Significant Perfusion Defects Research Articles

Significant myocardial perfusion defect during stress visible in prone but not in supine imaging

Significant myocardial perfusion defect during stress visible in prone but not in supine imaging

The impact of cardiac SPECT in risk stratification for women with suspected coronary artery disease in a very high cardiovascular risk country

Abstract Funding Acknowledgements Type of funding sources: None. Background Risk stratification has become increasingly important in the management of women with coronary artery disease (CAD). Population based cross-sectional study of cardiovascular risk (CVR) factors in Latvia revealed that women in age 25 -74 are in a very high CVR group: more than 60% of women have dyslipidemia, 30% have arterial hypertension (AH) and are overweight. Purpose To evaluate CVR factor profile in women with suspected CAD and performed cardiac single photon emission computed tomography (SPECT) and to prove the need of perfusion imaging for women in a very high cardiovascular risk population. Methods Cardiac SPECT for women with suspected CAD and positive or non-informative exercise test was performed in a single center from 2018 till 2022. The patients were analyzed by risk factors and perfusion test result, divided into 2 groups: normal myocardial perfusion or true myocardial perfusion defect. Results 466 patients without known CAD were analyzed. The mean age of cohort patients was 59.3±10.9 years. 28 (6.0%) patients had no CVR factors, 90 (19.3%) women had only 1, but the rest of them (348, 74.7%) had 2 or more CVR factors. Dyslipidemia was present in 358 (76.8%), AH in 282 (60.5%) and type 2 Diabetes mellitus (T2DM) in 27 (5.8%) patients. More than half of patients (n=303, 65.0%) were overweight (BMI>25.0 kg/m2). 65 (13.9%) women were current or ex-smokers. True myocardial perfusion defect was detected in 96 patients (20.6%). There was no statistically significant difference between CVR risk factor count and cardiac SPECT result (p=0.229), although there were patients with significant perfusion defect without any risk factor present. However, significant correlation between risk factors and detection of obstructive coronary artery disease (CAD) after positive cardiac SPECT was found (p<0.001). Totally in study was detected 71 patients with suspected ischemia with non-obstructive CAD (INOCA), but further investigation with intracoronary physiology measurements – coronary flow reserve (CFR), index of microvascular resistance (IMR) and acetylcholine provocation test is required to define INOCA endotype. Conclusions The cardiac SPECT is an appropriate diagnostic method for women patients with suspected CAD. Even in patients with no CVR factors, but with positive or non-informative exercise test, the CAD is present, therefore they should be referred to cardiac SPECT in a very high CVR country. In patients with significant perfusion defect and absence of obstructive CAD, the performance of intracoronary physiology measurements is required.

Abstract 14023: Myocardial Perfusion Abnormalities: A Potential Biomarker for Ventricular Arrhythmias in Hypertrophic Cardiomyopathy Young Patients?

Introduction: Despite progress in the field, risk stratification for sudden death in patients with hypertrophic cardiomyopathy (HCM) remains challenging. Although ventricular arrhythmias (VA) account for most of these events, the mechanisms responsible for cardiac arrest in HCM are not understood. Hypothesis: Abnormalities in myocardial perfusion may create an arrhythmogenic substrate in HCM patients. Methods/ Results: A 12-year-old boy was admitted to our department after an out-of-hospital cardiac arrest, with documented ventricular fibrillation while running. A non-obstructive asymmetric HCM was diagnosed with echocardiography (max LV wall thickness 32 mm). He had one conventional risk factor for SCD. Genetic testing revealed a heterozygous state for a MYH7 variation: p.Glu500Ala (NM_000257.3:c.1499A>C). This variation was classified as “probably pathogenic” (class 4 according to ACMG). His father and his 15-year-old brother were heterozygous for the same variant and were asymptomatic. The brother displayed a similar HCM phenotype. The patient received an implantable defibrillator and suffered from appropriate exercise-related shocks within 6-months despite sotalol therapy (160 mg bid). Because the VA occurred always when the patient was engaged in vigorous physical activity despite beta blocker and since he could not refrain from physical activity, thallium-201 myocardial scintigraphy was performed. To further understand the arrhythmogenic phenotype, his brother underwent the same investigation. Significant uptake perfusion defects in both initial and delayed images were evident in the proband (15%) but not in the asymptomatic brother. Treatment with antianginal drug (amlodipine 5 mg/day) was initiated. With 10 mg/day amlodipine was associated with a significant improvement of the scintigraphy (6% versus 15% perfusion defect). At a follow-up of 12 months, there was no recurrence of VA. Conclusions: Regarding HCM patients, the present report 1) strengthens the hypothesis that myocardial perfusion defects may identify patients at risk for VA, 2) suggests that tailored anti-ischemic prescription may be useful, and 3) underscores the need of prospective studies quantifying ischemia in HCM patients with exercise-induced VF.

