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38 Early roll-off in hyperemic segments can potentially result in a significant underestimation of myocardial perfusion abnormalities with lower grade of coronary obstruction, particularly in conjunction with the use of pharmacological stress imaging. Figure 4 gives a schematic representation of the relationship between myocardial flow and uptake of various perfusion tracers and the mechanism of potential underestimation of flow heterogeneity at high flow rates because of early roll-off. Comparing the intensity and extent of perfusion abnormalities with simultaneously administered 2~ and 99mWctetrofosmin or 99mTc sestamibi, with the microsphere-determined myocardial blood flow in a canine model of varying degrees of coronary i artery occlusion and adenosine induced hyperemia, both 2~ and 99mTcagents underestimated the flow heterogeneity compared with the microspheres.

These data support a theoretical role for 99roTecationic agents as a means of assessing myocardial viability, as described in a later section of this article. Washout of activity from myocytes loaded with 99mTc cationic agents has been studied by transferring these cells to a 99mTcfree medium. Washout is found to be much slower than uptake and is biexponential with two compartments (approximately 20% and 80%). 5 and 246 minutes for 99roTe tetrofosmin and 6 and 90 minutes for 99roTe sestamibi. 41,43 This explains the apparent lack of or minimal redistribution with 99rnTccationic agents in human studies.

This can be reliably eliminated only with the use of an effective attenuation and scatter correction program. This is discussed in more detail in a separate article by Dr. Watson in this issue. Despite several important technical advances in the field of attenuation correction, this technique is not yet ready for routine clinical use. MYOCARDIAL PERFUSlON IMAGING IN ACUTE CORONARY PATIENTS Because 99mTc sestamibi and 99mTc tetrofosmin do not redistribute, these agents can capture the status of myocardial perfusion at the time of injection, which can be imaged even several hours later irrespective of the cardiac interventions performed in the interim.

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Cardiovascular Nuclear Medicine

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