1. Case No #1 Viability assessment
Presented by Dr L.Alizadeh M.D
Fellowship of cardiovascular Imaging/ Echocardiography

2. Medical History 65 year old male Hypertension +
Iron deficiency anemia,
Atrial fibrillation (not anticoagulated due to prior gastrointestinal bleed)
New onset of lower extremity edema, dyspnea on exertion, orthopnea, and profound fatigue.

3. Physical exam Jugular venous distention to 17 cm,
Bilateral basilar crackles on lung exam,
3+ pitting edema in the lower extremities to mid thighs
Guaiac positive brown stool.

4. LAB Findings Hemoglobin of 5.4, Normal kidney function
Mildly elevated troponin.
Patient denies chest pain and is hemodynamically stable with normal vitals.

5. ECG
Electrocardiogram shows new ST depressions in lateral leads

6. First Steps
TTE .New segmental wall motion abnormalities along with a newly reduced ejection fraction of 30%.
Capsule endoscopy shows non-bleeding angioectasias in the jejunum.

7. TTE
Echocardiogram strongly suggests ischemic cardiomyopathy due to the presence of regional wall motion abnormalities
Assessment of the patient’s coronary anatomy is warranted

8. What is next ?
The patient is started on medical therapy for congestive heart failure and presumed coronary artery disease (ACE-I, Beta blocker, diuretic)
Transfused to hemoglobin goal of 10 with improvement in his symptoms of dyspnea and fatigue,

9. What is your suggestion ?
cardiac catheterization
Coronary CT angiography
MRI/MRA

10. Dr Mirsadraee

11. The medical team and cardiology consult are reluctant to perform cardiac catheterization due to the risk of bleeding in a severely anemic patient who may require coronary artery stenting and subsequent long term anticoagulation.

12. What other modalities are available for assessing this patient’s new cardiomyopathy and coronary anatomy?

13. Do We Need Viability Assessment ?
Traditional viability assessment
Radionuclide myocardial perfusion imaging (using thallium, technetium-sestamibi,
Positron Emission Tomography
Dobutamin echocardiography.

14. Dr Hamedanchi

15. CMR one-stop shop
* it can provide a comprehensive assessment of the heart including myocardial wall motion, cavity size, ventricular ejection fraction, wall thickness, valvular function, infarct area, proximal coronary artery lesions, aortic disease including aneurysm and dissection, pericardial disease, congenital heart defects, and myocardial viability

16. Viability Assessment
dobutamine stress MRI had a 86% sensitivity and 74% specificity in terms of predicting viability when compared to dobutamine stress echocardiography which had a 85% sensitivity and 69% specificity.
When compared to positron emission tomography with F- 18 deoxyglucose (FDG-PET), CMR had similar sensitivity and specificity (94% and 84% respectively).
In comparison to resting thallium-201 perfusion imaging, CMR performs as well in terms of detecting transmural infarctions but is more accurate in detecting subendocardial infarctions.

17. CMRI
Assess for myocardial viability in our patient and thus guide future therapy (revascularization or optimal medical therapy).
Accurately determine ejection fraction and extent of proximal coronary artery atherosclerotic lesions, thus risk stratifying this patient.

18. Dr Alizadeh Sani

19. In our patient,
Cardiac MRI/MRA showed mildly dilated LV with moderately reduced LV ejection fraction,
Hypokinetic myocardium without scar in LAD territory, hypokinetic myocardium with mild scar in RCA territory, and hypokinetic but viable myocardium in LCX territory.
Coronary artery origins were incompletely visualized due to motion but there was patent origin of RCA, LAD, and LCX (L main couldn’t be visualized

20. What Is The Next Step ?
Patient was discharged home on medical therapy and planned to return for coronary angiogram and possible revascularization as his coronary anatomy was not completely delineated by the Cardiac MRI.

21. Conventional cathaterism VS CCT

22. PCI Vs CABG ?
Left main or triple vessel disease may necessitate a surgical intervention in this patient. However, medical therapy or single vessel PCI may be more appropriate than CABG despite multivessel CAD if there is limited or no viability in multiple infarct areas

23. Later Coronary angiography revealed
Nl Left main
Significant lesion proximal of LAD
Significant lesion of OM1
Aneurysmal dilation of RCA
LV was not injected

24. What Is The Surgical Point Of View ?
What is The Interventionalist point of view ?

25. End of Discussion …