IJCA-17761; No of Pages 3 International Journal of Cardiology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Successful 13N-ammonia positron emission tomography-guided percutaneous coronary intervention in a patent with single coronary artery ostium suffering acute myocardial infarction Ju Han Kim a, Henry Hee-Seung Bom b, Myung Ho Jeong a,⁎, Sang-Geon Cho b, Jae Yeong Cho a, Keun-Ho Park a, Doo Sun Sim a, Young Joon Hong a, Youngkeun Ahn a, Jeong Gwan Cho a, Jong Chun Park a a b
The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Republic of Korea Department of Nuclear Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
a r t i c l e
i n f o
Article history: Received 26 February 2014 Accepted 9 March 2014 Available online xxxx Keywords: Positron emission tomography Percutaneous coronary intervention Single coronary artery
A 49 year-old male presented with chest pain and dyspnea which developed 10 h previously. Hypotension and pulmonary congestion were accompanied on arrival at the emergency room. Risk factors included hypertension, diabetes, smoking and dyslipidemia. The electrocardiogram showed ST-segment depression in leads II, III, aVF, and V4 ~ 6 and cardiac troponin-I was elevated (1.35 ng/mL). Coronary angiography (CAG) showed a single origin of coronary artery from right coronary sinus of Valsalva with communication between right coronary artery (RCA) and middle left anterior descending artery (LAD) via right ventricular branch (Fig. 1A), moderate stenosis in middle LAD (Fig. 1A, arrowhead), and thrombotic total occlusion of the proximal RCA (Fig. 1B, arrowhead). A temporary pacemaker was inserted due to bradycardia and balloon angioplasty was performed for the RCA lesion using a 2.5 × 15 mm balloon, followed by thrombus aspiration with Thrombuster® (Kaneka Corporation, Osaka, Japan) and intracoronary administration of glycoprotein IIb/IIIa receptor blocker (abciximab). A 4.0 × 25 mm bare-metal stent (Coroflex blue®, Braun, Berlin, Germany) was deployed with good angiographic results (Fig. 1C). The echocardiography showed akinesia in RCA territory with mild left ventricular systolic dysfunction (ejection fraction = 44%). A follow-up coronary angiography 3 months later showed type II in-stent restenosis in the proximal RCA ⁎ Corresponding author at: The Heart Research Center of Chonnam National University Hospital, Jaebongro 167, Dong-gu, Gwangju, Republic of Korea 501-757. Tel.: +82 62 220 6243; fax: +82 62 228 7174. E-mail address: [email protected] (M.H. Jeong).
stent (Fig. 1D, arrowhead) and no change in moderate stenosis in the middle LAD. To evaluate the degree and extent of myocardial viability, 13 N-ammonia positron emission tomography (PET) was performed, which demonstrated a moderate degree of myocardial ischemia in RCA and LAD territory (Fig. 2A). Balloon angioplasty was performed for the proximal RCA in-stent restenosis and mid LAD stenosis using a 2.5 × 15 mm balloon at 20 and 4 atm., respectively (Fig. 2C and D, arrowheads). A follow-up 13N-ammonia PET demonstrated resolution of myocardial ischemia was observed in RCA and LAD territory (Fig. 2B). The incidence of single anomalous origin is approximately 1% among patients undergoing cardiac catheterization, especially anomalous origin of the left coronary artery is less frequent than RCA [1]. The correlation between coronary artery disease and coronary anomalies is uncertain [2]. In the present case, our patient had an anomalous left coronary artery originated from the right sinus of Valsalva with thrombusladen totally occluded proximal RCA causing acute MI, which was reperfused by primary PCI with bare-metal stent implantation. Later, the patient underwent successful 13N-ammonia PET-guided PCI for in-stent restenosis and non-culprit vessel stenosis. PET is an established noninvasive method of evaluating myocardial perfusion and viability. This technique has the advantage of being able to assess perfusion and metabolism simultaneously. Recently, the short term prognostic value of 82Rb PET myocardial perfusion imaging (MPI) has been documented [3] and an added value of coronary flow reserve has been found as assessed by either 13N-ammonia [4] or 82Rb [5]. In addition, long-term prognostic value of 13N-ammonia PET has been demonstrated in a recent study on 943 patients (coronary artery disease: 77%). During follow-up of 5.7 ± 2.5 years, abnormal perfusion on 13 N-ammonia PET was associated with a higher incidence of cardiac death and non-fatal myocardial infarction (MI), compared with normal PET MPI (24.7% vs. 12.5%, P b 0.001) [6]. Currently, there are no set guidelines on the non-culprit vessel PCI in patients with acute MI and the decision is frequently guided by the presence of myocardial viability. In such a setting, 13N-ammonia PET may play a role in the decision-making process. Acknowledgment This study was supported by a grant (A070001) from the Korea National Enterprise for Clinical Trials.
http://dx.doi.org/10.1016/j.ijcard.2014.03.069 0167-5273/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article as: Kim JH, et al, Successful 13N-ammonia positron emission tomography-guided percutaneous coronary intervention in a patent with single coronary art..., Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.03.069
e2
J.H. Kim et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Fig. 1. Coronary angiogram showed a single origin of coronary artery from right coronary sinus of Valsalva with communication between right coronary artery (RCA) and middle left anterior descending artery (LAD) via right ventricular branch (A), moderate stenosis in middle LAD (A, arrowhead), and thrombotic total occlusion of the proximal RCA (B, arrowhead). Coronary angiogram after primary percutaneous coronary intervention with stent implantation showed successful reperfusion with good distal flow (C). A follow-up coronary angiogram 3 months later showed in-stent restenosis of the proximal RCA stent (D, arrowhead).
