repro-
2. Stress study cessing, when necessary. Ventricular volumes
a. Instrumentation may be calculated using either count-based or
Refer to IV.E.1.a in this guideline. A high geometric methods. Calculation of the stroke
sensitivity or LEAP collimator is pre- volume ratio may be helpful in patients sus-
ferred for the stress equilibrium study. pected of valvular disease. Spatial and tempo-
b. Acquisition parameters ral filtering may be used, if desired, to enhance
Refer to IV.E.1.b in this guideline. Sixteen visual appearance of the images. Parametric
frames per R-R interval are sufficient for images (e.g., phase/amplitude images) may
assessment of ventricular wall motion also aid in image interpretation.
and LVEF. SPECT imaging with 8 or 16 H. Interpretation Criteria
frames is an acceptable substitute. Images 1. Cardiac morphology
may be acquired on a bicycle ergometer The morphology, orientation, and sizes of
in either a supine, semiupright, or up- the cardiac chambers and great vessels
right position using the best septal view should be evaluated subjectively and re-
as previously described or other views as ported. The thickness of the pericardial sil-
appropriate to visualize a specific region houette and the ventricular wall may also be
of interest (ROI). The most accurate deter- evaluated subjectively and reported. When
mination of the LVEF is usually obtained measured, absolute ventricular volumes
in the best septal view. may also be included, although measure-
Images may be acquired at multiple ments of absolute ventricular volumes by
levels of exercise. A 2–3-minute acquisi- planar images are problematic. SPECT mea-
tion may be attained at each new level of surements will be more reliable. Automated
exercise once a stable heart rate is at- programs to calculate ejection fraction and
tained (usually beginning after 1 minute volumes are preferable for gated SPECT.
of exercise at the new level). The last stage 2. Systolic ventricular function
of exercise may be extended to increase Global left ventricular function should be as-
image statistics, but workload should not sessed qualitatively and compared with the
be decreased. A postexercise RVG is de- calculated ejection fraction. Discrepancies
sirable to assess postexercise recovery; should be resolved by reprocessing, when
LVEF increases promptly in the great ma- necessary. Normal values for LVEF range
jority of patients. between ~50% and 80% at rest and between
Pharmacologic stress with inotropic 56% and 86% at stress. All left ventricular
agents, mental stress, and atrial or ven- segments should be assessed for regional
tricular pacing are other, less common al- function using cinematic display of each
ternatives to exercise testing. view. Abnormalities of contraction should
F. Interventions be described using the conventional terms of
Mental stress studies or pharmacologic stress mild, moderate, or severe hypokinesia, aki-
as well as pacing are potential interventions in nesia, and dyskinesia. Systematic reporting
patients who cannot exercise. may be aided by standardized recording
G. Processing forms. Parametric images, such as phase and
The cine loop should be reviewed for adequacy amplitude images, may be useful in evaluat-
of counting statistics, appropriate ECG gating, ing regional variations in the timing and
adequacy of radiopharmaceutical labeling, and magnitude of contraction, identifying valve
positioning of the heart. A subjective visual as- planes, and identification of conduction ab-
sessment of left ventricular systolic function normalities. The pattern of left ventricular
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL J UNE 2002 • 5

diastolic function may be evaluated qualita- dynamics.
tively from the volume curve and reported iv. Option: report left ventricular end-di-
with quantitative measurements. One can astolic and end-systolic volume.
adjust for differences that result from heart v. Report noncardiac vascular abnor-
rate or systolic function by dividing filling malities (e.g., aortic dilatation).
rate by emptying rate. Right ventricular sys- J. Quality Control
tolic function may be approximated by cal- Please refer to the Society of Nuclear Medicine
culation of RVEF; however, more accurate Procedure Guideline for General Imaging.
determination may require a different tech- K. Sources of Error
nique, such as first-pass RNA. Normal val- 1. RBC labeling
ues for RVEF range between ~46% and 70%. Certain medications and disease processes
3. Stress images (e.g., chronic renal failure) will decrease la-
The stress or intervention study should be beling efficiency and reduce the target-to-
displayed side-by-side with the resting background ratio.
