Hi,

this might serve as a starting point:

Effect of diabetes mellitus on myocardial 18F-FDG SPECT using acipimox for the assessment of myocardial viability. Schinkel AF, Bax JJ, Valkema R, Elhendy A, van Domburg RT, Vourvouri EC, Bountioukos MA, Krenning EP, Roelandt JR, Poldermans D.

J Nucl Med. 2003 Jun;44(6):877-83.

We do a hyperglycemic clamp in order to maximally standardize the measurement; but I would not say that this is simple ;)

Best regards

Stephan

For nondiabetic patients glucose loading with 80 g glucose in water (limonade) or a bar of chocholate 1 hour before FDG injection is the simplest, reliable method. You can add acipimox (olbetam) to lower free fatty acids in the blood hence to further increase glucose uptake in myocardium.

For diabetic patients there is no simple method, hyperinsulinaemic normoglycemic glucose-clamp is the most reliable technique, but it is way no simple, because it needs continuous glucose monitoring from vein in 5 min. intervals and two perfusion pumps with fast acting insulin and the other with 20% glucose solution. You can kill the subject easily without proper attention.

Hasn't that been conclusively shown that CMR is the reference standard for viability against all nuclear exams including PET for >10 years now?  Given the dificulty with insulin clamps and complex monitoring for diabetics with FDG I wonder why reinvent the wheel, may I ask?  CMR is cheaper, faster and reproducible with impeccable spatial resolution (

Well, without any ambition to get into pseudo-religious discussions on FDG PET vs LGE MRI : it really depends on the question. One  technique images basically viable myocytes and the other dead myocytes. ... BUT - then it would be a simple black and white world ;) From a practical point of view we still do more viability PETs than I would have imagined after our paper in 2002. Simple reason is the presence of implantable devices . Correct, there are MR compatible systems, but as you were talking about "fun"... Talking about "fun": so far, I have to admit,  "fun" was not reported by patients post MRI....oh, wait I second - I forgot the apnoe cave diver.

The international Journal of Cardiovascular Imaging

Soares J Jr, Rodrigues Filho F, Izaki M, Giorgi MC, Catapirra RM, Abe R, Vinagre CG, Cerri GG, Meneghetti JC

Low-carbohydrate diet versus euglycemic hyperinsulinemic clamp for the assessment of myocardial viability with 18F-fluorodeoxyglucose-PET: a pilot study 2013 Nov 20.

I feel to use the hyperinsulinemic clamp method one needs good support system and is cumbersome many times we used in some patients oral glucose load method both in Diabetic and Non diabetic (acipimox  n't available in our setup so far) but it works and easy to use, though at times this does not work either.

Positron emission tomography with

18F-fluorodeoxyglucose

(FDG-PET) is considered the gold standard for

myocardial viability.Apilot studywas undertaken to compare

FDG-PET using euglycemic hyperinsulinemic clamp before

18

F-fluorodeoxyglucose (18F-FDG) administration (PETCLAMP)

with a new proposed technique consisting of a 24-h

low-carbohydrate diet before

18F-FDGinjection (PET-DIET),

for the assessment of hypoperfused but viable myocardium

(hibernating myocardium). Thirty patients with previous

myocardial infarctionwere subjected to rest

99mTc-sestamibi-

SPECT and two

18F-FDG studies (PET-CLAMP and PETDIET).

Myocardial tracer uptake was visually scored using a

5-point scale in a 17-segment model. Hibernating myocardium

was defined as normal or mildly reduced metabolism

(

18F-FDG uptake) in areas with reduced perfusion (99mTcsestamibi

uptake) since

18F-FDG uptake was higher than the

degree of hypoperfusion–perfusion/metabolism mismatch

indicating a larger flow defect. PET-DIET identified 79 segments

and PET-CLAMP 71 as hibernating myocardium.

Both methods agreed in 61 segments (agreement

= 94.5 %,

j

= 0.78). PET-DIET identified 230 segments and PETCLAMP

238 as nonviable. None of the patients had hypoglycemia

afterDIET,while 20 %had it duringCLAMP. PETDIET

compared with PET-CLAMP had a good correlation for

the assessment of hibernating myocardium. To our knowledge,

these data provide the first evidence of the possibility of

myocardial viability assessment with this technique.

Thank you Dr Claudio for the information.