CLINICAL CHARACTERISTICS OF WOMEN REFERRED TO CARDIAC SPECT: WHEN AND WHO? DATA FROM LATVIAN CARDIAC SPECT REGISTRY

Objective: Population based cross-sectional study of cardiovascular risk (CVR) factors in Latvia from year 2009 till 2019 revealed that women in age 25 -74 are in a very high CVR group: 61% of women have dyslipidemia, more than 33% have arterial hypertension (AH) and 28% are overweight. The data indicates the necessity for focused diagnostics and early detection of cardiovascular disease. The aim of study was to define the clinical profile and risk factors for women with suspected coronary artery disease (CAD) reffered to cardiac single photon emission computed tomography (SPECT) in Latvia and to find out the correlation between nuclear test result and patient clinical presentation. Design and method: Cardiac SPECT was performed in a single centre from 2018 till 2021. The women patients were analyzed by risk factors and previous diagnosis of CAD. Exercise test was performed in all cases. Patients were divided into 2 groups: normal myocardial perfusion or true myocardial perfusion defect, defined as area of ischemia more than 10% of the left ventricle myocardium mass. Results: 726 SPECT data were analyzed. The mean age of women patients was 62.6 ± 10.6 years. More than half of the patients (n = 486,66.9%) were overweight (BMI> 25.0 kg/m2) and 33.3%(n = 242) were obese (BMI> 30.0 kg/m2). 87 (11.9%) women were current or ex-smokers. Dyslipidemia was present in in 614 (84.6%), AH in 535 (73.7%) and type 2 Diabetes mellitus (T2DM) in 60 (8.3%) patients. 104 (14.3%) patients were asymptomatic, but with intermediate to high pre-test probability for CAD. Known CAD was present in 298 (41.0%) patients. Exercise test was found positive in 306 (42.1%) patients and the test result was not always associated with ischaemia in SPECT (p = 0.063). True myocardial perfusion defect was detected in 125 patients (17.2%). Correlation was found between significant perfusion defect in SPECT and risk factors - AH (p = 0.013) and dyslipidemia (p = 0.029). Conclusions: The registry proves the high value of imaging with cardiac SPECT for diagnostics of CAD. Women patients with intermediate or high pre-test probability – even asymptomatic or with non informative exercise test should be reffered for cardiac SPECT.

Idiopathic Aortic Thrombosis and Thromboembolism in Young Women

Introduction: Spontaneous aortic thrombosis causing distal embolization and acute limb ischemia is an ominous medical condition with a poor prognosis. Herein are reported the clinical courses of two women who presented with severe lower extremity ischemia caused by distal embolization of spontaneous aortic thrombus without obvious antecedent arterial disease. This unusual diagnosis should be expected in patients presenting with persistent lower extremity pain and numbness even in the absence of overt physical findings. Case 1: A 42 year-old woman with mild hyperlipidemia complained of left leg numbness and weakness. She was treated with analgesia but her symptoms worsened. Lower extremity ultrasound revealed a significant infra-inguinal perfusion defect; computed tomography revealed mural thrombus in a normal aorta along with extensive thrombotic occlusion of the left popliteal and tibial arteries. Attempts at endovascular recanalization were unsuccessful; the patient underwent successful left popliteal-to-plantar artery bypass with autologous vein. Case 2: A 57 year-old woman without medical history presented to a local Emergency Room with a five-day history of numbness in the right lower extremity. Computed tomographic angiography revealed complete infrarenal aortic occlusion in a 3 cm diameter area of mild aortic ectasia along with iliac and distal right infrainguinal thromboembolism. The patient was treated with aortobifemoral bypass grafting with right leg fasciotomy, which restored perfusion and function. Conclusion: Spontaneous aortic thrombosis causing distal embolization and acute limb ischemia is an ominous medical condition with a poor prognosis. Episodes of embolization may be intermittent and asymptomatic such that, when symptoms finally occur, the distal thrombus is often chronic and inaccessible. The diagnosis should be suspected in patients with unexplained lower extremity symptoms and pulse deficits; it can be readily established with computed tomography.

Unusual Focal Lung Uptake without CT Abnormality on a Bone Scan: What Might It Mean?

A 48-year-old woman was referred for a bone scan as an assessment of bone metastasis from breast cancer. Surprisingly, two hot spots of lung uptake were present in the left lung without any abnormality on CT slices. No history of pulmonary disease was observed. An optimized CT scan with fine slices performed the same day was strictly normal (without any micronodule). A lung ventilation/perfusion scintigraphy showed no significant perfusion defect. A follow-up bone scan performed eight months later was normal and without any lung uptake. After exclusion of the main etiologies described in the literature, such as amylosis, sarcoidosis, abscess, or hypercalcemia, radiotracer microembolism seems to be the most likely hypothesis in this patient.

