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Case of the month

Case of the month. Dr P Arumugam Consultant Nuclear Physician Nuclear Medicine Centre Central Manchester University Hospitals NHS Foundation trust. History. 58 year old Female. Atypical chest pain.

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Case of the month

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  1. Case of the month Dr P Arumugam Consultant Nuclear Physician Nuclear Medicine Centre Central Manchester University Hospitals NHS Foundation trust

  2. History • 58 year old Female. • Atypical chest pain. • Status -post PCI mid LAD November 2009.LMS 50% lesion negative on IVUS. Equivocal DSE due to LBBB.

  3. Stress /Imaging protocol • Adenosine stress protocol (140mcg/kg/min over 4.5 minutes) without exercise due to LBBB. No ischaemic symptoms reported. Maximal HR 101. • 2 day rest/stress with Tc- Myoview 640 MBq for stress and rest (as per BMI) • Stress and rest images were acquired on GE Millennium Hawkeye 4 camera ( 120 minutes post stress due to extra cardiac activity and 70 minutes after rest injection). • Images were reconstructed iteratively. • Images were considered to be of good quality with no significant attenuation or scatter artefact.

  4. Q – What is your interpretation of the perfusion study? • A – • Apparent (visual) stress induced cavity dilation. • Moderate Anteroseptal reduction in perfusion post stress which completely normalises at rest ( 3 /20 segments).

  5. Gated study screen capture

  6. Q- What is your interpretation of the single frame captured gated study ? • A- • There appears to be reduced anterior and apical wall motion ‘post stress’ (images acquired 120 minutes post) with normal appearance at rest – ‘myocardial stunning’. • There is a significant difference between post stress and resting ejection fraction, again consistent with prolonged post ischaemic stunning.

  7. Q –What is your interpretation based on perfusion and wall motion assessment? • A – Presence of reversible perfusion abnormality, reversible wall motion abnormality and drop in systolic function post stress suggests angiographically significant disease in the LAD.

  8. Angiographic findings • Patient underwent a repeat angiogram 1 month post SPECT study • Reported to show proximal LAD stenosis but patent mid LAD stent. • No significant LCx, RCA or LM stenosis. • MDT – case discussed and being considered for single vessel CABG.

  9. Teaching points • Assessment of both perfusion and function provides additional information. • Regional wall motion abnormality post stress in ischaemic segments has been described with exercise1,2 myocardial imaging due to stunning. • True ischaemia is rare with vasodilator stress as it induces flow heterogeneity and hence wall motion abnormality is not expected with adenosine / dipyridamole. Steal phenomenon through collaterals is a rare exception.

  10. In a recent publication 3 however, 1/3rd of patients had post vasodilator stress wall motion abnormalities which was proportional to the amount of ischaemia. • In this patient, there is evidence of regional wall motion abnormality, elevated ESV and drop in ejection fraction post stress – all consistent with ischaemia induced LV dysfunction. • This may be related to critical narrowing of the coronary artery involved 2 and may also be an indicator of multi vessel disease 4.

  11. SPECT images are acquired 45 – 60 minutes post stress and do not reflect a true peak stress ejection fraction nor regional wall motion and in theory ,‘a resting one’. Hence some clinicians do not feel the need to perform 2 gated studies (i.e. at rest and post stress). • However demonstration of wall motion abnormality several minutes post stress would be consistent with post ischemic stunning. • As post stress gated information can be obtained without any additional radiation nor significant impact on throughput, it is useful to obtain this data .

  12. References • Louise Emmett et al. Reversible regional wall motion abnormalities on exercise technetium-99m–gated cardiac single photon emission computed tomography predict high-grade angiographic stenoses . J Am Coll Cardiol, 2002; 39:991-998 • Sharir T, Bacher-Stier C, Dhar S, et al. Identification of severe and extensive coronary artery disease by postexercise regional wall motion abnormalities in Tc-99m sestamibi gated single photon emission computed tomography. Am J Cardiol 2000;86:1171-5. • Druz et al. Postischemic stunning after adenosine vasodilator stress. Journal of Nuclear Cardiology 535 Volume 11, Number 5;534-41 • Lima RS, Watson DD, Goode AR, et al. Incremental value of combined perfusion and function over perfusion alone by gated SPECT myocardial perfusion imaging for detection of severe three-vessel coronary artery disease. J Am Coll Cardiol 2003;42:64-70.

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