123-I MIBG Imaging: Patient Preparation and Technologist’s...

123-I MIBG Imaging: Patient Preparation and Technologist’s Role

S. Seth Van Vickle1 BS, CNMT, NCT and Randall C. Thompson2, MD, FASNC

From: Saint Luke’s Mid America Heart Institute1,2 and Saint Luke’s Cardiovascular Consultants1,2 Kansas City, Missouri, USA Address for correspondences: S. Seth Van Vickle, Saint Luke’s Cardiovascular Consultants, 4330 Wornall Rd, Kansas City Missouri, 64111. Email: [email protected] Both authors indicate they have no financial conflicts to disclose

J of Nuclear Medicine Technology, first published online May 8, 2015 as doi:10.2967/jnmt.115.158394by on July 1, 2020. For personal use only. tech.snmjournals.org Downloaded from

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Abstract The radiopharmaceutical 123-I MIBG was approved by the Food and Drug Administration (FDA) in March 2013 for the assessment of myocardial sympathetic innervation in the evaluation of patients with heart failure and an ejection fraction ≤35%. Almost any well - equipped nuclear medicine / nuclear cardiology can perform this test, although special attention is needed for patient preparation, dose calibration, and proper timing of the image acquisition. This article reviews the role of the nuclear medicine technologist and the practical aspects of cardiac sympathetic 123-I MIBG imaging of which the nuclear medicine laboratory team needs to be mindful. Key words: 123-I MIBG, cardiac sympathetic imaging, cardiac denervation, Techniques for MIBG imaging.

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The radiopharmaceutical 123-I MIBG (AdreView) is indicated for the assessment of myocardial sympathetic innervation in evaluation of patients with New York Heart Association (NYHA) class 2-3 heart failure with an ejection fraction <35% and was approved by the Food and Drug Administration (FDA) in March 2013[1]. The role of this test in clinical practice is currently evolving. This article aims to outline the practicalities of use of 123-I MIBG. The use of 123-I MIBG can be best demonstrated by a case presentation. A 65-year-old man presented with mild limitations due to shortness of breath on exertion. He had had a heart attack 2 years prior and had been somewhat limited ever since. A recent myocardial perfusion imaging test showed left ventricular scarring, but no ischemia and a left ventricular ejection fraction of 36%. However, a recent echocardiogram obtained during a hospitalization at another facility showed an ejection fraction of 33%. The patient was advised to consider an implantable cardioverter defibrillator (ICD), but was very reluctant because of a relative who had an ICD that had frequently fired inappropriately.

It is certainly clear that ICDs save lives; their prophylactic implantation in patients who have known heart failure with low ejection fractions is considered standard therapy [2]. However, these devices are sometimes associated with complications, are expensive, and many are implanted for each life saved [3,4].

For patients like the one described above who have borderline indications for ICDs and are reluctant to proceed, physicians have a few options: 1. Accept the patient does not want the device 2. Try to convince the patient to have the device implanted 3. More exactly define the ejection fraction via another diagnostic medical imaging modality, or 4. Obtain cardiac sympathetic imaging with 123-I MIBG for risk stratification. The heart to mediastinal (H/M) ratio information provided by 123-I MIBG imaging is a powerful prognostic indicator in these patients, and such information might be useful in shared decision-making by physicians and patients [5-8]. Pre Patient Preparation: Technologist Considerations To properly perform 123-I MIBG imaging, the camera must allow for frontal planar imaging. Anterior frontal plane images are required while Single-Photon Emission Computed Tomography (SPECT) images are optional, but they are usually obtained. The nuclear cardiology system should come complete with low-energy, high-resolution collimation and the camera should be able to perform specific imaging sequences from the imaging protocol, e.g., static and SPECT imaging. Setting up and testing the imaging sequence prior to the day of dosing is often very helpful and recommended. The dose calibrator should also be inspected prior to ordering a study. The dose calibrator should have a 123-I specific setting and a correction factor specific for the laboratory’s instrument must be obtained. It is strongly recommended that a commercial copper sleeve or copper tube be used during dose calibration in order to lessen scatter counts from low energy photons, which can give falsely low readings for 123-I MIBG [9]. Planar Image Acquisitions (15 Minutes & 3 Hours, 50 Minutes Post Injection)