Contrast-free whole heart myocardial blood flow quantification from magnetic resonance imaging-determination of coronary sinus flow

Abstract Background Non-invasive reference quantification of whole heart myocardial blood flow (MBF) requires radioisotopes for PET and gadolinium contrast for cardiovascular magnetic resonance imaging (CMR) which in some cases is contraindicated. MBF may be determined from CMR quantification of flow in the coronary sinus (CSBF), the large vein draining the majority of the myocardium. Comparative studies of CSBF from CMR and MBF as determined from a reference technique have not yet been published in any larger cohorts. Purpose Our objective was to evaluate to what extent CMR CSBF measurements can be used to determine MBF as determined from gadolinium-contrast CMR in a cohort of normal subjects and patients with type 2 diabetes mellitus (T2DM) already demonstrated to display a wide range of MBFs. Methods 147 patients with T2DM and 25 age-matched controls were recruited to a cohort study on cardiovascular changes in DM. MBF was quantified from gadolinium-contrast perfusion sequences based on Fermi-constrained deconvolution. Myocardial segments with late gadolinium hyperenhancement or visually significant perfusion defects were included. CSBF was determined with CMR flow-sequences applied across the coronary sinus (VENC 0.5–1.0 m/s). Patients were studied during rest and maximal coronary artery dilatation by adenosine infusion (140 mg/kg/min). Blood flow stress-reserves were the ratio of stress to rest values. Co-variation of MBF and CSBF were determined from Bland-Altman plots with lines of agreement. Repeatability of CSBF was determined during the same experiment and calculated from single rater random intra class and repeatability coefficients. Results In normal subjects and patients with T2DM, MBF and CSBF increased during adenosine-stress (Fig. 1) with mean absolute increments of 172 and 163 mL/min/100g, and with mean stress-reserves of 3.35 and 3.24, respectively. Bland-Altman plots showed that MBF and CSBF covaried with a small bias, but in some cases with relatively large limits of agreement (Fig. 2). Overall, the mean bias of increase from rest-to-stress was 6 (CI: −1; 14) mL/min/100g with corresponding limits of agreement of 93 (CI 81; 105) and −80.2 (CI −92.6; 67.8) mL/min/100g. The mean bias of stress-reserve was 0.106 (CI: −0.0209; 0.234) with corresponding limits of agreement of −1.43 (CI: −1.65; −1.21) and 1.64 (CI: 1.42; 1.86). Intra-class and repeatability coefficients for coronary sinus flow were 0.95 (CI: 0.90; 0.95) and 5 mL/min/100g, respectively. Conclusion Myocardial blood flow can reproducibly and with a small bias be determined from the non-contrast technique of applying magnetic resonance imaging flow-sequences across the coronary sinus. Determination of MBF from coronary sinus blood flow may be useful in patient-groups where contrast is contraindicated, but limits of agreement with MBF must be taken into account. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Positron emission tomography absolute stress myocardial blood flow for risk stratification in nonischemic cardiomyopathy.

Sudden cardiac death is a substantial cause of mortality in patients with cardiomyopathy, but evidence supporting implantable cardioverter-defibrillator (ICD) implantation is less robust in nonischemic cardiomyopathy (NICM) than in ischemic cardiomyopathy. Improved risk stratification is needed. We assessed whether absolute quantification of stress myocardial blood flow (sMBF) measured by positron emission tomography (PET) predicts ventricular arrhythmias (VA) and/or death in patients with NICM. In this pilot study, we prospectively followed patients with NICM (left ventricular ejection fraction ≤ 35%) and an ICD who underwent cardiac PET stress imaging with sMBF quantification. NICM was defined as the absence of angiographic obstructive coronary stenosis, significant relative perfusion defects on imaging, coronary revascularization, or acute coronary syndrome. Endpoints were appropriate device therapy for VA and all-cause mortality. Subgroup analysis was performed in patients who had no prior history of VA (ie, the primary prevention population). We followed 37 patients (60 ± 14 years, 46% male) for 41 ± 23 months. The median sMBF was 1.56 mL/g/min (interquartile range: 1.00-1.82). Lower sMBF predicted VA, both in the whole population (hazard ratio [HR] for each 0.1 mL/g/min increase: 0.84, P = .015) and in the primary prevention subset (n = 27; HR for each 0.1 mL/g/min increase: 0.81, P = .049). Patients with sMBF below the median had significantly more VA than those above the median, both in the whole population (P = .004) and in the primary prevention subset (P = .046). Estimated 3-year VA rates in the whole population were 67% among low-flow patients vs 13% among high-flow patients, and 39% vs 8%, respectively, among primary-prevention patients. sMBF did not predict all-cause mortality. In patients with NICM, lower sMBF predicts VA. This relationship may be useful for risk stratification for ventricular arrhythmia and decision making regarding ICD implantation.

