Noninvasive Detection of Programmed Cell Loss
with 99mTc-Labeled Annexin A5 in Heart Failure
Bas L.J.H. Kietselaer1, Chris P.M. Reutelingsperger2, Hendrikus H. Boersma3,4, Guido A.K. Heidendal4, Ing Han Liem5,
Harry J.G.M. Crijns1, Jagat Narula6, and Leo Hofstra1
1Department of Cardiology, University Hospital of Maastricht, Maastricht, The Netherlands; 2Department of Biochemistry, University of
Maastricht, Maastricht, The Netherlands; 3Department of Clinical Pharmacy, University Hospital of Maastricht, Maastricht, The
Netherlands; 4Department of Nuclear Medicine, University Hospital of Maastricht, Maastricht, The Netherlands; 5Department of
Nuclear Medicine, Maxima Medical Center, Veldhoven, The Netherlands; and 6Division of Cardiology, University of California, Irvine
College of Medicine, Irvine, California
Apoptosis, or programmed cell death (PCD), contributes to the
decline in ventricular function in heart failure. Because apoptosis
comprises a programmed cascade of events, it is potentially reversible, and timely intervention should delay the development of
cardiomyopathy. 99mTc-Labeled annexin A5 has successfully
been used for the noninvasive detection of PCD in myocardial infarction and heart transplant rejection. The present study evaluated the role of annexin A5 imaging for detection of PCD in heart
failure patients. Methods: Annexin A5 imaging was performed
on 9 consecutive heart failure patients with advanced nonischemic cardiomyopathy (dilated, n 5 8; hypertrophic, n 5 1) and in 2
relatives having the same genetic background as the hypertrophic cardiomyopathy patient but no heart failure. Results: Four
of the patients with dilated cardiomyopathy and the 1 with hypertrophic cardiomyopathy and heart failure showed focal, multifocal, or global left ventricular uptake of annexin A5. No uptake was
visualized in the remaining 4 patients or in the 2 controls. All
cases showing annexin A5 uptake within the left ventricle experienced significant reduction in left ventricular function or functional class. In cases with no annexin A5 uptake, left ventricular
function and clinical status remained stable. Conclusion: These
data indicate the feasibility of noninvasive PCD detection with
annexin imaging in heart failure patients. Annexin A5 uptake is
associated with deterioration in left ventricular function, and
this association may lend itself to the development of novel management strategies.
Key Words: apoptosis; heart failure; annexin A5
J Nucl Med 2007; 48:562–567
eart failure is becoming the most important cardiovascular health problem (1), and strategies that allow recognition of potentially reversible myocardial damage may
have a significant clinical impact. Heart failure is charac-
Received Jul. 18, 2006; revision accepted Jan. 10, 2007.
For correspondence or reprints contact: Leo Hofstra, University Hospital of
Maastricht, Department of Cardiology, P.O. Box 5800, 6202 AZ, Maastricht,
E-mail: [email protected]
COPYRIGHT ª 2007 by the Society of Nuclear Medicine, Inc.
terized by inexorable deterioration in ventricular function
(2,3). Apoptosis, or programmed cell death (PCD), of cardiomyocytes has been proposed as an important process that
mediates the slow, ongoing loss of heart muscle cells and
ventricular dysfunction (4–7). Antiapoptotic intervention is
known to delay and prevent the occurrence or minimize the
severity of heart failure in animal models (8,9). Because
apoptosis is genetically programmed and can be modified,
it is important to develop techniques for noninvasive detection of PCD in heart failure (10).
