Case Author(s): Brennan M. Haraden, M.D. and Robert J. Gropler, M.D. , 06/09/98 . Rating: #D4, #Q5
Diagnosis: Abnormal cardiac imaging after angioplasty
Brief history:
41 YOM with history of hypertension, diabeties mellitus, who presents with left sided chest pain.
Images:
Initial stress test imaging
View main image(mi) in a separate image viewer
View second image(an).
The cardiac catheterization which showed a 90 percent circumflex lesion. This lesion was removed by rotaional atherectomy and adjunctive stenting.
View third image(mi).
Five weeks after the intervention, the patient represents with chest pain. The patient undergoes a second stress study.
Full history/Diagnosis is available below
Diagnosis: Abnormal cardiac imaging after angioplasty
Full history:
This is a 41 year old male who presented with chest pain. The patient underwent perfusion imaging with resting thallium and a stress sestamibi. The exam shows a near completely reversible defect of the lateral wall (Image 1). Patient then had a cardiac catherterization and he was found to have a significant circumflex stenosis (Image 2). Patient underwent revascularization of the lesion and initially did well. The patient represents to the emergency room five weeks later complaining of chest pain. A second rest thallium and a stress sestamibi study was performed (Image 3).
Radiopharmaceutical:
In the first case the patient was injected with 2.6 mCi of thallium and 21.6 mCi of sestamibi. The second study used 2.5 mCi of thallium and 21.3 mCi of sestamibi.
Findings:
There is a completely reversible defect in the lateral wall that is unchanged from the prior exam.
Discussion:
This case demonstrates an example of imaging a patient within 6 weeks after an interventional angioplasty was performed. The initial defect seen on the stress study is still present five weeks later. In patients who undergo an intervention, it is recommended to not perform early perfusion imaging due to the increased prevelance of false postive exams. Once the endothelium has been disrupted, it take approximately 6 to 8 weeks to recover complete function. In this case it is unknown if the reversible defect represents restenosis or endothelial dysfunction. In this case the false postive exam probably represents endothelial dysfunction after an intervention.
Followup:
Since the patient was having chest pain and the stress exam remained abnormal the patient was brought back to the cardiac catheterization lab.
View followup image(mm).
Patient underwent recatheterization and found to have a patent stent in the circumflex artery.
Major teaching point(s):
Reimaging before 6 weeks after revascularization has a high prevelence of a false postive exam. It can not be determined that if a defect occurs whether it represents restenosis of the stent or if it represents residual endothelial dysfunction.
ACR Codes and Keywords:
References and General Discussion of Myocardial Imaging (Anatomic field:Heart and Great Vessels, Category:Organ specific)
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Case number: mi014
Copyright by Wash U MO