P707 Positive rest and negative adenosine stress perfusion in typical angina

Abstract Clinical Presentation A 45 year old gentleman seen in Rapid Access Chest Pain Clinic with typical angina (exertional chest pain). No risk factors for CAD. Normal ECG. Pre-test probability of significant CAD 51% . Diagnostic techniques and findings The patient was referred for adenosine stress CMR. CMR was performed on a 1.5 Tesla scanner. Cine was performed first, followed by stress perfusion, gadolinium enhance images and finally rest perfusion images. LV systolic function was normal. A significant perfusion defect of the LAD territory was noted on the rest but not on the stress perfusion images. The radiographers confirmed that stress and rest perfusion images were performed normally (stress first). A good physiological response was obtained during the assumed vasodilator stress with > 20% in the HR (from 65-75bpm to 91-107bpm respectively). During the presumed rest perfusion acquisition, HR was similar to the previously recorded resting HR. The spleen was not adequately visible to comment on splenic switch off. This type of perfusion defect (normal stress/abnormal rest) had not been described before, and there is no evidence that it was due to acquisition error. A coronary CT was advised to assess the LAD. CT coronary angiogram showed mild coronary calcification. A severe (80%), focal, non-calcified mid LAD stenosis was identified. A mild proximal OM1 stenosis was also noted. The patient subsequently underwent an invasive angiogram which confirmed the presence of a severe mid LAD stenosis. PCI was performed in the same setting with deployment of a single 4x18mm XIENCE drug eluting stent. The successful procedure was optimised with OCT guidance. Learning points Resting perfusion is often considered an integral part of adenosine perfusion imaging in order to overcome dark ring artefact, but it requires an additional contrast injection, prolongs imaging time and adds to cost. Some experts suggest that resting perfusion does not add to clinical interpretation and is not required. Our case is interesting, showing a previously unreported phenomenon. We cannot explain the reason for it but do not believe that the stress/rest order was reversed (as this would require two radiographers to go off protocol, and they and the supervising physician to be lying) and the physiological response is as expected. It therefore suggests that a rest study may occasionally provide helpful diagnostic information. Abstract P707 Figure.

P4469Reduced myocardial perfusion reserve in type 2 diabetes is caused by increased rest perfusion as well as decreased maximal perfusion during stress

Abstract Background Reduced myocardial perfusion reserve is a well-known complication in patients with type 2 diabetes mellitus (T2DM). Furthermore, reduced myocardial perfusion reserve has been linked to the development of diastolic dysfunction, a key characteristic in diabetic cardiomyopathy. However, it is not fully explored whether a decrease in perfusion during stress or an increase in perfusion during rest is responsible for this reduction in myocardial perfusion reserve, nor is it clear what causes these changes. Purpose The purpose of this study was to examine differences in myocardial perfusion in rest and during stress in patients with T2DM compared to healthy control subjects, and to identify potential predictors for changes in perfusion during rest and stress among patients with T2DM. Methods 200 patients with T2DM and 25 healthy volunteers matched for age and sex underwent a comprehensive cardiac MRI protocol including gadolinium first-pass perfusion during rest and stress (adenosine infusion 140 mg/min–1/kg–1). Perfusion was measured on a per-segment basis based on the AHA model and averaged to calculate global perfusion index both during rest and stress. Any areas with infarctions and/or significant perfusion defects were excluded from the analysis. Backwards stepwise multiple linear regression was performed to identify predictors for perfusion changes during rest and stress in patients with T2DM. Variables with P<0.1 in a univariate analysis were included into the models. Results Patients with T2DM had significantly higher rest perfusion index (0.135±0.024 vs. 0.120±0.016; P=0.001) and significantly lower stress perfusion index (0.174±0.041 vs. 0.225±0.027; P<0.001) compared to healthy volunteers. In a multiple linear regression model among patients with T2DM female sex (P<0.001) was associated with increased rest perfusion. In a similar analysis for stress perfusion, diabetes duration (P=0.01), albuminuria (P<0.001) and the presence of ischaemic heart disease (P<0.001) were associated with reduced myocardial stress perfusion index in patients with T2DM. Conclusion In patients with T2DM reductions in myocardial perfusion reserve is caused by a combination of increased basal myocardial blood flow and a decrease in maximal blood flow during stress. Decreased stress perfusion is associated with coronary vascular disease and the diabetic complication albuminuria related to renal microvascular disease. Stress perfusion also decreased with increasing duration of T2DM. This suggest that the coronary microcirculation is gradually damaged in patients with T2DM and that the mechanism responsible is similar to that causing renal microvascular damage. Acknowledgement/Funding Local science committee of Region Zealand, Regional science committee of Region Zealand, The Danish Heart Association

