1. A 62-year-old CKD 5 male on HD due to diabetic nephropathy. He received a kidney offer from his son, 111 mismatch with no DSA. During the routine pre-transplant work up, MYOVIEW scan (cardiac scintigraphy) reported reversible antro-lateral perfusion defect, not due to artefact. Echocardiogram is satisfactory
- What is the significance of the MYOVIEW scan finding?
Dear All
The correct answers are: A,B,C and E
D is wrong as stress ECHO MPI both characterise the ischemic areas. All patients with CAD need to be on dual anti platelets
Please choose the correct answer regarding reversible ischaemia on MPI
A. Needs a coronary angiogram
B. These patients need to be on dual antiplatelets
C. Need better control of blood sugar and blood pressure
D. Need stress ECHO to characterize the ischaemic area
E. Lose weight
Please choose the correct answer regarding reversible ischaemia on MPI
A. Needs a coronary angiogram- True
B. These patients need to be on dual antiplatelets-True
C. Need better control of blood sugar and blood pressure-True
D. Need stress ECHO to characterize the ischaemic area- False
E. Lose weight- True
A, B, C, E
A B C E
Regarding reversible ischaemia on MPI
A. Needs a coronary angiogram: True
B. These patients need to be on dual antiplatelets: False
C. Need better control of blood sugar and blood pressure: True
D. Need stress ECHO to characterize the ischaemic area: False
E. Lose weight: True
Please choose the correct answer regarding reversible ischemia on MPI
A. True coronary angiogram is needed for possible revascularization ( PCI vs CABG ).
B. False Patients with PCI need to be on dual antiplatelet
C. True all patients need good control of blood sugar blood pressure and dyslipidemia
D . False echocardiography is needed to assess TLVSF, EF %, cardiomyopathy, and pulmonary hypertension
E. True weight reduction part of lifestyle modification in such high-risk candidates.
The correct answers are (A, B, C & E).
A true
b true
c true
d false
E true
A,B,C AND E ARE TRUE BUT D IS FALSE
Correct answer is A B C E
A,b,c,e
Please choose the correct answer regarding reversible ischaemia on MPI
A. Needs a coronary angiogram : yes
B. These patients need to be on dual antiplatelets ; yes
C. Need better control of blood sugar and blood pressure : yes
D. Need stress ECHO to characterize the ischaemic area : no , just echo without stress to evaluate the EF , valvular disease , area of hypokinesia
E. Lose weight : yes
Please choose the correct answer regarding reversible ischaemia on MPI
A. Needs a coronary angiogram – True
B. These patients need to be on dual antiplatelets – True
C. Need better control of blood sugar and blood pressure – True
D. Need stress ECHO to characterize the ischaemic area – False
E. Lose weight – True
So, this recipient will require coronary angiogram to assess the coronary stenosis status and need for further angioplasty before transplantation.
Fathala A. Myocardial perfusion scintigraphy: techniques, interpretation, indications and reporting. Ann Saudi Med. 2011 Nov-Dec;31(6):625-34. doi: 10.4103/0256-4947.87101. PMID: 22048510; PMCID: PMC3221136.
the corect answer are
A, B , C , E
Except D
Moderate risk patient for CAD :
( DM and CKD5 on regular hemodialysis )
(cardiac scintigraphy) reported reversible antro-lateral perfusion defect
so the preferred next step is Percutaneous coronay angiography to detect if he needs more intervention or not ( Angioplasty with stenting or bypass surgery )
The result meant the detection of any reduction to the blood supply in that heart wall, however the echocardiogram ruled out changes, ruling out a change in functionality.
He needs CAG and revascularisation ,good contro f DM ,dual anti platelet and to lose weight
What is the significance of the MYOVIEW scan finding?
62 year old diabetic patient on HD and presented with antero-lateral perfusion defect (reversible ischemia) on MYOVIEW scan so he needs proper assessment with a cardiologist as well as proceeding to coronary angiography +_ revascularisation before proceeding with kidney Tx .
The other aspects in this case scenario, which require evaluation include:
Full assessment of Diabetes Mellitus, Blood pressure management, as well as vascular assessment to check for iliac vasculature for fear of complications of DM which include atherosclerosis or PVD
MYOVIEW scanning suggestive of area of hypo perfusion. upon finding this next step is to check if it is reversible , if so then timely interventions with coronary angiogram is warranted for best out come.
Please choose the correct answer regarding reversible ischaemia on MPI
A. Needs a coronary angiogram
B. These patients need to be on dual antiplatelets
C. Need better control of blood sugar and blood pressure
D. Need stress ECHO to characterize the ischaemic area
E. Lose weight-
A, C and E are correct
Due to risk factors (diabetes and ESRD), he is at risk for CAD. The results of a MYOVIEW scan point to coronary ischemia due to a perfusion defect that is reversible. He needs coronary angiography with or without revascularisation as per angiogram findings.
