|Number 10-19 Clinical Utility of Stress CMR to Guide Management|
Number 10-19 Clinical Utility of Stress CMR to Guide Management
Case from: Azcárate PM, Bastarrika G, Castaño S, Gavira JJ, Coma I, Calabuig J, Fernandez-Jarne E.
Clinical history: A 49 year-old male patient with previous history of inferior infarction treated with angioplasty and stenting of the RCA, was admitted for new onset angina at rest.
Coronary angiogram on admission showed diffuse LAD disease as well as lesions of the RCA and 3rd marginal. The RCA, LAD and 1st diagonal all benefited from angioplasty and stenting [right click mouse on movies to enlarge]. Despite these interventions, the patient had persistent angina in CCS class 3. He was therefore referred for CMR perfusion and viability assessment.
Standard SSFP cine images at rest (top panel) in the basal, mid and apical short axis views and 2 chamber long axis view showed normal bi-ventricular volumes and preserved ejection fraction despite regional wall motion abnormalities (basal inferior wall dyskinesia and mid inferior wall hypokinesia).
First pass perfusion imaging using a 3-slice hybrid-EPI sequence (basal, mid and apical short axis views and 2 chamber long axis view) was also performed after 4 minutes of adenosine infusion (top panel). A reversible perfusion defect was seen in mid and apical anterior segments, as well as in the apical lateral wall, corresponding to the same inducible wall motion abnormalities observed on SSFP cine imaging during stress. There was also a perfusion defect visible in the basal inferior wall during stress.
Movie comparing stress perfusion images in the top panel, with SSFP cine images at stress in the bottom panel.[Right click mouse on movie to enlarge].
Corresponding late-gadolinium enhanced sequences (bottom panel) confirmed a transmural infarction of the basal inferior wall, and revealed sub-endocardial (25-50%) infarction of the mid-anterior, mid-inferior, and apical lateral segments. Note how the perfusion defects at stress are more extensive than the necrotic myocardium on late-gadolinium enhanced images (top panel) indicating the presence of peri-infarct ischemia. [Right click mouse on movie to enlarge]
Following these CMR findings, a second coronary angiogram was scheduled, which unfortunately was ultimately declined by the patient.
COTW handling editor: Monica Deac