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Archivos de cardiología de México

versión On-line ISSN 1665-1731versión impresa ISSN 1405-9940

Arch. Cardiol. Méx. vol.93 no.4 Ciudad de México oct./dic. 2023  Epub 28-Nov-2023

https://doi.org/10.24875/acm.22000119 

Images in cardiology

Assessment of coronary flow capacity by positron emission tomography in coronary artery disease

Evaluación de la capacidad de flujo coronario medida por PET en enfermedad coronaria

Mauricio García-Cárdenas1 

Valente Fernández-Badillo1 

Adrián Espejel-Guzmán1 

Javier Serrano-Román1 

Enrique Solorzano-Pinot1 

Salvador Hernández-Sandoval1 

Erick Alexanderson-Rosas1 

Nilda Espínola-Zavaleta1  * 

1Department of Nuclear Cardiology, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México


A 65-year-old man with a history of recent non-reperfused myocardial infarction presented to the emergency department due to 3-day progressive dyspnea during mild physical activity (functional class III) and chest pain, which later required myocardial revascularization. Transthoracic echocardiogram revealed a left ventricular ejection fraction (LVEF) of 38%.

Perfusion study exhibited a transmural infarction of the apex and apical third of the left ventricular anterior wall that extended as non-transmural to the other segments of the anterior and septal walls, and no ischemia was found; the FDG metabolism study showed moderate uptake in the anterior wall suggestive of hibernating myocardium (Fig. 1).

Figure 1 Positron emission tomography-fluorodeoxyglucose (FDG) viability. A moderate FDG uptake in the basal and middle thirds, with reduced uptake toward the more apical segments and the apex is visualized. 

Calculated mismatch was approximately 10%. A significant reduction in coronary flow capacity (CFC: On the basis of a scatter plot of CFR vs. absolute stress flow) is observed in the apex, with an area with decreased FDG uptake, and a moderately reduced CFC in the rest of the anterior wall (Fig. 2). Absolute myocardial blood flow (MBF) analysis showed a positive result with a value of 110.21 ml/100 ml/min, while relative MBF analysis showed a negative result with a ratio of 0.71.

Figure 2 Dynamic polar maps of positron emission tomography NH3/fluorodeoxyglucose (FDG) flows and viability. Note the correlation between higher uptake and mismatch in segments with moderately reduced coronary flow capacity (CFCs) and less FDG uptake in zones with lower CFCs. Global MFR: 1.71; mismatch: 10%. 

Myocardial perfusion quantified by regional pixel distribution of CFC is the final common expression of coronary artery disease severity for which revascularization reduces mortality. Decreased coronary flow reserve (CFR) is associated with an increased risk of cardiovascular events1.

CFC represents a novel diagnostic and prognostic parameter measured by positron emission tomography [PET], with a CFR > 3.37 and stress MBF (SMBf) > 2.39 cc/min/g considered as normal. Revascularization of patients with reduced CFC (within 90 days of PET) is associated with decreased mortality in approximately 54%2.

Mismatch between perfusion and metabolism ≥ 7% can predict LVEF recovery; but the use of CFC to predict hibernating myocardium requires further investigations. Our patient had a severe reduction of CFC defined as CFR < 1.23 and SMBf < 0.83 in the segments with the lowest FDG uptake2,3. CFC represents a highly underused parameter, compared with CFR and SMBf, yet it may have future prognostic and therapeutic implications.

References

1. Juárez-Orozco LE, Alexanderson E, Dierckx RA, Boersma HH, Hillege JL, Zeebregts CJ, et al. Stress myocardial blood flow correlates with ventricular function and synchrony better than myocardial perfusion reserve:a Nitrogen-13 ammonia PET study. J Nucl Cardiol. 2018;25:797-806. [ Links ]

2. Johnson NP, Gould KL. Integrating noninvasive absolute flow, coronary flow reserve, and ischemic thresholds into a comprehensive map of physiological severity. JACC Cardiovasc Imaging. 2012;5:430-40. [ Links ]

3. Gould KL, Johnson NP, Roby AE, Nguyen T, Kirkeeide R, Haynie M, et al. Regional, artery-specific thresholds of quantitative myocardial perfusion by PET associated with reduced myocardial infarction and death after revascularization in stable coronary artery disease. J Nucl Med. 2019;60:410-7. [ Links ]

FundingNone.

Ethical disclosures

Protection of human and animal subjects. The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).

Confidentiality of data. The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent. The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.

Received: April 07, 2022; Accepted: December 13, 2022

* Correspondence: Nilda Espínola-Zavaleta E-mail: niesza2001@hotmail.com

Conflicts of interest

None.

Creative Commons License Instituto Nacional de Cardiología Ignacio Chávez. Published by Permanyer. This is an open ccess article under the CC BY-NC-ND license