P3596The role of MSCT and SPECT in patients with acute coronary syndromes and non-obstructive coronary artery disease

Abstract Background Approximately 1–14% of patients with ACS not have obstructive changes in the coronary arteries according to the data of invasive coronary angiography (ICA) is myocardial infarction (AMI) with non-obstructive coronary artery- MINOCA. MSCT has the ability to assess the lumen of the vessel, visualize the artery wall, the structure of the atherosclerotic plaque. SPECT is used to detect myocardial ischemia, determine the functional significance of atherosclerotic plaques, and evaluate regional tissue perfusion. There are no data on a research of a structurally functional condition of a coronary blood-groove by means of MSCT, SPECT.Aim. To study the role of MSCT and SPECT in patients with MINOCA, to compare MSCT with invasive coronarography. Material and methods The study is registered on ClinicalTrials.gov. Inclusion criteria are listed on the site. All patients underwent CT, SPECT, on the 6th day from the beginning of the index event. All MSCT and SPECT studies were performed on a 64-section combined single-photon-emission and X-ray computer tomograph GE Discovery NM/CT 570C. Endpoint: Frequency of occurrence of atherosclerosis, frequency of occurrence of unstable plaques according to MSCT, the magnitude of a transient defect in myocardial perfusion according to SPECT. Results The study included 14 patients with MINOCA, women predominate – 11 (78.6%), the average age was 61.1±14 years. The risk of GRACE was moderate in 8 (57%) pts. 12 (85.7%) pts were hospitalized within the first 6 hours of the onset of the disease.Thrombolytic therapy was performed in 3 (21.4%) pts, 2 of them were effective (14%). 57% of patients at admission were troponin-positive.According to the results of ICA, intact coronary arteries were detected in 9 (64.3%) pts, 5 (35%) had stenosis up to 50%. Coronary slow flow (TIMI 2) was determined in 11 (78.6%) pts, of which 8 (57%) pts have coronary slow flow and intact coronary arteries. Coronary spasm was in 1 (7.1%) patient. According to MSCT, the proportion of pts with intact coronary arteries decreased (9 (64.3%) → 5 (35.7%)) and the proportion with non-obstructive atherosclerosis increased (5 (35%) → 9 (64.3%)). All pts had a positive remodeling index, soft-tissue, predominantly calcified stenoses and eccentric plaques. The average Segment Involvement Score was 2.1 (0; 5), the Segment Stenosis Score was −2.4 (1; 3). 12 pts (85%) had transitory perfusion defects. The median SSS values were 7.5 (4; 13), SRS 4.7 (1.0; 9.0), SDS 4.7 (3.0; 8.0). Conclusion In 78% of pts had a slowing of the coronary blood flow and intact coronary arteries according to ICAG. However, according to MSCT, only 36% of the patients did not have plaques. MSCT allows to identify eccentric soft tissue atherosclerotic plaques that have a high risk of rupture/erosion, and, accordingly, the high risk of the development of AMI in this group. Using SPECT revealed a statistically significant transient perfusion defect.

Pulmonary Artery Occlusion and Mediastinal Fibrosis in a Patient on Dopamine Agonist Treatment for Hyperprolactinemia.

Unusual forms of pulmonary hypertension include pulmonary hypertension related to mediastinal fibrosis and the use of serotonergic drugs. Here, we describe a patient with diffuse mediastinal fibrosis and pulmonary hypertension while she was on dopamine agonist therapy. A young woman, who was treated with cabergoline and bromocriptine for hyperprolactinemia, presented with progressive dyspnea over several months. Based on the clinical investigation results, in particular, elevated pulmonary arterial pressures and significant perfusion defects on computed tomography (CT) pulmonary angiography and ventilation/perfusion (V/Q) scintigraphy, chronic thromboembolic pulmonary hypertension (CTEPH) was initially considered the most plausible diagnosis. However, during an attempted pulmonary endarterectomy, loose fibrous tissues were observed in the mediastinum and cryosection of the right pulmonary artery showed fibrosis and chronic inflammation. Subsequent investigations revealed that diffuse mediastinal fibrosis with concurrent pulmonary hypertension, and not CTEPH, was the most likely diagnosis and cabergoline and bromocriptine may have triggered the fibrotic changes. Both drugs are ergot-derived dopamine agonists, which are known to cause cardiac valve fibrosis and less frequently, non-cardiac fibrotic changes. The underlying mechanism is attributed to their interactions with serotonin receptors. There is much evidence that serotonin, a potent vasoconstrictor and mitogen, is involved in the pathogenesis of pulmonary hypertension. In conclusion, as CT and V/Q scintigraphy findings can occasionally be deceptive, physicians should be particularly aware of differential diagnoses in patients without obvious history of venous thromboembolism that are suspected of having chronic thromboembolic pulmonary hypertension.