Activation of caspase 3, the hallmark of PCD, leads to
alterations in the assortment of phospholipids in the sarcolemmal lipid bilayer, resulting in externalization of phosphatidyl serine (PS) to the outer surface of the cell membrane
(11,12). PS externalization has successfully been detected
noninvasively by radionuclide imaging with 99mTc-labeled
annexin A5 (13,14). The clinical feasibility of imaging with
annexin A5 has been demonstrated in patients presenting
with acute myocardial infarction (13), cardiac allograft rejection (15), or malignant intramyocardial masses (14). We
studied the feasibility of annexin A5 imaging for the detection of PCD in a small group of patients with advanced
MATERIALS AND METHODS
Annexin A5 imaging was performed on 9 consecutive patients
admitted with nonischemic cardiomyopathy and advanced heart
failure. Their ages ranged from 35 to 64 y, and 6 of the 9 patients
were male. New York Heart Association class II, III, and IV symptoms were reported for 1, 5, and 3 patients, respectively. Eight
patients had idiopathic dilated cardiomyopathy (patients 1–8), and
failure had recently worsened in 4 (patients 3, 6, 7, and 8), with a
reduction by at least 1 New York Heart Association functional class
during the past 3 mo. In the remaining patient (patient 9) heart
failure had developed secondary to familial hypertrophic cardiomyopathy caused by a mutation in the myosin gene at locus 14q11–
q12. Two relatives of patient 9 (aged 33 and 36 y, both women) with
the same myosin gene mutation, a hypertrophic echocardiographic
phenotype, and normal left ventricular ejection fraction (LVEF)
NUCLEAR MEDICINE • Vol. 48 • No. 4 • April 2007
also underwent annexin A5 imaging as hypertrophic but nonfailing controls. Patient characteristics are summarized in Table 1.
Echocardiography was performed on all patients at the time of
imaging. LVEF was assessed by 2-dimensional echocardiography.
The inner myocardial wall of the left ventricle was traced in both
the end-diastolic phase and the end-systolic phase. Using modified
Simpson’s analysis (16), we assessed LVEF. Patients were
followed up routinely in the cardiology department of our hospital
as outpatients. LVEF was reassessed by echocardiography after
1 y in all patients except the hypertrophic controls.
Annexin A5 Labeling and SPECT Study Protocol
Human recombinant annexin A5 (Theseus Imaging Corp.) was
labeled with 1 GBq of 99mTc for imaging. Six hours before imaging,
0.25 mg of human recombinant 99mTc-annexin A5 was administered intravenously. In addition, 32–48 MBq of 201Tl were administered 30 min before imaging. All scintigraphic studies were
performed using a MultiSPECT2 dual-head g-camera (Siemens).
A dual-isotope imaging protocol was used to acquire 99mTc and
201Tl data simultaneously. For 99mTc data, an energy peak of 140
keV with a window of 10% was used. 201Tl data were acquired using
peaks of 166 keV and 70 keV and windows of 15% and 20%,
respectively. We used a 64 · 64 matrix and 64 angled views, counting
each angle for 60 s. Studies were reconstructed with a backprojection method. Standard views of the left ventricle were constructed
using the 201Tl dataset. Limits and orientation of the left ventricle
were transferred onto the 99mTc-annexin dataset. Because of simultaneous acquisition of these data, we were able to precisely localize
myocardial uptake of 99mTc-annexin A5. Radiation exposure was
calculated to between 3.4 and 4.5 mSv. Two readers, unaware of the
clinical information, assessed the SPECT data independently. The
study complied with the Declaration of Helsinki and was approved
by the institutional review committee of the University Hospital of
Maastricht. All subjects gave written informed consent.
Patients 1–9 had advanced heart failure due to nonischemic cardiomyopathy. Before a patient was entered into
the study, the absence of coronary artery disease was confirmed by coronary angiography. Standard 2-dimensional
echocardiography did not show regional wall motion abnormalities. LVEF ranged from 15% to 31% at the time of
annexin A5 imaging. LVEF in the 2 control subjects was
52% and 73%, respectively.
Of the 9 congestive heart failure patients, 5 showed
annexin A5 uptake in the left ventricular myocardium; no
uptake was observed in the right ventricle. The uptake was
focal in 1 patient (patient 6), multifocal in 2 patients
(patients 3 and 7) (Fig. 1A), and diffuse in 1 patient (patient
9) (Fig. 1B). Myocardial perfusion was essentially normal
in these patients, and the areas of annexin A5 uptake did
not correspond to a single coronary territory as often
observed in myocardial infarction. All 4 dilated cardiomyopathy patients with annexin A5 uptake had experienced a
significant worsening or the onset of heart failure in the past
3 mo. Similarly, the patient with the myosin gene mutation
demonstrated positive, diffuse uptake and had experienced
a substantial decrease in LVEF in the past 6 mo.
