pyrophosphate and Contusions

Blunt trauma to the chest and abdomen frequently results in cardiac injury. A wide spectrum of pathology can follow, including myocardial concussion and contusion, valvular disruption, and pericardial effusion and tamponade. Likewise, sequelae may be inconsequential or lead to sudden death, and may occur immediately at the time of trauma or be delayed by days to years. Despite the increasingly common occurrence of myocardial contusion there remains much confusion as to how the diagnosis is made. The various diagnostic studies utilized are frequently misinterpreted. The pathophysiology, clinical presentation, and a critical evaluation of the diagnostic tests used in the confirmation of this entity are reviewed, and an approach to the evaluation and management of these patients is presented.

Topics: Animals; Contusions; Creatine Kinase; Diphosphates; Dogs; Echocardiography; Electrocardiography; Heart; Heart Injuries; Humans; Isoenzymes; Radiography; Radionuclide Imaging; Technetium; Technetium Tc 99m Pyrophosphate

In the patient with cardiac trauma, radionuclide imaging may provide important information about cardiac mechanical function, vascular anatomy and integrity, myocardial perfusion, and myocardial metabolism. Studies require only minimal patient cooperation, can be performed relatively rapidly and often at the bedside, and may be repeated at frequent intervals for serial evaluations. These studies provide valuable adjunctive knowledge when selected and interpreted with knowledge of the mechanism of injury, timing of the examination relative to the time of injury, and most likely differential diagnoses.

Topics: Aged; Contusions; Diagnosis, Differential; Diphosphates; Electric Injuries; Female; Heart Aneurysm; Heart Injuries; Heart Neoplasms; Humans; Male; Methods; Middle Aged; Myocardial Infarction; Myxoma; Pericardial Effusion; Technetium; Technetium Tc 99m Pyrophosphate; Tomography, Emission-Computed; Tricuspid Valve Insufficiency; Wounds, Gunshot

Topics: Contusions; Coronary Artery Bypass; Coronary Disease; Diagnosis, Differential; Diphosphates; Heart Injuries; Humans; Myocardial Infarction; Myocardium; Necrosis; Radionuclide Imaging; Technetium; Time Factors

In 16 patients with blunt trauma to the chest, the role of cardiovascular nuclear medicine was evaluated using anterior chest flow assessment, with first-pass ejection fraction of left and right ventricles and 99mTc-pyrophosphate scintigraphy. The radiopharmaceutical used was pyrophosphate, labelled with approximately 20 mCi 99mTc. The anterior chest flow and first-pass ejection fractions were initially obtained during the injection of 99mTc-pyrophosphate and were followed up 3 h later by anterior, LAO 45 degrees, and left lateral views of the chest, using an LFOV gamma camera with a data processor. The results were compared with serial cardiac enzymes studies, electrocardiograms and echocardiograms. Of the patients, 77% showed scintigraphic evidence of cardiac contusion. The intensity of activity varied from grades I to II; five patients had abnormal echocardiographic findings. Only two had abnormal ejection fractions, and one patient had evidence of left ventricular aneurysm along with poor ventricular performance. Cardiac enzymes were found to be the least helpful. Electrocardiograms, though non-specific for myocardial damage, were abnormal in 62% of the patients. Eleven of our patients had both abnormal ECG and increased PYP uptake. Even though there is no agreement as to which noninvasive parameter is more sensitive in the diagnosis of myocardial contusion, 99mTc-pyrophosphate scintigraphy, in conjunction with ECG, seems promising in this respect.

Topics: Contusions; Creatine Kinase; Diphosphates; Echocardiography; Electrocardiography; Heart; Heart Injuries; Humans; Infant, Newborn; Isoenzymes; Radionuclide Imaging; Stroke Volume; Technetium; Technetium Tc 99m Pyrophosphate

Topics: Adult; Aged; Contusions; Creatine Kinase; Diphosphates; Echocardiography; Electrocardiography; Female; Heart Injuries; Humans; Isoenzymes; Male; Middle Aged; Technetium; Technetium Tc 99m Pyrophosphate; Thoracic Injuries

Because myocardial dysfunction may result from severe trauma, the author assessed, prospectively, left and right ventricular function in 25 patients who had sustained severe trauma, including blunt chest injury, by electrocardiographically gated blood pool radionuclide angiography. Focal abnormalities of ventricular wall motion were defined in 17 patients: right ventricular in 12, left ventricular in 2 and biventricular in 3. Traumatic tricuspid insufficiency demonstrated in two patients was subsequently verified by contrast angiography. Other means of detecting myocardial contusion (enzymatic, electrocardiographic and scintigraphic) proved to be insensitive when compared with radionuclide angiography. Two of the five deaths were attributed to refractory arrhythmias. Surgical or autopsy evidence of traumatic myocardial injury was obtained in five instances when radionuclide angiography indicated contusion. Of the 13 patients available for follow-up, 11 showed complete or partial resolution of the ventricular wall abnormality and in 2 there was no change. Comprehensive cardiopulmonary monitoring revealed an inverse relation between the right ventricular ejection fraction and pulmonary vascular resistance as well as between the pulmonary vascular resistance and left ventricular ejection fraction and left ventricular end-diastolic volume. Further, as the right ventricular end-diastolic volume was increased in trauma, left ventricular function and compliance were reduced. In blunt chest trauma, right ventricular contusion occurs more frequently than has been recognized previously and positive radionuclide angiography constitutes prima facie evidence of direct myocardial injury. Moreover, left ventricular function remains preload-dependent, but may be depressed by elevated pulmonary vascular resistance, impeding the blood flow from the right to left ventricle, and decreased left ventricular compliance, or both.

