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Simultaneous assessment of coronary stenosis, myocardial perfusion, and ventricular function in a patient with acute myocardial infarction
Journal of Cardiovascular Computed Tomography (2008) 2, 123–125
Images in Cardiovascular CT
Simultaneous assessment of coronary stenosis, myocardial perfusion, and ventricular function in a patient with acute myocardial infarction Michael Shen, MD, MS, FACC, FASNC*, Luis Ortiz, MD, Howard Bush, MD, FACC, FACI, Eduardo Vargas, BS, Eric Dandes, BS Section of Cardiac Imaging, Cardiovascular Medicine, Cleveland Clinic, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA KEYWORDS: CTA, CT angiography; MIP, multiple intensity projection; PCI, percutaneous coronary intervention; OM-1, first obtuse marginal artery
Abstract. Cardiac CT angiography (CTA) is an ideal tool to investigate cardiac and noncardiac causes of acute chest pain. In this case, careful planning of the CTA acquisition and reconstruction limits permitted not only the exclusion of aortic dissection and provided high resolution images of coronary anatomy but also showed a concordant abnormality in myocardial perfusion and ventricular function in the setting of an acute coronary syndrome. Detailed planning of every CTA acquisition reconstruction protocol is essential to obtain the information necessary for clinical decision-making strategies and interventions in the patient with chest pain. © 2008 Society of Cardiovascular Computed Tomography. All rights reserved.
A 64-year-old man with hypertension presented to the emergency department with chest pain after blunt chest trauma from a 14-foot sailboat. An electrocardiogram (ECG) was nondiagnostic, and a troponin level was mildly elevated. Cardiac CT angiography (CTA) was performed with an ECG-gated protocol, slice thickness of 0.75 mm, and designated selected field of view to exclude aortic dissection and to evaluate coronary artery anatomy and patency. The aorta was normal (lateral image; Fig. 1). A 3-dimensional reconstruction (Fig. S1; see supplementary material online at www.CardiacCTJournal.com) and multiple intensity projection images in the posterolateral projection showed a critical stenosis at the first obtuse marginal of Supplementary material for this article may be found at www. CardiacCTJournal.com. Conflict of interest: The authors report no conflicts of interest. * Corresponding author. E-mail address: [email protected] Submitted October 19, 2007. Accepted for publication January 16, 2008.
the circumflex artery (Fig. 2). Short axis views of the left ventricle in diastole (Fig. 3) and systole (Fig. 4) showed hypoperfusion with hypokinesia at lateral wall, suggesting on-going myocardial infarction. While discussing the plan for coronary angiography with primary angioplasty, the patient developed ventricular fibrillation (Fig. S2) and was resuscitated. A repeat ECG showed 3-mm S-T segment elevation in the lateral leads (Fig. S3). Emergent coronary angiography showed subtotal occlusion of the first obtuse marginal branch (Fig. 5), which was successfully stented (Fig. S4). The patient was discharged to home after 4 days of hospitalization. Cardiac CTA is an ideal tool to investigate cardiac and noncardiac causes of acute chest pain.1,2 In this case, careful planning of the CTA acquisition and reconstruction limits permitted not only the exclusion of aortic dissection and provided high resolution images of coronary anatomy but also showed a concordant abnormality in myocardial perfusion and ventricular function in the setting of an acute coronary syndrome. Detailed planning of every CTA acqui-
1934-5925/$ -see front matter © 2008 Society of Cardiovascular Computed Tomography. All rights reserved. doi:10.1016/j.jcct.2008.01.002
124
Journal of Cardiovascular Computed Tomography, Vol 2, No 2, March/April 2008
Figure 1
Normal aorta on lateral projection.
Figure 2 A multiple intensity projection image showing an occlusion at the first obtuse marginal artery of the circumflex artery.
Figure 3 Short axis image of left ventricle at end-diastole showing hypoperfusion and hyperkinesis of lateral wall.
Figure 4 Short axis image of left ventricle at end-systole showing hypoperfusion and hyperkinesis of lateral wall.
Shen et al
Coronary CTA with perfusion and function in AMI
125 sition reconstruction protocol is essential to obtain the information necessary for clinical decision-making strategies and interventions in the patient with chest pain.
References 1. Rubinshtein R, Halon DA, Gaspar T, Jaffe R, Karkabi B, Flugelman MY, Kogan A, Shapira R, Peled N, Lewis BS. Usefulness of 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin. Circulation. 2007; 115:1762– 8. 2. Goldstein J, Gallagher MJ, O’Neil BJ, O’Neil WW, Ross MA, Raff GL. A randomized trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. 2007;49:863–71.