He also needs to change his lifestyle, engage in moderate exercise, control blood pressure, manage his diabetes, engage in timely dialysis schedule to avoid fluid overload and maintain weight to near normal as per BMI.
MYOVIEW scan helps in prognosis and risk Stratification, whether therapeutic Intervention can be done and also about myocardial viability.In the above case,62 year diabetic male ,on maintenance hemodialysis with potential donor –his son ,had myocardial perfusion scan done which revealed reversible antero-lateral perfusion defect. Reversible ischemia suggests hypoperfused myocardium(decreased radiopharmaceutical activity )which can return back to normal if timely intervention done. Therefore, patient should be subjected to coronary angiogram and then revascularization according to the findings. Nephrologist and cardiologist both should be taken on board in such cases .Cardiac Evaluation Sheffield protocol also suggest this. In such patients ,pre –transplant evaluation also includes blood sugar and blood pressure control, address all complications of CKD and diabetes, , lifestyle changes like weight reduction, regular exercise, and iliac vasculature assessment to look for atherosclerosis/ vascular calcification).
REFERENCES:
1- Fathala A. Myocardial perfusion scintigraphy: techniques, interpretation, indications and reporting. Ann Saudi Med. 2011 Nov-Dec;31(6):625-34.
2- Renal Transplant Recipient lecture (Part 1) By professor, Ahmed Halawa (Cardiac Evaluation Sheffield Protocol).
This a62 years old man with DM with reversible antro-lateral defect in MYOVIEW scan so he need farther assessment by coronary angiography and control of his DM
Cardiovascular death is responsible for 50% of graft loss post-transplant. There are no specific guidelines for cardiac assessment preoperative and its center-based experience. According to Sheffield protocol patients are divided into 3 main categories:
· Mild risk: the patient is asymptomatic and his age below 50 years with no diabetes or hypertension.
· Moderate risk: the patient is asymptomatic, his age is more than 50 years, and is diabetic.
· High-risk patient: the patient is symptomatic.
This patient is 62 years old and diabetic so according to risk stratifications, he is considered moderate risk. The assessment of moderate-risk patients usually includes an MYOVIEW scan (cardiac scintigraphy) for better evaluation which detected reversible antero-lateral perfusion defect, not due to artifact. This means this patient has true ischemia and he mostly he will get benefits from percutaneous coronary angiography diagnostic and therapeutic if needed.
Male patient, 62 years old,diabetic and CKD
MYOVIEW scan reported reversible antro-lateral perfusion defect, reversible ischaemia need further assessment with coronary angiography .
There are three main options for the management of coronary artery disease: medical therapy, percutaneous coronary intervention and coronary artery bypass grafting.
Medical therapy includes antiplatelets, statins, ACEI and B-blockers.
According to his cardiac scintigraphy, he has an ischemic area in the basolateral myocardial wall which needs assessment by coronary angiography and revascularization if needed in order to have a better outcome. He should receive dual antiplatelet therapy after revascularization and his transplant should be delayed for at least 6 months. In addition, after transplantation the risk of cardiovascular mortality is increased because of the history of diabetes and its worsening after transplantation. Therefore, after transplantation he should be well controlled regarding blood sugar, blood pressure or an appropriate weight.
Myoview scan showed reversible defect which indicates ischaemia. It is important to refer him urgently to cardiologist because he might need coronary angiography for diagnosis and possible intervention and stenting. Post stenting, dual antiplatelets is needed so the operation should be postponed for at least 6 months.
Our patient is :
-62 years old
-Diabetic
-renal failure
-Ischemic findings by the cardiac scintigraphy
The MYOVIEW scan results are evident for ischemia and possible infarction , our patient needs proper cardiological assessment ;
-ECG , stress ECG
-Echo
-coronary angiography
management accordingly and anti-ischemic measures including :
-Weight management
-Dialysis optimization
-Diet control
-blood sugar optimization
-Antiplatelets
-ACEI-ARBS-Bblockers
-Statins
Among patients with ESRD and on dialytic support as well as planned for transplantation, cardiovascular events remain of a major concern as it is the leading cause of mortality in these patients. Meticulous investigations to rule out cardiac diseases and establish optimum plan of therapy if coexists is mandatory.
Such patient in this case being old age above 60 years, even diabetic, on HD confers a high risk personnel. Myoview scanning showing reversible anterolateral ischemia is probably highly suggestive IHD and CAD. Cardiology and anesthesiology consultations for further investigation as well as management is a must in this case.
Nephrological wise, this patient needs to adjust his dry weight according to his fluid status on HD sessions, low pump and blood flow during the session with more duration is advisable, careful assessment of electrolyte imbalance if occurred, examination of the vascular access to exclude the presence of infection or any hemodynamic manifestations concerning AVF, dual antiplatelet therapy, ACEI or ARBS as indicated by cardiology team would be recommended.