Two static anterior planar acquisitions are obtained when imaging with 123-I MIBG. With a dual-head camera, the detector heads should be positioned in the anterior and left lateral position. The anterior field of view (FOV) will be focused on acquiring the myocardium and the mediastinal region for later processing (see Figure 1). The organs of interest should be positioned in the center of the FOV—being mindful to keep the apex of both lungs closer to the top central FOV and the base of the myocardium in the bottom of the central FOV. A ten minute anterior acquisition in a 128x128x16 matrix allows for adequate counting statistics. Photon acquisition should be centered on a 159 keV peak with a 20% window. Preparing a patient for 123-I MIBG imaging When a clinical laboratory is preparing a patient for cardiac 123-I MIBG imaging, most of the usual steps inherent to nuclear cardiology imaging are followed. The imaging team should be mindful of the patient’s past medical history including allergies, medications, and general health history. There are also some medical issues particular to 123-I MIBG imaging. 123-I MIBG is contraindicated in patients with known hypersensitivity to iobenguane or iobenguane sulfate, however, it is also customary to screen potential patients for allergies to iodine containing materials by asking if they have had any prior reactions to iodinated contrast material, shellfish, strawberries, or cranberries. Particular attention must be paid to medication history. Table 1 provides a list of medications which impact 123-I MIBG imaging. This list includes medicines that might not be recorded by the patient without specific query; for example, over the counter cold medicines and cocaine. Certain common cardiac medications including labetalol and calcium channel antagonists also need to be stopped temporarily prior to 123-I MIBG imaging. Two particularly relevant medical conditions include Parkinson's disease and kidney disease. Patients with Parkinson’s disease have impaired cardiac uptake of 123-I MIBG [10]. Renal insufficiency is considered a relative contraindication for 123-I MIBG testing since the radiopharmaceutical is cleared by the kidneys, although a recent report calls this conventional position into question [11]. Patients who have increased risk for thyroid cancer should be considered for potassium iodide pre-treatment in order to block thyroid uptake and to lower the radiation dose to the thyroid [1,12]. Increased risk would presumably include young patients and those with a personal or family history of thyroid cancer. Potassium iodine was not routinely administered prior to 123-I MIBG in the pivotal Admire HF trial [5]. What to tell the patient The patient should be informed of key elements of the 123-I MIBG test to help eliminate some of the uncertainty and apprehension prior to the test. Nuclear medicine procedures have the potential to sound frightening for members of the general population, so it is important to outline the procedure, time requirements, and reasons for the test. Patients are generally instructed to be well



hydrated prior to the test, but care should be taken with heart failure patients who are on fluid restriction. Radiation dosimetry and should be mentioned too. The effective dose for an adult patient is 5.07 mSv for the injection of 370 MBq (10 mCi) of I-123 (13.7 μSv/MBq x 370 MBq or 0.507 mSv/mCi x 10 mCi) [1]. There is also a small amount of radiation exposure from attenuation correction. The total exposure is relatively low compared to other procedures in nuclear cardiology and is comparable to about 15 months of average background radiation. The cost and logistics of this radiopharmaceutical cause one laboratory feature–the no show policy – to be more important than usual. 123-I MIBG is a particularly expensive radiopharmaceutical and the dose travels a long distance before administration. Health insurance companies, including the Centers for Medicare & Medicaid Services, allow for nuclear cardiology facilities to bill patients for no-shows, but the laboratory must have a written policy in place and it is good practice to have the patient acknowledge the policy in writing. Preparing the radiopharmaceutical The dose of 123-I MIBG is calibrated to be 370 MBq (10 mCi) at 12:00pm on the day of administration. The dose arrives in a single use vial containing 5 mL of 123-I MIBG (concentration of 74 MBq/mL or 2 mCi/mL). The radiopharmaceutical expires 36 hours post calibration time and should be stored at a temperature between (68-77 degrees F), following hospital safety protocols. Using aseptic techniques and proper radiation safety, the technologist should draw 370 MBq (10 mCi) into a shielded syringe (see Figure 2). The syringe should be placed into the dose calibrator to verify proper MBq (mCi) amount prior to injection. The dose can then be administered to the patient, via a large peripheral vein over a period of 1-2 minutes. The IV should be flushed with saline prior to isotope injection to verify proper venous access, and again post injection to flush any accumulated residual activity. During the timed administration, the patient should be continually monitored for any hypersensivity or other reactions to the medication, e.g., itching, burning, or tingling sensations at the injection site. A post injection assay is performed on the syringe to determine residual radioactivity and the total administered activity to the patient. 123-I MIBG Imaging Sequence Due to the short injection-to-scan time, the technologist should ensure the camera is clear and unoccupied before administration of the pharmaceutical. Having the acquisition setup prior to injection is also helpful. Exact timing of the image acquisition is important and a stopwatch should be used. An early 10-minute, anterior planar image is obtained starting at 15 minutes post injection, as is a 3 hour 50 minute anterior planar acquisition. These combined images allow for the calculation of the washout ratio of the isotope (see package insert) [1].