References [1] Leberthson RR, Dinsmore RE, Bharati S, et al. Aberrant coronary artery origin from the aorta. Diagnosis and clinical significance. Circulation 1974;50:774–9. [2] Lee BY. Anomalous right coronary artery from the left coronary sinus with an interarterial course: is it really dangerous? Korean Circ J 2009;39:175–9. [3] Yoshinaga K, Chow BJW, Williams K, et al. What is the prognostic value of myocardial perfusion imaging using rubidium-82 positron emission tomography? J Am Coll Cardiol 2006;48:1029–39.
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[4] Herzog BA, Husmann L, Valenta I, et al. Long-term prognostic value of N-ammonia myocardial perfusion positron emission tomography: added value of coronary flow reserve. J Am Coll Cardiol 2009;54:150–6. [5] Ziadi MC, deKemp RA, Williams KA, et al. Impaired myocardial flow reserve on rubidium-82 positron emission tomography imaging predicts adverse outcomes in patients assessed for myocardial ischemia. J Am Coll Cardiol 2011;58:740–8. [6] Fiechter M, Gebhard C, Ghadri JR, et al. Myocardial perfusion imaging with (13) N-Ammonia PET is a strong predictor for outcome. Int J Cardiol 2013;167:1023–6.
Please cite this article as: Kim JH, et al, Successful 13N-ammonia positron emission tomography-guided percutaneous coronary intervention in a patent with single coronary art..., Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.03.069
J.H. Kim et al. / International Journal of Cardiology xxx (2014) xxx–xxx
e3
Fig. 2. 13-N ammonia PET before PCI showed moderate degree of myocardial ischemia in the LAD and RCA territory (A). Coronary angiogram after successful 13-N ammonia PET-guided PCI for mid-LAD stenosis (C, D). 13-N ammonia PET after PCI showed resolution of ischemia both in the LAD and RCA territory (B).
Please cite this article as: Kim JH, et al, Successful 13N-ammonia positron emission tomography-guided percutaneous coronary intervention in a patent with single coronary art..., Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.03.069
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Successful 13N-ammonia positron emission tomography-guided percutaneous coronary intervention in a patent with single coronary artery ostium suffering acute myocardial infarction Ju Han Kim a, Henry Hee-Seung Bom b, Myung Ho Jeong a,⁎, Sang-Geon Cho b, Jae Yeong Cho a, Keun-Ho Park a, Doo Sun Sim a, Young Joon Hong a, Youngkeun Ahn a, Jeong Gwan Cho a, Jong Chun Park a a b
The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Republic of Korea Department of Nuclear Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
a r t i c l e
i n f o
Article history: Received 26 February 2014 Accepted 9 March 2014 Available online xxxx Keywords: Positron emission tomography Percutaneous coronary intervention Single coronary artery
A 49 year-old male presented with chest pain and dyspnea which developed 10 h previously. Hypotension and pulmonary congestion were accompanied on arrival at the emergency room. Risk factors included hypertension, diabetes, smoking and dyslipidemia. The electrocardiogram showed ST-segment depression in leads II, III, aVF, and V4 ~ 6 and cardiac troponin-I was elevated (1.35 ng/mL). Coronary angiography (CAG) showed a single origin of coronary artery from right coronary sinus of Valsalva with communication between right coronary artery (RCA) and middle left anterior descending artery (LAD) via right ventricular branch (Fig. 1A), moderate stenosis in middle LAD (Fig. 1A, arrowhead), and thrombotic total occlusion of the proximal RCA (Fig. 1B, arrowhead). A temporary pacemaker was inserted due to bradycardia and balloon angioplasty was performed for the RCA lesion using a 2.5 × 15 mm balloon, followed by thrombus aspiration with Thrombuster® (Kaneka Corporation, Osaka, Japan) and intracoronary administration of glycoprotein IIb/IIIa receptor blocker (abciximab). A 4.0 × 25 mm bare-metal stent (Coroflex blue®, Braun, Berlin, Germany) was deployed with good angiographic results (Fig. 1C). The echocardiography showed akinesia in RCA territory with mild left ventricular systolic dysfunction (ejection fraction = 44%). A follow-up coronary angiography 3 months later showed type II in-stent restenosis in the proximal RCA ⁎ Corresponding author at: The Heart Research Center of Chonnam National University Hospital, Jaebongro 167, Dong-gu, Gwangju, Republic of Korea 501-757. Tel.: +82 62 220 6243; fax: +82 62 228 7174. E-mail address: [email protected] (M.H. Jeong).