Special attention to anaemia and treatment with erythropoietin stimulating agents in addition to iron supplements to improve his outcome and his cardiac condition too. Perioperative period would need strict fluid balance assessment regarding fluid input particularly.
The MYOVIEW cardiac scan is a cardiac scintigraphy scan by nuclear medicine imaging….Stress Echo or Cardiac scintigraphy is indicated in all the cases of transplant recipients as recommended by American Society of Transplantation….
We commonly see in clinical scenario that most of the recipients when referred to cardiologist if they are asymptomatic and have no exertional dyspnea with ability to do > 4METS as per ACC they are not subjected to further investigations and cleared…On the other hand we have seen CAG being recommended for everyone …..Stress ECHO either treadmill or pharmacological ECHO/ Nuclear Medicine SPECT is recommended for all recipients…If the patients have cardiac symptoms or reversible defect in the myocardial perfusion scan CAG is recommended…. If there is irreversible perfusion defect then CAG or revascularization will not help….All the recipients needs is a detailed 2D echo for cardiac assessment…Sometimes the MYOVIEW scan show reversible defects when there hibernating or stunning myocardium also….
In this patient given his age, diabetes and reversible perfusion defect it is best to CAG to treat the coronary artery disease before the transplant
*This recipient is old age 60 years , DM, long time HDX so, he has high risk of CAD.
*His cardiac scintigraphy shows: Reversible perfusion defect when activity of tracer decreased during stress , regained during rest (which indicates reversible ischemia) , so coronary angiography must be done pre-transplantation.
*Patient will not benefit from coronary-angio and possible intervention, and control risk factors as obesity, DM, lipid profile ), planned to be on dual anti-platelets before renal transplantation
*If ,there is irreversible ischemia ( fixed) means previous old myocardial infarction healed with fibrosis or scarring.
High cardiavascular risk for tranplant. Optimize his heart medication mainly ACE, betablocker , antiplatelet and statin. Ensure good diabetic control. Regarding fitness to transplant is best to decide after MDT discussion with intervention cardiologist / transplant team, nephrologist, endocrinologist.
A= Correct
B= Correct
C= Correct
D= Incorrect
E= Correct
What is the significance of the MYOVIEW scan finding?
Cardiovascular complications continue to be the leading cause of mortality in the kidney transplant population, accounting for over 30% of deaths with a functioning allograft. Thus, pre-operative cardiac risk assessment is critical to optimize patient selection and outcomes. Currently there is no consensus for cardiovascular evaluation in the chronic kidney disease and ESRD population prior to kidney transplantation.
There is consensus that cardiovascular assessment is needed in high-risk patients prior to kidney transplantation. However, optimal screening protocols and frequency of testing have not been fully established. The (ACC/AHA) recommend no cardiac evaluation prior to an intermediate risk surgery such as a kidney transplant if the patient’s functional status is greater or equal to 4 metabolic equivalents without cardiac symptoms. A metabolic equivalent is the quantity of oxygen consumed while resting or sitting and is approximately 3.5 ml of oxygen per kilogram of body weight per minute .
Examples of activities equivalent to 4 metabolic equivalents include
· walking up a flight of stairs,
· walking at 4 miles per hour on level ground,
· heavy housework like scrubbing or moving furniture,
· activities like bowling or golfing.
The (ASN and AST) advocate non-invasive cardiac stress imaging, including stress echocardiography or nuclear myocardial perfusion testing for patients with diabetes, prior ischemic heart disease, or two of the following: men > 45 years, women > 55 years, ischemic disease in a first degree relative, smoking, hypertension, cholesterol > 200 mg/dL, HDL < 35 mg/dL or left ventricular hypertrophy. If the non-invasive testing is positive for ischemia, then the patient undergoes angiography for potential revascularization prior to transplantation.
Up to half of asymptomatic ESRD patients initiating renal replacement therapy with no known cardiac disease have significant coronary artery disease on angiography . The progression of coronary disease also increases with increasing dialysis vintage. In one study , new coronary artery disease was diagnosed in 59% of patients at the time of the first angiography, while 34% had no disease. Progression of coronary artery disease was found in 50% of patients at the second angiography.
What is the significance of the MYOVIEW scan finding?
This patient is 62y, male diabetic, oh hemodialysis patient , which make patient at high risk.
Appositive (reversible ) cardiac scintigrsghy means a hgih risk of perioperative complication. Therefore this patient should undergo a coronary angiography. .
REFFERENCES
De Lima J., Gowdak L., Paula F., Ramires J., and Bortolotto L. The role of myocardial scintigraphy in the assessment of cardiovascular risk in patients with end stage chronic kidney disease on the waiting list for renal transplantation. Nephrology Dialysis Transplantation, 2012; 27(7): 2979-2984.