The remaining 4 heart failure patients did not show
uptake of the radiotracer (Fig. 1C). These patients had poor
left ventricular function (LVEF, 25%–31%) but had no
recent evidence of worsening of heart failure. The 2 family
members of the hypertrophic cardiomyopathy patient, with
the myosin gene mutation and echocardiographic evidence
of left ventricular hypertrophy and preserved LVEF, did not
show radiolabeled annexin uptake (Fig. 1D).
During a follow-up of 1 y, the 4 patients with annexin A5
uptake showed, on average, a decline in LVEF. On the other
hand, in the annexin A5–negative patients, LVEF remained
stable or increased somewhat after 1 y of follow-up. Figure
2 depicts the change in ejection fraction, subtracting LVEF
at the time of imaging from LVEF 1 y after imaging. Student
t testing for paired samples showed a significant difference
Patient Characteristics and Outcome of Annexin A5 SPECT
LVEF study (%)
At time of
At time of
After 1 y of
Outcome of annexin
Focal, mainly lateral
NYHA 5 New York Heart Association; DCM 5 dilated cardiomyopathy; HCM 5 hypertrophic cardiomyopathy; NA 5 not applicable.
HEART FAILURE • Kietselaer et al.
FIGURE 1. Dual-isotope imaging using 201Tl for left ventricular contour detection and, simultaneously, radiolabeled annexin A5 in
patients with dilated cardiomyopathy. (A) Dilated cardiomyopathy patient with rapid deterioration of left ventricular function. Note
focal uptake in apex and lateral wall, and slight septal uptake. (B) Dilated cardiomyopathy patient in acute heart failure. Note global
uptake of radiolabeled annexin A5. (C) Dilated cardiomyopathy patient in stable clinical condition. Uptake is absent even when
image is enhanced to the extent that background radioactivity can be observed. (D) Family member of patient in panel B. No clinical
evidence is seen of dilated cardiomyopathy. Note absence of uptake of radiolabeled annexin A5. ANT 5 anterior; INF 5 inferior;
LAT 5 lateral; SEPT 5 septal.
between patients positive and negative for annexin A5 uptake (P 5 0.038).
Apoptosis in Heart Failure
PCD contributes to slow, ongoing myocardial dysfunction in heart failure (17). Cytokinemia and ischemic/oxidative
stress have been shown to lead to a release of cytochrome c
from the mitochondria into the cytoplasmic compartment
and to the activation of caspase 3 (18). Active caspase 3
cleaves contractile proteins and activates DNA fragmentation enzymes. The loss of cytochrome c (hence the loss of
the energy production mechanism in mitochondria) and the
fragmentation of contractile proteins contribute to a decline
in left ventricular function. Activation of caspase 3 also results in scrambling of cell membrane phospholipids, thereby
expressing PS (target for annexin imaging). However, the
simultaneous activation of various antiapoptotic factors in the
failing myocardium inhibits caspase-mediated activation of
NUCLEAR MEDICINE • Vol. 48 • No. 4 • April 2007
annexin A5 imaging for the detection of PCD in heart
failure patients. Annexin A5 uptake was seen predominantly in those patients who had demonstrated a recent
worsening in their left ventricular function or functional
class. In addition, these patients on average continued to
show a decrease in LVEF for up to 1 y during follow-up.
Other Noninvasive Imaging Studies of Heart Failure
FIGURE 2. Change in LVEF 1 y after annexin imaging. Green
bar shows patients with negative scan findings (mean LVEF
increase, 7%); red bar shows patients with positive scan
findings (mean LVEF decrease, 10%). P 5 0.038.
DNases. Such protective steps represent the survival instinct of the apoptotic myocardium and interrupt the apoptotic process (19–21). The greater the number of
antiapoptotic factors, the better should be the survival of
cardiomyocytes. On the other hand, more activation
of caspase 3 results in more PS exposure and, presumably,
a worse prognosis.
Noninvasive Imaging of PCD
Radionuclide imaging targets cell-surface alterations to
noninvasively recognize various forms of cell death associated with cardiovascular diseases (13,15,22). Myocardial
necrosis is characterized by a loss of sarcolemmal integrity,
with the cell membrane allowing free access to radiotracers
such as glucarate (binding to positively charged histones in
the disintegrating nuclei) and antimyosin antibody (binding
to fragmenting, insoluble heavy-chain myosin molecules)
(23). On the other hand, the sarcolemma remains intact in
PCD, but the asymmetry of the phospholipid distribution in
the lipid bilayer of the membrane is lost (24). As such, abundant PS is exteriorized to the outer surface of the membrane
that serves as a marker for macrophage phagocytosis (24).