A role of endothelial dysfunction for development of microcirculation and cardiopulmonary blood flow abnormalities in patients with COPD and different alpha-1-antitrypsin phenotypes

The aim of this study was to investigate structural and functional changes of pulmonary vessels and cardiopulmonary blood flow in COPD patients with different alpha-1-antitrypsin (A1AT) phenotypes and endothelial dysfunction. Methods. Patients with COPD stage 2 to 3 (n = 113) with different A1AT phenotypes underwent clinical and radiological examination; endothelial dysfunction markers were measured. Results. More severe COPD was associated with more severe pulmonary microcirculation disorders and more significant perfusion defects. Patients with ZZ phenotype had worse pulmonary blood flow abnormalities compared to patients with MM phenotype. Pulmonary blood flow abnormalities were closely related to endothelial dysfunction (r = 0.75) and were more significant than structural abnormalities diagnosed on multi spiral computed tomography. Severe disorders of pulmonary blood flow were not accompanied by severe pulmonary hypertension. Conclusions: Blood levels of main endothelial dysfunction markers were directly related to COPD severity. Angiotensin-converting enzyme concentration was significantly below the normal level and was related to pulmonary artery pressure. The pulmonary blood flow differed in patients with different A1AT phenotypes and COPD stage 3 or higher. Perfusion defects were more severe in patients with ZZ phenotype.

THREE-YEAR RESULTS OF MEDICAL AND SURGICAL REPERFUSIONAL TREATMENT OF PATIENTS TRANSPOSED BY THROMBOEMBOLIA OF PULMONARY ARTERY: OUTCOME, CLINICAL STATUS, STATE OF PULMONARY PERFUSION

The purpose . To estimate hospital and three-year results of reperfusion treatment in pulmonary embolism (PE) patients. Methods. One-center prospective study included 30 patients with intermediate high-risk and high-risk acute PE that had indications for reperfusion: thrombolytic therapy (TLT) and / or surgical thrombectomy. The endpoints of the study in the hospital and long-term follow-up period were such unfavorable cardiovascular events as death, myocardial infarction, acute cerebrovascular accident / transient ischemic attack, re-PE. Results . It was shown that reperfusion treatment had satisfactory rates of hospital survival (97%), efficacy, with significant regression of clinical symptoms and pulmonary hypertension (from 56.93 ± 17.18 to 36.72 ± 14.47 mm Hg.). There was a significant decrease of tricuspid insufficiency (from 77% initially to 24% at the time of discharge) (p <0.05). After 3 years, the rate of fatal outcomes reached 33%, most of which occurred in the TLT group and was associated with re-PE. Fifty fife percent of the surviving patients had pulmonary hypertension, 15% had major or segmental perfusion defects according to perfusion lung scintigraphy (PSL) data. Conclusion . The presence of significant pulmonary perfusion defects according to the results of PSL in one out of seven surviving patients in more than half of the cases is likely to be a result of insufficiently frequent use of the surgical option of treatment in clinical practice. The high frequency of fatal outcomes in the long-term follow-up period, realized through re-PE, indicates insufficient compliance of patients to medical therapy.

Additive Role of Coronary Magnetic Resonance Angiography for the Evaluation of Coronary Artery Disease.

Coronary magnetic resonance angiography (CMRA) allows a noninvasive assessment of the coronary anatomy without exposing the patients to radiation. It is also superior to coronary computed tomography angiography (CCTA) for the evaluation of luminal narrowing in heavily calcified coronary segments. We report a case with triple-vessel disease, but it could not be accurately assessed by CCTA because of calcification and lack of a significant perfusion defect or myocardial scarring on cardiac magnetic resonance imaging (MRI). However, whole-heart CMRA performed as part of the cardiac MRI protocol demonstrated significant triple-vessel disease with left main involvement, confirmed by subsequent invasive angiography with a fractional flow reserve measurement.