Figure 5 A 100% stenosis of the first obtuse marginal artery on coronary angiography.
Images in Cardiovascular CT
Simultaneous assessment of coronary stenosis, myocardial perfusion, and ventricular function in a patient with acute myocardial infarction Michael Shen, MD, MS, FACC, FASNC*, Luis Ortiz, MD, Howard Bush, MD, FACC, FACI, Eduardo Vargas, BS, Eric Dandes, BS Section of Cardiac Imaging, Cardiovascular Medicine, Cleveland Clinic, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA KEYWORDS: CTA, CT angiography; MIP, multiple intensity projection; PCI, percutaneous coronary intervention; OM-1, first obtuse marginal artery
Abstract. Cardiac CT angiography (CTA) is an ideal tool to investigate cardiac and noncardiac causes of acute chest pain. In this case, careful planning of the CTA acquisition and reconstruction limits permitted not only the exclusion of aortic dissection and provided high resolution images of coronary anatomy but also showed a concordant abnormality in myocardial perfusion and ventricular function in the setting of an acute coronary syndrome. Detailed planning of every CTA acquisition reconstruction protocol is essential to obtain the information necessary for clinical decision-making strategies and interventions in the patient with chest pain. © 2008 Society of Cardiovascular Computed Tomography. All rights reserved.
A 64-year-old man with hypertension presented to the emergency department with chest pain after blunt chest trauma from a 14-foot sailboat. An electrocardiogram (ECG) was nondiagnostic, and a troponin level was mildly elevated. Cardiac CT angiography (CTA) was performed with an ECG-gated protocol, slice thickness of 0.75 mm, and designated selected field of view to exclude aortic dissection and to evaluate coronary artery anatomy and patency. The aorta was normal (lateral image; Fig. 1). A 3-dimensional reconstruction (Fig. S1; see supplementary material online at www.CardiacCTJournal.com) and multiple intensity projection images in the posterolateral projection showed a critical stenosis at the first obtuse marginal of Supplementary material for this article may be found at www. CardiacCTJournal.com. Conflict of interest: The authors report no conflicts of interest. * Corresponding author. E-mail address: [email protected] Submitted October 19, 2007. Accepted for publication January 16, 2008.
the circumflex artery (Fig. 2). Short axis views of the left ventricle in diastole (Fig. 3) and systole (Fig. 4) showed hypoperfusion with hypokinesia at lateral wall, suggesting on-going myocardial infarction. While discussing the plan for coronary angiography with primary angioplasty, the patient developed ventricular fibrillation (Fig. S2) and was resuscitated. A repeat ECG showed 3-mm S-T segment elevation in the lateral leads (Fig. S3). Emergent coronary angiography showed subtotal occlusion of the first obtuse marginal branch (Fig. 5), which was successfully stented (Fig. S4). The patient was discharged to home after 4 days of hospitalization. Cardiac CTA is an ideal tool to investigate cardiac and noncardiac causes of acute chest pain.1,2 In this case, careful planning of the CTA acquisition and reconstruction limits permitted not only the exclusion of aortic dissection and provided high resolution images of coronary anatomy but also showed a concordant abnormality in myocardial perfusion and ventricular function in the setting of an acute coronary syndrome. Detailed planning of every CTA acqui-
1934-5925/$ -see front matter © 2008 Society of Cardiovascular Computed Tomography. All rights reserved. doi:10.1016/j.jcct.2008.01.002
124
Journal of Cardiovascular Computed Tomography, Vol 2, No 2, March/April 2008
Figure 1
Normal aorta on lateral projection.
Figure 2 A multiple intensity projection image showing an occlusion at the first obtuse marginal artery of the circumflex artery.
Figure 3 Short axis image of left ventricle at end-diastole showing hypoperfusion and hyperkinesis of lateral wall.
Figure 4 Short axis image of left ventricle at end-systole showing hypoperfusion and hyperkinesis of lateral wall.
Shen et al
Coronary CTA with perfusion and function in AMI
125 sition reconstruction protocol is essential to obtain the information necessary for clinical decision-making strategies and interventions in the patient with chest pain.
References 1. Rubinshtein R, Halon DA, Gaspar T, Jaffe R, Karkabi B, Flugelman MY, Kogan A, Shapira R, Peled N, Lewis BS. Usefulness of 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin. Circulation. 2007; 115:1762– 8. 2. Goldstein J, Gallagher MJ, O’Neil BJ, O’Neil WW, Ross MA, Raff GL. A randomized trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. 2007;49:863–71.
Figure 5 A 100% stenosis of the first obtuse marginal artery on coronary angiography.