Between these acquisitions, the patient is allowed to eat and is encouraged to stay hydrated, but not to excess if they have heart failure. Patients should also be advised that they are radioactive and should avoid small children and going through some airport security systems. SPECT images are acquired after the late planar acquisition. The primary prognostic parameter supplied by 123-I MIBG imaging is the heart to mediastinal ratio on the delayed images, which has been shown to predict 2 year cardiac mortality rate (see Figure 3) [5] The regions of interest must be drawn around the heart and in the mediastinum in the prescribed fashion according to the product package insert. In brief, an irregular region of interest is drawn around the whole heart defining the epicardial border. The number of counts and pixels in the region of interest is recorded. For the mediastinal region of interest, a horizontal line is drawn at the apices of the lungs. A vertical line is then drawn about equidistant between the right and left lungs. At the intersection of horizontal and vertical lines, counts 15 pixels below are marked. Starting with the fourth pixel below intersection, one should identify an area with the lowest counts and, if there are multiple areas, select the most superior. At the lowest pixel one draws a 7 x 7 pixel region of interest and records the number of counts in this 49 pixel region of interest (ROI). The H/M ratio is equal to the counts per pixel in the cardiac ROI divided by the counts per pixel in the mediastinal ROI (see Figure 4). 4-Hour SPECT Image Acquisition The 4-Hour SPECT image data set allows the clinician the ability to visualize myocardial uptake and retention of 123-I MIBG in the classic short, vertical, and horizontal long axis views. Our laboratory uses a circular orbit with 180 degrees of acquisition and we acquire 64 projections, using 32 stops of approximately 25 seconds/stop. An attenuation correction map is acquired simultaneously. The study is acquired in a 64x64x16 matrix and is non-gated. Image Processing (Reconstruction & Display) A sample view of the anterior planar images is seen in Figure 5. We customarily display the planar images in a two-view panel (one image displaying the raw image and the other displaying the H/M ratio along with the ROIs). The SPECT reconstruction parameters may vary depending on site specific routines and the technologist should remain consistent with the reconstruction parameters best suiting the laboratory. The 123-I MIBG images are reconstructed in a manner similar to that of myocardial perfusion SPECT imaging. Either standard filtered back projection or iterative reconstruction can be employed. Typically, a low pass filter is used, with a cut off of 0.50 and an order of 5.00. The images are then displayed in a fashion similar to that of SPECT myocardial perfusion imaging. Creating reconstruction defaults can help to standardize methods. Flotats and colleagues have recently proposed standardization of 123-I MIBG cardiac sympathetic imaging on the half of the European Association of Nuclear Medicine Cardiovascular Committee and the European Council of Nuclear Cardiology [13]. This reference may be helpful to provide more details about the acquisition and reporting of 123-I MIBG imaging.



In summary, cardiac sympathetic I-123 MIBG imaging can be performed by almost all well equipped nuclear medicine / nuclear cardiology laboratories. This procedure requires special attention for patient preparation, dose calibration and timing of image acquisition. As clinicians have more opportunity to use this technique, the exact clinical role of cardiac sympathetic 123-I MIBG imaging should become clear and the test should help to provide clinicians with useful prognostic information about cardiovascular risk in those with heart failure.



References. 1. GE Healthcare AdreView™ Iobenguane I 123 Injection Prescibing Information

http://www3.gehealthcare.com/en/products/categories/nuclear_imaging_agents/adreview accessed November 16, 2014.

2. Passman R, Goldberger JJ. Predicting the future: risk stratification for sudden cardiac death in patients with left ventricular dysfunction. Circulation. 2012;125: 3031-7.

3. Vollmann D, Luthje L, Vonhof S, et al. Inappropriate therapy and fatal proarrhythmia by an implantable cardioverter-defibrillator. Heart Rhythm. 2005;2: 307-309.

4. Uslan DZ, Sohail MR, St Sauver JL, et al. Permanent pacemaker and implantable cardioverter defibrillator infection: a population-based study. Arch Intern Med 2007; 167:669-75.

5. Jacobson AF et al. Myocardial iodine-123 meta-iodobenzylguanidine imaging and cardiac events in heart failure. Results of the prospective ADMIRE-HF (AdreView Myocardial Imaging for Risk Evaluation in Heart Failure) Study. J Am Coll Cardiol. 2010; 55: 2212-2221.