CMR Guidance for Recanalization of Coronary Chronic Total Occlusion

ObjectivesThis study explored whether cardiac magnetic resonance (CMR) could help select patients who could benefit from revascularization by identifying inducible myocardial ischemia and viability in the perfusion territory of the artery with chronic total occlusion (CTO). BackgroundThe benefit of revascularization using percutaneous coronary intervention (PCI) in CTO is controversial. CMR offers incomparable left ventricular (LV) systolic function assessment in addition to potent ischemic burden quantification and reliable myocardial viability analysis. Whether CMR guided CTO revascularization would be helpful to such patients has not yet been explored fully. MethodsA prospective study of 50 consecutive CTO patients was conducted. Of 50 patients undergoing baseline stress CMR, 32 (64%) were selected for recanalization based on the presence of significant inducible perfusion deficit and myocardial viability within the CTO arterial territory. Patients were rescanned 3 months after successful CTO recanalization. ResultsAt baseline, myocardial perfusion reserve (MPR) in the CTO territory was significantly reduced compared with the remote region (1.8 ± 0.72 vs. 2.2 ± 0.7; p = 0.01). MPR in the CTO region improved significantly after PCI (to 2.3 ± 0.9; p = 0.02 vs. baseline) with complete or near-complete resolution of CTO related perfusion defect in 90% of patients. Remote territory MPR was unchanged after PCI (2.5 ± 1.2; p = NS vs. baseline). The LV ejection fraction increased from 63 ± 13% to 67 ± 12% (p < 0.0001) and end-systolic volume decreased from 65 ± 38 to 56 ± 38 ml (p < 0.001) 3 months after CTO PCI. Importantly, despite minimal post-procedural infarction due to distal embolization and side branch occlusion in 8 of 32 patients (25%), the total Seattle Angina Questionnaire score improved from a median of 54 (range 45 to 74) at baseline to 89 (range 77 to 98) after CTO recanalization (p < 0.0001). ConclusionsIn this small group of patients showing CMR evidence of significant myocardial inducible perfusion defect and viability, CTO recanalization reduces ischemic burden, favors reverse remodeling, and ameliorates quality of life.

0005 : Prognostic value of myocardial perfusion SPECT without significant perfusion defect using a dual isotope protocol and a novel CZT camera: interim results of the PROMHETE study

New dedicated cardiac gamma cameras using CZT detectors have shown significant improvement over the Anger camera regarding physical parameters, and their diagnostic performances have been validated in clinical studies. To date, few studies have evaluated the prognostic value of a low to intermediate risk single-photon emission tomography (SPECT) myocardial perfusion imaging (MPI) with these cameras, and only one with a HSDI stress thallium-201/rest Technetium-99m protocol on a CZT camera. The study included patients who had no or minimal perfusion defects (<10% of the LV myocardium) on a HS-DI MPI following a symptom-limited treadmill test or a pharmacological stress testing. These 578 patients were followed for 3.3±0.4 years (95% complete). The main endpoint was the occurrence a hard cardiac event (cardiac death or nonfatal myocardial infarction). 212 patients (37%) underwent exercise stress and 366 (63%) had pharmacological stress (of which 89% had dipyridamole and 11% had dobutamine). Mean summed stress score was 0.95±1.2 [0-5]. During the follow-up period 25 hard cardiac events occurred. Annualized event rate was 1.3%/y. In the subgroup of patients undergoing exercise stress test, annualized event rate was 0.43%/y. Multivariate Cox analysis identified age (HR 1.14 [1.08; 1.20], p<0.0001) and rest LVEF (HR 0.95 [0.92; 0.98], p=0.008) as independent predictors of cardiac death or myocardial infarction. Survival analysis showed that the occurrence of cardiac events was significantly higher in patients who had an altered LVEF compared to patients with a normal LVEF (16% vs. 3.8%, p=0.003). The use of a HS-DI protocol on a CZT camera provides prognostic information, comparable to single-isotope protocols on conventional Anger camera, while reducing imaging time and without increasing the injected activity. The author hereby declares no conflict of interest

High Concordance Between Mental Stress-Induced and Adenosine-Induced Myocardial Ischemia Assessed Using SPECT in Heart Failure Patients: Hemodynamic and Biomarker Correlates.

Mental stress can trigger myocardial ischemia, but the prevalence of mental stress-induced ischemia in congestive heart failure (CHF) patients is unknown. We characterized mental stress-induced and adenosine-induced changes in myocardial perfusion and neurohormonal activation in CHF patients with reduced left-ventricular function using SPECT to precisely quantify segment-level myocardial perfusion. Thirty-four coronary artery disease patients (mean age±SD, 62±10 y) with CHF longer than 3 mo and ejection fraction less than 40% underwent both adenosine and mental stress myocardial perfusion SPECT on consecutive days. Mental stress consisted of anger recall (anger-provoking speech) followed by subtraction of serial sevens. The presence and extent of myocardial ischemia was quantified using the conventional 17-segment model. Sixty-eight percent of patients had 1 ischemic segment or more during mental stress and 81% during adenosine. On segment-by-segment analysis, perfusion with mental stress and adenosine were highly correlated. No significant differences were found between any 2 time points for B-type natriuretic peptide, tumor necrosis factor-α, IL-1b, troponin, vascular endothelin growth factor, IL-17a, matrix metallopeptidase-9, or C-reactive protein. However, endothelin-1 and IL-6 increased, and IL-10 decreased, between the stressor and 30 min after stress. Left-ventricular end diastolic dimension was 179±65 mL at rest and increased to 217±71 after mental stress and 229±86 after adenosine (P<0.01 for both). Resting end systolic volume was 129±60 mL at rest and increased to 158±66 after mental stress (P<0.05) and 171±87 after adenosine (P<0.07), with no significant differences between adenosine and mental stress. Ejection fraction was 30±12 at baseline, 29±11 with mental stress, and 28±10 with adenosine (P=not significant). There was high concordance between ischemic perfusion defects induced by adenosine and mental stress, suggesting that mental stress is equivalent to pharmacologic stress in eliciting clinically significant myocardial perfusion defects in CHF patients. Cardiac dilatation suggests clinically important changes with both conditions. Psychosocial stressors during daily life may contribute to the ischemic burden of CHF patients with coronary artery disease.

