Hybrid solid-state SPECT/CT left atrial innervation imaging for identification of left atrial ganglionated plexi: Technique and validation in patients with atrial fibrillation

  • J. StirrupEmail author
  • S. Gregg
  • R. Baavour
  • N. Roth
  • C. Breault
  • D. Agostini
  • S. Ernst
  • S. R. Underwood
Original Article



Ablating left atrial (LA) ganglionated plexi (GP), identified invasively by high-frequency stimulation (HFS) during pulmonary vein isolation (PVI), may reduce atrial fibrillation (AF) recurrence. 123I-metaiodobenzylguanidine (123I-mIBG) solid-state SPECT LA innervation imaging (LAII) has the spatial resolution to detect LAGP non-invasively but this has never been demonstrated in clinical practice.


20 prospective patients with paroxysmal AF scheduled for PVI underwent 123I-mIBG LAII. High-resolution tomograms, reconstructed where possible using cardiorespiratory gating, were co-registered with pre-PVI cardiac CT. Location and reader confidence (1 [low] to 3 [high]) in discrete 123I-mIBG LA uptake areas (DUAs) were recorded and correlated with HFS.


A total of 73 DUAs were identified, of which 59 (81%) were HFS positive (HFS +). HFS + likelihood increased with reader confidence (92% [score 3]). 64% of HFS-negative DUAs occurred over the lateral and inferior LA. Cardiorespiratory gating reduced the number of DUAs per patient (4 vs 7, P = .001) but improved: HFS + predictive value (76% vs 49%); reader confidence (2 vs 1, P = .02); and inter-observer, intra-observer, and inter-study agreement (κ = 0.84 vs 0.68; 0.82 vs 0.74; 0.64 vs 0.53 respectively).


123I-mIBG SPECT/CT LAII accurately and reproducibly identifies GPs verified by HFS, particularly when reconstructed with cardiorespiratory gating.


Nuclear medicine imaging nervous system, autonomic atrial fibrillation ganglionated plexi mapping catheter ablation mIBG, SPECT/CT, CZT 



Atrial fibrillation




DUA-to-mediastinal ratio


Discrete uptake area


Ganglionated plexus


High-frequency stimulation


Iodine-123 metaiodobenzylguanidine


Single-photon emission computed tomography


Left atrial innervation imaging


Pulmonary vein isolation



The authors wish to thank U. Voss, Department of Nuclear Medicine, Royal Brompton and Harefield NHS Foundation Trust, United Kingdom for contributing to data collection; and Samy Bross, Spectrum Dynamics Medical, Caesarea, Isarel, for contribution to the development of the phantom model.


JS, SE, DA, and SRU receive consultancy fees from Spectrum Dynamics Medical. JS receives speaker honoraria from Canon Medical Systems Europe (previously Toshiba Medical Systems Europe). UV was employed by a restricted research grant while NR, RB, and CB are employees of Spectrum Dynamics Medical.

Ethical Approval

All procedures performed were in accordance with the ethical standards of the local Research Ethics Committee (London—Camberwell St Giles REC, reference 14/LO/2207) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards ( Identifier NCT02267889).

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

12350_2018_1535_MOESM1_ESM.pdf (1.3 mb)
Supplementary material 1 (PDF 1344 kb)
12350_2018_1535_MOESM2_ESM.pptx (589 kb)
Supplementary material 2 (PPTX 588 kb)


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Copyright information

© American Society of Nuclear Cardiology 2019

Authors and Affiliations

  • J. Stirrup
    • 1
    Email author
  • S. Gregg
    • 2
  • R. Baavour
    • 3
  • N. Roth
    • 3
  • C. Breault
    • 3
  • D. Agostini
    • 4
  • S. Ernst
    • 5
    • 6
  • S. R. Underwood
    • 2
  1. 1.Department of CardiologyRoyal Berkshire Hospital NHS Foundation TrustReadingUnited Kingdom
  2. 2.Department of Nuclear MedicineRoyal Brompton and Harefield NHS Foundation TrustLondonUnited Kingdom
  3. 3.Spectrum Dynamics MedicalCaesareaIsrael
  4. 4.Department of Nuclear MedicineCHU Caen and Normandy University EA 4650CaenFrance
  5. 5.Department of CardiologyRoyal Brompton and Harefield NHS Foundation TrustLondonUnited Kingdom
  6. 6.Cardiovascular Research Center, Royal Brompton and National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom

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