6. Tamaki S, Yamada T, Okuyama Y, et al. Cardiac iodine-123 metaiodobenzylguanidine imaging predicts sudden cardiac death independently of left ventricular ejection fraction in patients with chronic heart failure and left ventricular systolic dysfunction: results from a comparative study with signal-averaged electrocardiogram, heart rate variability, and QT dispersion. J Am Coll Cardiol 2009;53: 426-35.

7. Agostini D, Verberne HJ, Burchert W, et al. I-123-mIBG myocardial imaging for assessment of risk for a major cardiac event in heart failure patients: insights from a retrospective European multicenter study. Eur J Nucl Med Mol Imaging. 2008;35: 535-46.

8. Nakata T, Nakajima K, Yamashina S, et al. A pooled analysis of multicenter cohort studies of (123)I-mIBG imaging of sympathetic innervation for assessment of long-term prognosis in heart failure. JACC Cardiovasc Imaging. 2013;6: 772-84.

9. Kowalsky RJ, Johnston RE. Dose calibrator assay of iodine-123 and indium-111 with a copper filter. J Nucl Med Technol 1998;26: 94-8.

10. Braune S, Reibhardt M, Schnitzer R, et al. Cardiac uptake of (123 I) MIBG separates Parkinson’s disease from multiple system atrophy. Neurology. 1999;53: 1020-5.

11. Malhotra S, Wang L, Bunker CH, et al. Renal dysfunction does not affect the prognostic value of myocardial iodine – 123 meta-iodobenzylguanidine imaging in heart failure. Nucl Med Commun 2014;35: 58-63.

12. Friedman NC, Hassan A, Grady E, et al. Efficacy of thyroid blockade on thyroid radioiodine uptake in 123I-mIBG imaging. J Nucl Med 2014;55: 211-5.

13. Flotats A, Carrió I, Agostini D, et al. EANM Cardiovascular Committee; European Council of Nuclear Cardiology. Proposed standardization of 123I-metaiodobenzylguanidine (MIBG) cardiac sympathetic imaging by the EANM Cardiovascular Committee and the European Council of Nuclear Cardiology. Eur J Nucl Med Mol Imaging 2010;37: 1802-1812.



Figure 1. Anterior View of 123-I MIBG (AdreView) 3 Hours 50 Minutes Post Injection.



Figure 2

2. Proper tecchnique for d

drawing a 1223-I MIBG DDose.



Figure 3. Association of cardiac death with heart to mediastinal (H/M) ratio.



Figure 4. Heart to mediastinal (H/M) Ratio Obtained with 123-I MIBG.



Figure 5. Classic SPECT Myocardial Display of 123-I MIBG Images Post Reconstruction.



Table 1. (from Flotats et al. EJNMM 2010) [13] Drug or class Examples Mechanism of interference

(known or expected) Discontinuation prior to MIBG scan (days)

Opiod Uptake inhibition 7-14Cocaine Uptake inhibition 7-14Tramadol Uptake inhibition 7-14Tricyclic antidepressants

Amitriptyline and derivatives, imipramine and derivatives, amoxapine, doxepine and others Uptake inhibition 7-21Symapthicomimeticsa Phenylpropanolamine, ephedrine, pseudoephedrine, phenylephrine, amphetamine, dopamine, isoproterenol, salbutamol, tertbutaline, phenoterol, xylomeazoline Depletion of granules 7-14Antihypertensive/ cardiovascular agents

LabetalolReserpine Bretylium, guanethidine Calcium channel blockers (nifedipine, nicardipine, amlodipine) Inhibition of uptake and depletion Depletion and transport inhibition Depletion and transport inhibition Increased uptake and retention

2114 14 14 Antipsychotics Phenothiazonesb (chlorpromazine, promethazine, fluphenazine, others) Thioxanthenes (meprotiline, trazolone) Butyrophenones (droperidol, haloperidol) Loxapine

Uptake inhibition Uptake inhibition Uptake inhibition Uptake inhibition 21-28 21-28 21-28 7-21

a Components of bronchodilators, decongestants and diet aids b Frequent components of antiemetic and antiallergic agents Table 1. (from Flotats et al. EJNMM 2010)

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Doi: 10.2967/jnmt.115.158394Published online: May 8, 2015.J. Nucl. Med. Technol. Stephen Seth Van Vickle and Randall C Thompson 123-I MIBG Imaging: Patient Preparation and Technologist's Role

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