E-071 initial experiences with the 5max ace 64 in the endovascular management of acute ischemic stroke

Purpose To report our initial experiences with the new version of the 5Max ACE, the ACE “64”, (Penumbra) in the endovascular management of acute ischemic stroke Materials and methods Between December 2014–February 2015, 5 patients with acute ischemic stroke were treated with a recently developed, large bore aspiration catheter, the 5Max ACE 64. There were 4 thromboembolic occlusions of the MCA, and one BA. The patients were selected by CT/CTA and CT-perfusion confirming the occlusion of the mentioned arteries, and showing significant perfusion defect, and considerable volume of viable brain tissue - penumbra. All patients were treated under general anesthesia, starting with DSA of the possible sources of collateral arteries, confirming the existing leptomeningeal collaterals followed by DSA of the target artery, confirming the persisting occlusion. After that, a NeuronMax was placed in the ICA or VA, and the ACE 64 was navigated over a Velocity (Penumbra) microcatheter in 2 cases, or a 3Max (Penumbra) microcatheter in 3 cases, to the target lesion. In our experience, the ACE 64 was difficult to navigate through the carotid syphon, especially at the orifice of the ophthalmic artery, over the smaller microcatheter, why we, after the first two cases, followed the company’s recommendation to use the 3Max instead. When direct contact between the thrombus and the ACE 64 was established, confirmed by flow arrest in the ACE, aspiration with the Penumbra pump was started, and maintained either until the thrombus was aspirated through the ACE, or until 5 min. After this time, the ACE was slowly removed, and the patency of the target artery was checked by DSA through the long sheath. Results The thrombus was removed in all cases at the first attempt, with excellent flow in the target arteries. No complications occurred during the procedures. Four patients showed significant clinical improvement directly after the procedure, the fifth was unchanged, having hemiparesis following a previous stroke. Conclusion In our experience, this new version of the 5Max is very efficient in the aspiration of the thrombus. Due to its larger lumen, it’s more difficult to navigate over the smaller microcatheters through tortuous segments of the target vessels, especially the ophthalmic region of the ICA. Using the 3Max instead, the navigation gets easy, but it’s very difficult to get a roadmap or perform an angiogram through the ACE, due to the larger OD of the 3Max. Partially retrieving the 3Max, or preparing the roadmap while the 3Max is still in the proximal part of the ACE has solved this issue in our experience. Disclosures G. Gal: 2; C; Penumbra.

Role of coronary artery calcium score for risk stratification in patients with non significant perfusion defects by myocardial perfusion single photon emission computed tomography.

Myocardial perfusion scintigraphy (MPS) is an important diagnostic tool in the management of patients with suspected coronary artery disease (CAD). However, the presence of mild-moderate perfusion defects can be challenging and may lead to unnecessary cardiac catheterization. The coronary artery calcium (CAC) score is a method with excellent negative predictive value in the evaluation of CAD, but its role in this setting of patients has not been fully defined. This study aims to assess the potential of CAC in the prediction of cardiac adverse events in patients with suspected CAD with mild-moderate perfusion by MPS. We conducted a cohort study in 292 patients presenting with mild-moderate perfusion defects by MPS undergoing a CAC measurement. The patients were followed for a mean of 34 months for occurrence of major cardiac adverse events (MACE). The majority of the patients (64.7%) were male, mean age of 57.9 ± 12.6 years. During the follow-up there were 37 MACE. In multivariate Cox proportional hazards model, hypertension and CAC were independent predictors of MACE. The patients who presented a CAC score of ≥ 400 had a high risk of MACE (HR 20.9; 95% CI 4.79-91.42; p < 0.001). Kaplan-Meier curve showed a significant difference (log-rank χ²; p< 0.001) using CAC scores in predicting MACE. CAC score carries a powerful prognostic value in predicting adverse events in patients with suspected CAD and MPS with mild-moderate perfusion defects and may be useful in risk stratification of these patients.