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Number 10-19 Clinical Utility of Stress CMR to Guide Management
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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.
Institute: Departments of Radiology and Cardiology. Clínica Universidad de Navarra, Pamplona, Navarra, Spain.

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).
During stress, after intravenous infusion of adenosine 140 µg/kg/min for 4 minutes, standard SSFP cine images (basal, mid and apical short axis views and 2 chamber long axis view - bottom panel), revealed new inducible wall motion abnormalities with severe hypokinesia appearing in the mid and apical anterior segments, as well as in the apical lateral wall. [Right click mouse on movie to enlarge].

 


   

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.
First pass perfusion imaging was repeated at rest (bottom panel), and confirmed the presence of a fixed perfusion defect in the basal inferior wall, corresponding to the previously infarcted area. [Right click mouse on movie to enlarge].

 


 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.

Clinical Perspective:

An increasing amount of literature supports the clinical application of stress CMR in patients with coronary artery disease (1-3). In this particular case, the CMR study provided relevant additional clinical information about the severity of the inducible ischemia in the territories of the left anterior descending artery and circumflex artery. Both the stress perfusion deficits and the stress inducible wall motion abnormalities were matched. CMR with the late-gadolinium enhancement sequences also enabled to determine that these territories were viable. Thus, in one study, CMR allowed for the diagnosis of ischemic and viable myocardium for this patient with persistent angina despite recent angioplasty.

References:

1.Bucciarrelli-Ducci C, Di Mario C, Pennell DJ. Perfusion Cardiovascular Magnetic Resonance in the Clinical Secenario of Patients With Coronary Artery Disease. Journal of the American College of Cardiolgy 2010 January 5;55:78-79.
2. Vick GW. The gold Standard for Noninvasive Imaging in Coronary Heart Disease: Magnetic Resonance Imaging. Current Opinion in Cardiology 2009;24:567-579.
3. Husser O; Bodí V; Sanchís J; Mainar L; Núñez J; et al. Additional Diagnostic Value of Systolic Dysfunction Induced by Dipyridamole Stress Cardiac Magnetic Resonance Used in Detecting Coronary Artery Disease. Rev Esp Cardiol. 2009; 62(04) :383-91

 


COTW handling editor: Monica Deac

 

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