study in cinematic mode. Changes in cham- 2. Patient positioning
ber sizes, regional wall motion, and global The ejection fraction may be inaccurately
ejection fraction of both ventricles should be calculated by inadequate separation of the
addressed qualitatively and reported with left ventricle from other cardiac structures,
quantitative measures of ejection fraction. especially the left atrium (which has a
4. Comparison with previous studies time–activity curve that is the opposite of
Results should be compared with any previ- that of the left ventricle).
ous studies by direct comparison of the cine- 3. Gating errors
matic displays of the two studies, whenever A poor ECG signal or one in which com-
possible. Discrepancies should be resolved plexes other than the QRS complex are dom-
by reprocessing when necessary. inant may result in spurious gating and data
I. Reporting that are not interpretable. Care should be
1. Procedures and materials taken to ensure that the QRS complex is the
Reporting of the method of ECG gating (for- triggering signal (e.g., choosing an ECG lead
ward only, buffered beat averaging), beat ac- in which the QRS is much larger than the T
ceptance/rejection, and underlying cardiac wave). The best gating can be obtained from
rhythm is optional. Type and dose of radio- systems that compute the rate of change of
labeling (Tc-99m RBCs in vivo, modified in voltage on the ECG to be sure that the QRS
vivo, in vitro; Tc-99m HSA) and views ob- and not the T wave is the signal used.
tained should be reported. 4. Heart rate variability
2. Findings Significant heart rate variability may com-
a. Cardiac morphology promise the determination of diastolic fill-
Comment on size of various cardiac ing indices.
chambers, ventricular wall thickness and 5. Image statistics
pericardial silhouette. Inadequate counts/frame may compromise
b. Systolic function image interpretation as well as decrease the
i. Report global LVEF. statistical reliability of quantitative mea-
ii. Report regional left ventricular wall surements.
motion. 6. Processing errors
iii. Option: report global RVEF. Inclusion of nonventricular activity or exclu-
iv. Option: report diastolic filling indices. sion of ventricular activity from ventricular
v. Option: report systolic emptying in- ROIs may cause underestimation or overes-
dices. timation of the ejection fraction. Including
c. Stress images the left atrium in the ROI my also alter the
i. Report baseline, peak and recovery LVEF. Inclusion of structures such as the
LVEF. spleen or the descending aorta in the back-
ii. Report any alteration in visually as- ground ROI may alter the LVEF.
sessed regional wall motion, global
left and right ventricular function, and
V. Issues Requiring Further Clarification
volumes.
iii. Option: report stress ECG and hemo- None
6 • RADIONUCLIDE VENTRICULOGRAPHY

VI. Concise Bibliography ventricular ejection fraction and cardiac volumes
as assessed by rest and exercise gated radionu-
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clide angiography. J Am Coll Cardiol.
ment of doxorubicin cardiotoxicity with quantita-
1991;18:112–119.
tive radionuclide angiocardiography. N Engl J
Massardo T, Gal RA, Grenier RP, et al. Left ventricu-
Med. 1979;300:278–283. lar volume calculation using a count-based ratio
Bacharach SL, Bonow RO, Green MV. Comparison of method applied to multigated radionuclide an-
fixed and variable temporal resolution methods giography. J Nucl Med. 1990;31:450–456.
for creating gated cardiac blood-pool image se- Miller TR, Goldman KJ, Sampathkumaran KS, et al.
quences. J Nucl Med. 1990;31:38–42. Analysis of cardiac diastolic dysfunction: applica-
Bacharach SL, Green MV, Borer JS, et al. Left ventric- tion in coronary artery disease. J Nucl Med.
ular peak ejection rate, peak filling rate, and ejec- 1983;24:2–7.
tion fraction: frame rate requirements at rest and Palmeri ST, Bonow RO, Meyers CE, et al. Prospective
exercise. J Nucl Med. 1979;20:189–193. evaluation of doxorubicin cardiotoxicity by rest
Bonow RO. Radionuclide angiography for risk strati- and exercise radionuclide angiography. Am J Car-
fication of patients with coronary artery disease diol. 1986;58:607–613.