Topics: Accidents, Traffic; Cineangiography; Contusions; Diphosphates; Electrocardiography; Heart Injuries; Hemodynamics; Humans; Prospective Studies; Radionuclide Imaging; Technetium; Technetium Tc 99m Pyrophosphate; Wounds, Nonpenetrating

Currently available diagnostic techniques for myocardial contusion following blunt chest trauma were evaluated. We investigated 30 patients prospectively over a period of 1 year for the presence of myocardial contusion. Among the 30 patients, eight were found to have myocardial contusion on the basis of abnormal electrocardiograms, elevated creatine phosphokinase MB fraction (CPK-MB), and positive myocardial scan. Myocardial scan was positive in seven of eight patients (87.5%). CPK-MB fraction was elevated in four of eight patients (50%). Definitive electrocardiographic changes were seen in only two of eight patients (25%). It appears that myocardial scan using technetium pyrophosphate and CPK-MB fraction determinations are the most reliable aids in diagnosis of myocardial contusion following blunt chest trauma.

Topics: Adult; Aged; Clinical Enzyme Tests; Contusions; Creatine Kinase; Diphosphates; Electrocardiography; Female; Heart Injuries; Humans; Isoenzymes; Male; Middle Aged; Prospective Studies; Radionuclide Imaging; Technetium; Technetium Tc 99m Pyrophosphate; Wounds, Nonpenetrating

Nonpenetrating trauma to the chest can result in cardiac damage that may be overlooked because of associated injuries and the lack of obvious thoracic injury. The clinical diagnosis of important cardiac damage in this setting is difficult. We evaluated noninvasive tests for detecting myocardial damage in 100 patients with severe, nonpenetrating chest trauma. The noninvasive tests included serial ECG, serial total CPK and CPK-MB enzymes, continuous Holter monitor recording to detect dysrhythmia, and technetium-99m pyrophosphate scintigraphy. Peak CPK-MB elevations occurred in 72 patients. ECG abnormalities were noted in 70 patients, and 27 patients had Lown grade 3 or greater dysrhythmias. Fifteen patients died and all had autopsies. The noninvasive abnormalities were nonspecific and did not reflect myocardial contusion that led to clinically important cardiac complications.

Topics: Adolescent; Adult; Aged; Contusions; Creatine Kinase; Diphosphates; Electrocardiography; Female; Heart Injuries; Humans; Isoenzymes; Male; Middle Aged; Myocardium; Radionuclide Imaging; Technetium; Technetium Tc 99m Pyrophosphate; Wounds, Nonpenetrating

Twelve patients who sustained significant blunt chest trauma and had abnormal electrocardiographic changes unrelated to hypotension, hypoxia, or pre-existing myocardial disease were studied prospectively during a one-year period. The patients were divided into two groups on the basis of serum creatine phosphokinase (CPK)/MB isoenzyme concentrations: Group A (six patients) had normal CPK/MB isoenzymes (less than 8 IU), and Group B (six patients) had elevated CPK/MB isoenzymes (greater than 8 IU). All patients underwent cardiac scanning with technetium99m pyrophosphate. All studies were interpreted as normal. These data suggest that technetium99m pyrophosphate scanning is not a reliable adjunctive test to confirm myocardial contusion in patients with significant blunt trauma of the chest. However, the diagnosis of myocardial contusion in such patients can be established by the presence of abnormal electrocardiographic changes associated with an elevation of the serum CPK/MB isoenzyme concentration.

Topics: Adolescent; Adult; Aged; Contusions; Creatine Kinase; Diphosphates; Female; Heart Injuries; Humans; Isoenzymes; Male; Middle Aged; Prospective Studies; Radionuclide Imaging; Technetium; Technetium Tc 99m Pyrophosphate; Wounds, Nonpenetrating

A new method of diagnosing myocardial contusion was studied in 8 patients in whom the injured mycardium was visualized as an abnormal area of increased activity in the region of the heart one hour after intravenous injection of 10 mCi of 99m-Tc-Sn-polyphosphate or pyrophosphate. Serum enzymes in these patients were elevated, but electrocardiograms were nonspecific for myocardial injury. It is hoped that this new technique of imaging the injured myocardium will provide specific and confirmatory diagnosis of myocardial contusion associated with closed chest injuries.

Topics: Animals; Aspartate Aminotransferases; Contusions; Creatine Kinase; Diphosphates; Dogs; Electrocardiography; Heart Injuries; Humans; L-Lactate Dehydrogenase; Phosphates; Radionuclide Imaging; Scintillation Counting; Technetium; Tin