5 - Chest pain – can you be more precise? Combining perfusion mapping, dark blood enhancement and CT coronary angiography

Thursday, February 13, 2020

3:28 PM – 3:38 PM

Location: Salon J2

Description of Clinical Presentation: A 64-year-old man presented with recurrent chest pain and exertional shortness of breath on a background history of ischaemic heart disease, hypertension, hypercholesterolaemia and depression. He previously had two proximal and mid left anterior descending artery (LAD) stents deployed two decades earlier and remained asymptomatic until two years ago when he developed recurrent chest pain which he attributed to panic attacks. His CT coronary angiogram (CTCA) a year earlier revealed patent LAD stents and 50-70% mid right coronary artery (RCA) stenosis. He was initially treated medically as his symptoms abated, however, a functional scan was organised when he developed recurrent symptoms.

Diagnostic Techniques and Their Most Important Findings: The stress perfusion CMR was performed at 1.5T (Siemens Aera) using a standard clinical protocol including cine imaging, adenosine stress (4 minutes at 140ug/kg/min) and rest perfusion, early and late gadolinium enhancement. Perfusion imaging was performed with a novel perfusion mapping sequence (outputting inline myocardial blood flow maps), and late gadolinium enhancement consisted of conventional white-blood and dark-blood LGE imaging.
Baseline CMR images revealed normal LV size and function without regional wall motion abnormalities. At peak hyperaemia, the myocardial blood flow maps showed two small foci of adenosine-induced perfusion defects in the LAD territory extending beyond the area of LGE (Figure 1A-B). LGE imaging demonstrated two small areas of subendocardial LGE in the same areas (Figure 2C-D). Review of the CTCA found a correlation with the CMR findings with stent related jailing of very small first septal and first diagonal arteries. It is unclear if the infarction occurred peri-procedurally or secondary to recurrent ischaemia. The arteries however appear too small for stenting and the patient was recommended for medical treatment.

Learning Points from this

Case: High resolution adenosine stress perfusion mapping CMR combined with CTCA showed in this instance the power of diagnosing even a relatively small burden of ischaemia and pin-pointing the likely culprit vessels as part of the work up for revascularisation strategy.

Presenting Author(s)

Linda Lin

Fellow
Barts Heart Centre at St Bartholomew's Hospital

Disclosure: Disclosure information not submitted.

Primary Author(s)

Linda Lin

Fellow
Barts Heart Centre at St Bartholomew's Hospital

Disclosure: Disclosure information not submitted.

Co-Author(s)

Joao B Augusto, MD

Cardiologist
Barts Heart Centre and University College London

Disclosure: Disclosure information not submitted.
GT

George D. Thornton, MD, BSc

Barts Heart Centre at St Bartholomew's Hospital

Disclosure: Disclosure information not submitted.
EC

Emma Cheasty

Barts Heart Centre at St Bartholomew's Hospital

Disclosure: Disclosure information not submitted.
Anna S. Herrey, MD, PhD

Consultant Cardiologist
Barts Heart Centre at St Bartholomew's Hospital

Disclosure: Disclosure information not submitted.
RD

Rhodri Davies, MD, PhD

Cardiology imaging fellow
Barts Heart Centre at St Bartholomew's Hospital

Disclosure: Disclosure information not submitted.
James C. Moon, MD

Clinical Director, Imaging
Barts Heart Centre and UCL

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
TT

Thomas A. Treibel, PhD

Clinical Research Fellow
St Bartholomew's Hospital

Disclosure: Disclosure information not submitted.