As an endogenous protein, annexin A5 has high affinity for
PS and has therefore successfully been used for the detection of PCD in vivo (13,22). PS exposure is closely linked
to the activation of the executioner caspase 3 and can be
prevented by administration of caspase inhibitors (25).
These cell death inhibitors have been shown to reduce the
extent of myocardial damage in various myocardial diseases (8,25). The present study confirmed the feasibility of
Previous imaging studies for detection of cell death in
heart failure were performed using antimyosin antibodies
and showed evidence of myocardial necrosis in such patients
(23,26). Patients with antimyosin uptake were shown to have
a high likelihood of myocarditis or evidence of noninflammatory myocyte degeneration in their endomyocardial biopsy samples. Patients with scans positive for antimyosin
showed functional improvement over time, in contrast to
those with scans negative for antimyosin. The functional
improvement in antimyosin-positive patients appears to be
counterintuitive. It was proposed that the antimyosin positivity in dilated cardiomyopathy represented merely the
extent of acute myocardial insult and that the accompanying
irreversibly damaged, antimyosin-negative myocytes were
responsible for functional resolution (23). In contrast, in
annexin A5 imaging, annexin-positive patients continue to
show a decrease in left ventricular function, and annexinnegative patients show improved left ventricular function.
We can only surmise that the antimyosin-positive cells were
an indirect marker of reversible cells, whereas the annexinpositive cells represented the true state of balance of
proapoptotic and antiapoptotic factors in the cardiomyocytes
and should be more predictive of prognosis. It is apparent that
the cells with lower amounts of antiapoptotic factors (hence
more PS expression and annexin A5 positivity) would be
better candidates for exogenous antiapoptotic therapy. These
findings have been translated into Figure 3.
Limitations of Study
These data should be interpreted carefully because of the
small number of patients in the study. Further prospective
trials including larger numbers of dilated cardiomyopathy
patients with sequential scans and functional follow-ups
may clarify the current observations. Because 201Tl g-photons
also have an energy peak at 166 keV, there may be some
downscatter into the 140-keV window of 99mTc. However,
this downscatter was not observed in the family members of
the hypertrophic cardiomyopathy patient (Fig. 1D). In addition, we did not observe downscatter in patients included in
other studies (unpublished data, November 2006). Furthermore, annexin A5 uptake is focal in most patients, whereas
downscatter from 201Tl should appear throughout the left
ventricle. Endomyocardial biopsies were not performed in the
present study. Because biopsies are not likely to influence
management strategy, the ethical committee did not allow
biopsies for research purposes and merely for comparison
with the results of annexin A5 scans. In addition, serial annexin A5 scans were not allowed. The lack of endomyocardial
HEART FAILURE • Kietselaer et al.
FIGURE 3. Cytokine and oxidative
stress (reactive oxygen species) in heart
failure lead to caspase 3 activation by
release of cytochrome c from mitochondria into cytoplasmic compartment.
Activation of caspase 3 results in cytoplasmic proteolysis and DNA fragmentation and, hence, apoptosis. Endogenous
upregulation of BCl2- and XIAP-like proteins and loss of DNA fragmentation
factors prevent completion of apoptotic
process (apoptosis interruptus). Amount
of activated caspase 3 is determined by
balance of antiapoptotic and proapoptotic factors. The fewer the endogenous
antiapoptotic factors, the greater is the
residual caspase, the PS externalization,
the likelihood of an annexin-positive
scan, and the necessity for apoptosis
inhibition therapy and the poorer is the
biopsies precludes the diagnosis of myocarditis in scanpositive patients. Because none of the scan-positive patients
showed an improvement in LVEF, the likelihood of myocarditis in those cases is low.
This proof-of-principle study suggests that annexin A5
imaging may identify accelerated myocardial cell loss in
nonischemic dilated cardiomyopathy patients with a recent
worsening of heart failure. Such a strategy may offer a new
possibility for studying interventions to minimize the progression of myocardial dysfunction.
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inadvertently transposed. The authors regret the error.
HEART FAILURE • Kietselaer et al.