Imaging-Guided Selection of Patients With Ischemic Heart Failure for High-Risk Revascularization Improves Identification of Those With the Highest Clinical Benefit

Abstract

A 65-year-old man presented to his local emergency department with rapid atrial fibrillation and acute pulmonary edema. This patient had a history of hypertension, and 2 months before this presentation, he developed progressive exertional dyspnea. The patient deteriorated in the emergency department and went into cardiogenic shock. Emergent coronary angiography revealed diffuse 3-vessel disease: a 99% proximal left anterior descending coronary artery lesion, 90% mid-right coronary artery lesion, occluded large first marginal branch, and diffuse severe disease of the left circumflex coronary artery. The initial ejection fraction (EF) on echocardiography was 15%, with mild mitral regurgitation and an estimated pulmonary artery pressure of 55 mm Hg. The patient stabilized with an intraaortic balloon pump and intensive care unit management; however, because of the diffuse nature of the disease, he was not believed to be a surgical candidate. He was transferred to another tertiary-care facility for consideration of cardiac transplantation. As part of this evaluation, a PET viability study was done that demonstrated a significant area of perfusion-metabolism mismatch in the entire anteriolateral wall. Less than 1% of the myocardium was scar, and 28% was defined as hibernating (Figure 1). Response by Velazquez on p 270The results of the viability test were pivotal in the decision to perform coronary artery bypass graft (CABG) surgery in a patient who otherwise would not have had surgery. Approximately 2 months after his initial presentation, the patient had a 4-vessel CABG. His predischarge echocardiogram demonstrated an EF of 25%. Six months after surgery, the patient was clinically stable with New York Heart class II functional symptoms and an EF of 45%.

Cardiac Radionuclide Imaging to Assess Patients With Heart Failure

“…97 Despite recent controversy from results of STICH, there remains much reason to believe that imaging can play an important role in evaluating patients with ischemic and nonischemic HF. 98 Beanlands and collaborators from Canada and Finland have undertaken the "Imaging Modalities to Assist with Guiding Therapy and the Evaluation of Patients with Heart Failure" project. 99 The program consists of 3 randomized controlled trials-the first (1A, Alternative Imaging Modalities in Ischemic Heart Failure) comparing the effect of imaging strategies (SPECT, PET, and MRI) in the evaluation and diagnosis of ischemic HF as a complement to STICH and PARR-2, the second (1B) evaluating cardiac MRI in addition to standard echocardiography in evaluation and diagnosis of nonischemic HF, and the third (1C) comparing standard coronary angiography with cardiac CT in detection of CAD.…”

Nuclear Perfusion Imaging for Functional Evaluation of Patients With Known Or Suspected Coronary Artery Disease: the Future is Now

“…Furthermore, the role of nuclear imaging in the assessment of heart failure patients will be examined in one arm of the multicenter IMAGE HF trial with comparison of the effectiveness of both PET, MRI or SPECT imaging in guiding therapy in patients with ischemic cardiomyopathy, particularly in terms of revascularization [95,96].…”

Cardiac autonomic imaging with SPECT tracers

“…The clinical utility of MPI has been well described and is broadly accepted. [1][2][3][4][5][6][7][8][9][10][11] Nevertheless, heart disease encompasses more than CAD, and nuclear cardiology has much to offer beyond MPI. In particular, radionuclide imaging can assess molecular processes, helping to better understand the underlying cardiac pathophysiology, and thereby improving our ability to manage patients.…”