[editorial]. Am J Cardiol. 1993;72:735–739. Polak JR, Kemper A, Bianco JA, et al. Resting early
Bonow RO, Kent KM, Rosing DR, et al. Exercise-in- peak diastolic filling rate: a sensitive index of my-
duced ischemia in mildly symptomatic patients ocardial dysfunction in patients with coronary
with coronary artery disease and preserved left artery disease. J Nucl Med. 1982;23:471–478.
ventricular function: identification of subgroups Rocco TP, Dilsizian V, Fischman AJ, et al. Evaluation
at risk of death during medical therapy. N Engl J of ventricular function in patients with coronary
Med. 1984;311:1339–1345. artery disease. J Nucl Med. 1989; 30:1149–1165.
Bonow RO, Picone AL, McIntosh CL, et al. Survival Sandler MP, Coleman RE, Patton JA, et al. Diagnostic
and functional results after valve replacement for Nuclear Medicine. 3rd ed. Baltimore, MD: Williams
aortic regurgitation from 1976 to 1983: impact of and Wilkins; 1996.
preoperative left ventricular function. Circulation. Spirito P, Maron BJ, Bonow RO. Non-invasive assess-
1985;72:1244–1256. ment of left ventricular diastolic function: com-
Bonow RO, Rosing DR, Kent KM, et al. Timing of op- parative analysis of Doppler echocardiographic
eration for chronic aortic regurgitation. Am J Car- and radionuclide techniques. J Am Coll Cardiol.
diol. 1982;50:325–336. 1986;7:518–526.
Breisblatt WM, Vita NA, Armuchestegui M, et al. Stewart RAH, McKenna WJ. Assessment of diastolic
Usefulness of serial radionuclide monitoring dur- filling indexes obtained by radionuclide ventricu-
ing graded nitroglycerin infusion for unstable lography. Am J Cardiol. 1990;65:226–230.
angina pectoris for determining left ventricular Upton MT, Rerych SK, Newman GE, et al. The repro-
function and individual therapeutic dose. Am J ducibility of radionuclide angiographic measure-
Cardiol. 1988;61:685–690. ments of left ventricular function in normal sub-
Dilsizian V, Rocco TP, Bonow RO, et al. Cardiac jects at rest and during exercise. C i r c u l a t i o n.
blood-pool imaging II: applications in noncoro- 1980;62:126–132.
nary heart disease. J Nucl Med. 1990;31:10–22. U.S. Department of Health and Human Services, Pub-
Juni JE, Chen CC. Effects of gating modes on the anal- lic Health Service. Clinical Practice Guideline
ysis of left ventricular function in the presence of Number 11. Heart failure: evaluation and care of
heart rate variation. J Nucl Med. patients with left-ventricular systolic dysfunc-
1988;29:1272–1278. tion. AHCPR Publication No. 94-0612. Washing-
Lee KL, Pryor DP, Peiper KS, et al. Prognostic value of ton, DC: HHS; 1994.
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VII. Disclaimer
son with clinical and catheterization variables.
Circulation. 1990;82:1705–1717. The Society of Nuclear Medicine has written and
Links JM, Becker LC, Shindledecker JG, et al. Mea- approved guidelines to promote the cost-effective
surement of absolute left ventricular volume from use of high quality nuclear medicine procedures.
gated blood pool studies. C i r c u l a t i o n. These generic recommendations cannot be applied
1982;65:82–91. to all patients in all practice settings. The guide-
Mahmarian JJ, Moye L, Verani MS, et al. Criteria for lines should not be deemed inclusive of all proper
the accurate interpretation of changes in the left procedures or exclusive of other procedures rea-
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL JUNE 2002 • 7

sonably directed to obtaining the same results. The care for patients may vary greatly from one medi-
spectrum of patients seen in a specialized practice cal facility to another. For these reasons, guide-
setting may be quite different than the spectrum of lines cannot be rigidly applied.
patients seen in a more general practice setting. Advances in medicine occur at a rapid rate.
The appropriateness of a procedure will depend in The date of a guideline should always be consid-
part on the prevalence of disease in the patient ered in determining its current applicability.
population. In addition, the resources available to