A 69-year-old, asymptomatic, and haemodynamically stable male was admitted 48 h following chest pain with lateral ST-segment elevation acute coronary syndrome (STEACS).
Photon-counting computed tomography angiography (PCCTA) with the NAETOM Alpha (Siemens Healthineers) at ultra-high-resolution revealed a re-canalized non-calcified plaque at the left circumflex (LCx, Panel A) and a totally occluded, retrogradely filling right coronary artery (RCA). To confirm the culprit vessel, perivascular fat analysis was performed and fat attenuation index scores were measured (CaRi-Heart® v2.6, Caristo Diagnostics) demonstrating a highly inflamed LCx (Panel B) and less inflamed left anterior descending (Panel C) and RCA (Panel D).
Myocardial extracellular volume (ECV) was assessed on PCCTA at 55 keV (CT Cardiac Functional Analysis 2.1.0 prototype, Siemens Healthineers). First-pass (Panel E) and delayed phase (7-min; see Supplementary data online; Panels F–H) acquisitions identified a sub-endocardial area of hypodense myocardium and late iodine enhancement in the lateral wall. First-pass iodine-based ECV mapping confirmed microvascular obstruction (MVO, Panel I). Transmyocardial polar plots of delayed phase iodine-based ECV mapping showed a lateral wall infarction with 50–75% transmurality (Panels J–L).
Cardiac magnetic resonance confirmed the sub-endocardial core of MVO on pre-contrast–native T1 map and early gadolinium enhancement imaging (Panels M and N) and the 50–75% transmural lateral wall infarction on late gadolinium enhancement imaging (Panels O and P).
This is the first case of simultaneous assessment of coronary inflammation/plaque and myocardium with PCCTA in a patient with STEACS, revealing the culprit artery and evaluating the myocardial tissue state. Pending clinical validation, PCCTA may provide a practical, one-stop shop for fast comprehensive assessment of acute coronary syndromes, guiding the re-vascularization strategy and long-term management.
Supplementary Material
Acknowledgements
We would like to thank Siemens Healthineers and in particular Ernst Klotz for the provision of the iodine-based ECV mapping figures. We would also like to thank Caristo Diagnostics LTD and particularly Drs Pete Tomlins and Chris Mathers, for the development of the photon-counting CT compatibility package for the CaRi-Heart device, used to analyse this case.
Contributor Information
Rafail A Kotronias, Acute Multidisciplinary Imaging and Interventional Centre (AMIIC), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, West Wing L6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
Betty Raman, Acute Multidisciplinary Imaging and Interventional Centre (AMIIC), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, West Wing L6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
Vanessa Ferreira, Acute Multidisciplinary Imaging and Interventional Centre (AMIIC), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, West Wing L6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
Stefan Neubauer, Acute Multidisciplinary Imaging and Interventional Centre (AMIIC), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, West Wing L6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
Charalambos Antoniades, Acute Multidisciplinary Imaging and Interventional Centre (AMIIC), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, West Wing L6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
Supplementary data are available at European Heart Journal - Cardiovascular Imaging online.
Funding
This work is supported by British Heart Foundation grants (FS/CRTF/23/24460, CH/F/21/90009, and RG/F/21/110040), the Onassis Foundation, and the Oxford Biomedical Research Centre.
Data availability
The data underlying this article will be shared on reasonable request to the corresponding author.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data underlying this article will be shared on reasonable request to the corresponding author.