stent (Fig. 1D, arrowhead) and no change in moderate stenosis in the middle LAD. To evaluate the degree and extent of myocardial viability, 13 N-ammonia positron emission tomography (PET) was performed, which demonstrated a moderate degree of myocardial ischemia in RCA and LAD territory (Fig. 2A). Balloon angioplasty was performed for the proximal RCA in-stent restenosis and mid LAD stenosis using a 2.5 × 15 mm balloon at 20 and 4 atm., respectively (Fig. 2C and D, arrowheads). A follow-up 13N-ammonia PET demonstrated resolution of myocardial ischemia was observed in RCA and LAD territory (Fig. 2B). The incidence of single anomalous origin is approximately 1% among patients undergoing cardiac catheterization, especially anomalous origin of the left coronary artery is less frequent than RCA [1]. The correlation between coronary artery disease and coronary anomalies is uncertain [2]. In the present case, our patient had an anomalous left coronary artery originated from the right sinus of Valsalva with thrombusladen totally occluded proximal RCA causing acute MI, which was reperfused by primary PCI with bare-metal stent implantation. Later, the patient underwent successful 13N-ammonia PET-guided PCI for in-stent restenosis and non-culprit vessel stenosis. PET is an established noninvasive method of evaluating myocardial perfusion and viability. This technique has the advantage of being able to assess perfusion and metabolism simultaneously. Recently, the short term prognostic value of 82Rb PET myocardial perfusion imaging (MPI) has been documented [3] and an added value of coronary flow reserve has been found as assessed by either 13N-ammonia [4] or 82Rb [5]. In addition, long-term prognostic value of 13N-ammonia PET has been demonstrated in a recent study on 943 patients (coronary artery disease: 77%). During follow-up of 5.7 ± 2.5 years, abnormal perfusion on 13 N-ammonia PET was associated with a higher incidence of cardiac death and non-fatal myocardial infarction (MI), compared with normal PET MPI (24.7% vs. 12.5%, P b 0.001) [6]. Currently, there are no set guidelines on the non-culprit vessel PCI in patients with acute MI and the decision is frequently guided by the presence of myocardial viability. In such a setting, 13N-ammonia PET may play a role in the decision-making process. Acknowledgment This study was supported by a grant (A070001) from the Korea National Enterprise for Clinical Trials.
http://dx.doi.org/10.1016/j.ijcard.2014.03.069 0167-5273/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article as: Kim JH, et al, Successful 13N-ammonia positron emission tomography-guided percutaneous coronary intervention in a patent with single coronary art..., Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.03.069
e2
J.H. Kim et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Fig. 1. Coronary angiogram showed a single origin of coronary artery from right coronary sinus of Valsalva with communication between right coronary artery (RCA) and middle left anterior descending artery (LAD) via right ventricular branch (A), moderate stenosis in middle LAD (A, arrowhead), and thrombotic total occlusion of the proximal RCA (B, arrowhead). Coronary angiogram after primary percutaneous coronary intervention with stent implantation showed successful reperfusion with good distal flow (C). A follow-up coronary angiogram 3 months later showed in-stent restenosis of the proximal RCA stent (D, arrowhead).
References [1] Leberthson RR, Dinsmore RE, Bharati S, et al. Aberrant coronary artery origin from the aorta. Diagnosis and clinical significance. Circulation 1974;50:774–9. [2] Lee BY. Anomalous right coronary artery from the left coronary sinus with an interarterial course: is it really dangerous? Korean Circ J 2009;39:175–9. [3] Yoshinaga K, Chow BJW, Williams K, et al. What is the prognostic value of myocardial perfusion imaging using rubidium-82 positron emission tomography? J Am Coll Cardiol 2006;48:1029–39.
13
[4] Herzog BA, Husmann L, Valenta I, et al. Long-term prognostic value of N-ammonia myocardial perfusion positron emission tomography: added value of coronary flow reserve. J Am Coll Cardiol 2009;54:150–6. [5] Ziadi MC, deKemp RA, Williams KA, et al. Impaired myocardial flow reserve on rubidium-82 positron emission tomography imaging predicts adverse outcomes in patients assessed for myocardial ischemia. J Am Coll Cardiol 2011;58:740–8. [6] Fiechter M, Gebhard C, Ghadri JR, et al. Myocardial perfusion imaging with (13) N-Ammonia PET is a strong predictor for outcome. Int J Cardiol 2013;167:1023–6.
Please cite this article as: Kim JH, et al, Successful 13N-ammonia positron emission tomography-guided percutaneous coronary intervention in a patent with single coronary art..., Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.03.069
J.H. Kim et al. / International Journal of Cardiology xxx (2014) xxx–xxx
e3
Fig. 2. 13-N ammonia PET before PCI showed moderate degree of myocardial ischemia in the LAD and RCA territory (A). Coronary angiogram after successful 13-N ammonia PET-guided PCI for mid-LAD stenosis (C, D). 13-N ammonia PET after PCI showed resolution of ischemia both in the LAD and RCA territory (B).
Please cite this article as: Kim JH, et al, Successful 13N-ammonia positron emission tomography-guided percutaneous coronary intervention in a patent with single coronary art..., Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.03.069
