Abstract
A 74-year-old man returned to the clinic for follow-up of residual nonculprit lesions after reperfused acute inferior ST-segment elevation myocardial infarction. Stress cardiac magnetic resonance perfusion imaging demonstrated a severe perfusion defect in the anterior wall. Surprisingly, subsequent invasive assessment did not reveal hemodynamically significant obstruction in the nonculprit vessels. (Level of Difficulty: Beginners.)
Key Words: cardiac magnetic resonance, fractional flow reserve, multivessel disease, myocardial ischemia, perfusion, ST-segment elevation myocardial infarction
Abbreviations and Acronyms: CMR, cardiac magnetic resonance
Graphical abstract
A 74-year-old man returned to the clinic for follow-up of residual nonculprit lesions after reperfused acute inferior ST-segment elevation myocardial…
Approximately 50% of patients presenting with ST-segment elevation myocardial infarction have residual lesions in nonculprit vessels after revascularization of the culprit artery (1). If left unattended, these nonculprit lesions confer unfavorable prognosis (2). Several strategies are available for treatment of the nonculprit lesions. Among these strategies, staged revascularization supported by measurements of fractional flow reserve is a frequently used option. An alternative strategy for management of the nonculprit lesions is noninvasive detection of ischemia using cardiac magnetic resonance (CMR) imaging.
We present the case of a 74-year-old male patient who presented with an inferior ST-segment elevation myocardial infarction. The patient was rushed to emergency angiography, which revealed a thrombotic occlusion of the right coronary artery (Figure 1A, Video 1) and intermediate stenosis of the left anterior descending artery (Figures 1B and 1C, Videos 2 and 3). The culprit was successfully treated through implantation of 2 drug-eluting stents (Video 4). The patient returned to our clinic 1 month after discharge for follow-up of the lesion in the left anterior descending artery. Although the patient was asymptomatic, CMR revealed a transmural stress perfusion defect in 1 segment anterior mid (Figure 1E, Video 5), with normokinesia on cine imaging (Figure 1D, Video 6) and no contrast enhancement on the late gadolinium enhancement image (Figure 1F), opposite to an infarction of the inferior wall. Surprisingly, subsequent angiography did not reveal a significant nonculprit stenosis and fractional flow reserve in the left anterior descending artery was measured to be 0.94. However, after careful re-evaluation of the angiogram, we noted a chronic total occlusion of the second diagonal branch with a tapered proximal cap and anterograde filling of the distal segment through micro channels or bridging collaterals (Figures 1B and 1C). After discussion among our team, it was decided not to attempt revascularization because of the high lesion complexity and limited area of ischemia.
Figure 1.
Invasive Coronary Angiography and CMR
(A) The invasive coronary angiogram of the culprit artery obtained during primary intervention. (B,C) Angiographic images of the nonculprit artery. The arrows indicate the chronic total occlusion of the second diagonal branch. (D to F) CMR images of myocardial function (D), stress perfusion (E), and late gadolinium enhancement (F). Note the transmural perfusion defect anterior mid (E, arrow).
Online Video 1.
Emergency Coronary Angiogram of the RCA
Emergency invasive coronary angiogram demonstrating thrombotic occlusion of the right coronary artery (RCA).
Online Video 2.
Invasive Coronary Angiogram of the LCA
Invasive coronary angiogram of the left coronary artery (LCA) in the left anterior oblique view. In addition to intermediate stenosis of the left anterior descending artery, note the chronic total occlusion of the second diagonal branch.
Online Video 3.
Invasive Coronary Angiogram of the LCA
Invasive coronary angiogram of the LCA in the right anterior oblique view. Again, note the chronic total occlusion of the second diagonal branch in addition to intermediate stenosis of the left anterior descending artery.
Online Video 4.
Invasive Coronary Angiogram of the RCA After Primary PCI
Invasive coronary angiogram of the RCA after successful restoration of coronary patency through implantation of 2 drug-eluting stents.
Online Video 5.
CMR Stress Perfusion Images
Short-axis perfusion images obtained at the mid-level during vasodilator stress. A transmural perfusion defect is observed in the anterior segment in addition to a perfusion defect in the inferior wall.
Online Video 6.
CMR Cine Images
Short-axis cine images obtained at the mid-level showing hypokinesia of the inferior wall. Note that no wall motion abnormalities are present in the anterior wall.
This case beautifully underscores the value of CMR in the management of ST-segment elevation myocardial infarction patients with multivessel disease. Not only does CMR provide vital information on cardiac function and infarct size, it also allows to identify ischemia in nonculprit vascular territories, even when this eludes us during invasive assessment.
Footnotes
Dr. Nijveldt has received research grants from Philips and Biotronik; and has received financial support from the Netherlands Organization for Health Research and Development (grant 9071544). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reportsauthor instructions page.
Appendix
For supplemental videos, see the online version of this paper.
References
- 1.Sorajja P., Gersh B.J., Cox D.A. Impact of multivessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Eur Heart J. 2007;28:1709–1716. doi: 10.1093/eurheartj/ehm184. [DOI] [PubMed] [Google Scholar]
- 2.Pasceri V., Patti G., Pelliccia F. Complete revascularization during primary percutaneous coronary intervention reduces death and myocardial infarction in patients with multivessel disease: meta-analysis and meta-regression of randomized trials. J Am Coll Cardiol Intv. 2018;11:833–843. doi: 10.1016/j.jcin.2018.02.028. [DOI] [PubMed] [Google Scholar]