How do we establish cardiac sympathetic nervous system imaging with 123I-mIBG in clinical practice? Perspectives and lessons from Japan and the US

Abstract

Cardiac denervation is associated with progressive left ventricular (LV) dysfunction, ventricular arrhythmias, and sudden cardiac death (SCD) in heart failure (HF). In this regard, it is important to evaluate cardiac-specific sympathetic nervous system (SNS) function. The radiotracer Iodine-123 meta-iodobenzylguanidine (I-mIBG) can noninvasively evaluate pre-synaptic SNS function. Recent multicenter trials have shown I-mIBG to have strong predictive value for fatal arrhythmias and cardiac death in HF.I-mIBG was initially developed in the USA in the 1970s. In 1992, the Japanese Ministry of Health and Labour approved I-mIBG for the assessment of cardiac function. Following approval, the Japanese nuclear cardiology community developedI-mIBG imaging services in various medical centers. Japanese groups have been trying to establish the clinical utility of I-mIBG and standardize parameters for data acquisition and image analysis. The US Food and Drug Administration (FDA) has approved clinical use ofI-mIBG for cardiac and non-cardiac imaging. However, clinical use of I-mIBG in the US has been very limited. The number ofI-mIBG studies in Japan has also been limited. There are similarities and differences between the two countries. To establish the clinical utility of I-mIBG in both countries, it is important to characterize the situations ofI-mIBG in each.

Prognostic value of cardiac 123I‐metaiodobenzylguanidine imaging for predicting cardiac events after transcatheter aortic valve replacement

“…Cardiac sympathetic nervous (CSN) dysfunction is associated with a high incidence of unfavourable cardiac events, such as fatal arrhythmias and sudden cardiac death 1–4 . Cardiac 123 I‐metaiodobenzylguanidine (MIBG) imaging is a useful diagnostic tool for assessing CSN function and has been recommended for assessing the severity of heart failure (HF) and prognosis of HF patient 5 .…”

Cardiac 123I-MIBG normal uptake values are population-specific: Results from a cohort of controls over 60 years of age

“…However, as well as the differential diagnosis of Lewy body disease from other conditions [30][31][32], cardiac MIBG scintigraphy is also used for the estimation of risk of sudden cardiac death in heart failure patients and predicting those who could benefit from an implantable cardiac defibrillator (ICD) [18,33] and this is currently the principal application in Europe and the US [34]. The largest study of healthy controls recruited to a cardiac MIBG research study (n=94) was that of Jacobsen et al [35] carried out as part of the ADMIRE-HF heart failure study [18].…”

Expanding the clinical potential of cardiac radionuclide adrenergic imaging

“…For example, there is currently much interest in cardiac 123 I-mIBG imaging to more accurately distinguish Parkinson's disease and dementia with Lewy bodies from other similar appearing neurologic conditions. 7 However, a key organ that interacts closely with the heart, and that is highly controlled by autonomic innervation, is the kidney. Renal sympathetic efferent and afferent neurons innervate the kidneys via their course within and just adjacent to the renal artery wall, proceeding to renal vasculature, tubules, and the juxtaglomerular apparatus, serving to regulate volume retention through sodium reabsorption, control renal blood flow via neutrally mediated effects on local vascular tone, and stimulate renin release that directs the renin-angiotensin-aldosterone system (RAAS), while also sending afferent signals to the brain that in turn sends out efferent signals adjusting cardiac function and systemic vascular tone.…”

“…Consequently, and also because of financial constraints, after decades of investigation and discussions about this relatively easy, noninvasive technique that assesses a crucial component of cardiovascular function in health and disease, it is not being used. 7…”