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What is this image? 2018: Image 1 result
The value of diastole perfusion
Francesco Nudi, MD,
Orazio Schillaci, MD,
Alessandro Nudi, MD,
Giuseppe Biondi-Zoccai, MD, MStat
Service of Hybrid Cardio Imaging, Madonna della Fiducia Clinic, Rome, Italy
Ostia Radiologica, Rome, Italy
ETISAN, Rome, Italy
Division of Nuclear Medicine, Tor Vergata University, Rome, Italy
Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy
Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome,
A 68-year-old gentleman underwent stress/rest
myocardial perfusion imaging (MPI) at our institution
for recurrence of chest pain during exercise ECG testing.
He reported prior smoking, hypercholesterolemia, arte-
rial hypertension, and obesity. His clinical history was
signiﬁcant for ST-elevation myocardial infarction
(STEMI) due to mid left anterior descending (LAD)
disease 6 months earlier, which had been treated with
primary percutaneous coronary intervention (PCI) with
drug-eluting stent (DES) implantation (Figure 1).
Discharge echocardiography had shown a mild
reduction in global left ventricular systolic function
(ejection fraction 48%), with apical hypokinesis. Sub-
sequently, he had felt well and maintained an active
lifestyle, without recurrence of cardiovascular symp-
toms. Medical therapy included aspirin, metoprolol,
lisinopril, amlodipine, simvastatin, ezetimibe, and lan-
soprazole. Follow-up exercise ECG testing 6 months
after PCI showed equivocal non-diagnostic changes of
ST segment and T wave, due to baseline abnormalities,
but was positive for mild anginal chest pain during stress
(Figure 2). Thus, he was referred for stress/rest MPI.
After adequate drug washout (temporary discontin-
uation of metoprolol), he underwent bicycle exercise
stress with administration of
Tl and image acquisition
with a cadmium-zinc-telluride (CZT) camera (Discovery
NM 530c with Alcyone technology, GE Healthcare,
Haifa, Israel). He developed mild angina at maximum
workload of 100 Watts, but without ST-T changes.
Ungated images showed the presence of moderate apical
necrosis (scar, ﬁxed defect) with mild residual ischemia
(reversible defect, Maximal Ischemia Score [MIS] = 2;
Maximal Necrosis Score [MNS] = 3) (Figures 3, 4).
Gated end-systole single photon emission computed
tomography (SPECT) images suggested the presence of
a severe apical necrosis with minimal residual ischemia
(MIS = 1; MNS = 4) (Figure 5).
Conversely, gated end-diastole SPECT images
showed a largely reversible perfusion defect compatible
with severe apical ischemia with minimal residual
necrosis (MIS = 4, MNS = 1) (Figure 6; Table 1).
Additional ungated analysis with bullseye and 3D
reconstruction, as well as 3D-gated imaging and phase
analysis all suggested that the apical region was char-
acterized by myocardial necrosis with mild residual
ischemia associated with abnormal wall motion/thick-
ening, i.e., severe hypokinesis (Figures 7, 8, 9). The
images also show inferior and distal anterior ischemia.
Funding This work was supported by Etisan, Rome, Italy.
Reprint requests: Francesco Nudi, MD, Service of Hybrid Cardio
Imaging, Madonna della Fiducia Clinic, Via Giuseppe Mantellini 3,
00179, Rome, Italy; email@example.com
J Nucl Cardiol
Copyright Ó 2018 American Society of Nuclear Cardiology.