Predicting Benefit From Revascularization in Patients With Ischemic Heart Failure

Abstract

Case History : A 62-year-old male with a history of hypertension and coronary artery disease with prior stenting to the left circumflex artery presented with chest pain. Echocardiography on admission demonstrated a globally reduced ejection fraction of 10% to 15% with regional wall-motion abnormality consistent with prior anterior and inferolateral infarction. End-diastolic volume of the left ventricle (LV) was 210 mL. Coronary angiography showed evidence of multivessel disease, with 100% occlusion of the left anterior descending coronary artery, 70% in-stent restenosis of the left circumflex artery, and 90% stenosis of the posterior descending artery. To evaluate for the presence of ischemia, the patient underwent a rest-stress myocardial perfusion imaging study, which showed a large area of moderate ischemia throughout the mid left anterior descending coronary artery territory. In addition, there was a small area of scar in the proximal left circumflex artery territory (Figure 1). Clinical discussion ensued as to whether this patient would benefit from bypass surgery or percutaneous revascularization. Figure 1. A, Stress-rest rubidium 82 (82Rb) myocardial perfusion PET/computed tomography study in corresponding short-axis (SA; top), horizontal long-axis (HLA; middle), and vertical long-axis (VLA; bottom) slices. The LV is severely dilated (end-diastolic volume of 335 mL), and LV ejection fraction is reduced at 18%. There is a large and severe perfusion defect throughout the anterior and anteroseptal walls and the LV apex, consistent with extensive stress-induced ischemia throughout the left anterior descending coronary artery territory. In addition, there is an associated small area of fixed perfusion deficit that involves the basal inferior and inferolateral walls, consistent with scar in the left circumflex artery territory indicated. B, Three-dimensionally rendered reconstructions of the LV demonstrating the quantitative extent and severity of perfusion deficit (blackout region) and the magnitude of stress-induced ischemia or defect reversibility (pink). Prospective identification of patients with ischemic …