Please choose the correct answer regarding reversible ischaemia on MPI
A. Needs a coronary angiogram – True
B. These patients need to be on dual antiplatelets – True
C. Need better control of blood sugar and blood pressure – True
D. Need stress ECHO to characterize the ischaemic area – False
E. Lose weight – True
So, this recipient will require coronary angiogram to assess the coronary stenosis status and need for further angioplasty before transplantation.
Fathala A. Myocardial perfusion scintigraphy: techniques, interpretation, indications and reporting. Ann Saudi Med. 2011 Nov-Dec;31(6):625-34. doi: 10.4103/0256-4947.87101. PMID: 22048510; PMCID: PMC3221136.
The MYOVIEW scan significance is, it tells us about the reversibility of perfusion defect indicating ischemia in any walls.
It assess myocardial perfusion at rest and during stress.
Considering the risk of cardiovascular disease is high, like male gender, >50years, DM, and CKD. considering this it reflects fixed perfusion defect and the next step should be coronary angiography, anti plateletes, and beta bladder.
correct answers are A, B, C, E.
Post solid organ transplant, both graft & patient survival are important as a transplant outcome. CVD is the most common cause of post transplant death, so pre- transplant cardiac assessment is crucial. ACC/AHA recommend no cardiac evaluation needed for intermediate risk surgery e.g. kidney transplant if patient functional status equal or>4 metabolic equivalent( O2 consumption during rest ~3.5O2l/kg/min) without cardiac symptoms. While ASN/AST guidelines recommend that non invasive cardiac testing needed as stress ECHO or scintigraphy for patients with DM, history of IHD, or 2 of the following smoking, HT, age >60yr, family history of IHD, cholesterol>200mg/dl, HDL<35, or LVH.
If non invasive cardiac testing result was positive( reversible ischemia) the patient should undergo coronary angiography for revascularization, because it was found that reversible ischemia associated with 6 fold increase the risk of MI & 4 folds increase in risk of cardiac death.
This patient need to undergo coronary angiography with instruction about well control of blood pressure & blood sugaring addition to keep BMI within normal.
References:
*This patient 62 year old CKD 5, diabetic nephropathy with reversible antro-lateral perfusion defect, MYOVIEW scan, offer from his son 1-1-1 mismatch, with no DSA.
He is at high risk for CAD with reversible ischemia, so he need perfect evaluation with MDT including cardiologist, coronary angiogram, lose weight, control the BP and DM, need to be on Dual anti platelets therapy, ACEI and B- blockers.
Diabetic patient, over 60 years old, is already classified as a high-risk patient. Cardiac scintigraphy with the finding described above is suggestive of ischemia.
The findings would already define dual anticoagulation (aspirin with antiplatelet agent) and the need for cardiac catheterization (angiography) with contrast to assess possible injuries and the need or not for additional procedures.
· the presence of reversible defects of inducible myocardial ischemia was associated with six-fold increased risk of myocardial infarction and almost four-fold risk of cardiac death( meta-analysis )
· High risk (>50 and diabetic): MPI, if showed reversible ischaemia, coronary angiogram( according to Cardiac Evaluation Sheffield Protocol)
As this patient considered in the high risk group, and has reversible ischemia, with high mortality and morbidity, MYOVIEW scan result should be taken seriously and go for coronary angiography pre-transplantation.
our recipient is a high cardiac risk patient
age > 50 , DM , on HD duration on mentioned (long duration > 1 yr ), H/O MI
Echo good
Myoview scan shows reversible perfusion defect which indicates reversible ischemia, so he needs to undergo coronary angiography as diagnostic and therapeutic if there is significant stenosis before preceded to transplantation.
if there is irreversible ischemia this means the patient had an old infarction healed with fibrosis, so the patient will not benefit from coronary angio, except to diagnose other hidden ischemia
This patient consider high risk for CVD , as he is older than 50 year , diabetic and on HD so this patient definitely needs ECG and MPI scan
Non-reversible defect (fixed) shows no significant changes in activity between post-stress or rest images.
Severe fixed defect most likely represents scarring or fibrosis from prior MI, but a mild or moderate fixed defect may indicate hibernating myocardium or prior nontransmural MI
reversible perfusion deficit (stress ischemia) when the radiotracer’s activity is reduced during the stress examination, but not during the rest examination
Patients with significant reversible stress-induced ischemia should be considered for early coronary angiography and possible intervention as they considered higher risk scan .
as MPI scan showed reversible antro-lateral perfusion defect so this patient needs coronary angiogram ( PCI or CABG ) better control of risk factors ( stop smoking , BP , lipids and sugar control ) . weight lose and encourge exercise ) before proceeding with transplantation ,
thanks
This gentleman has diabetes and his age is greater than 50 year old therefore he is an high risk patient. He will require Mioview scan. As the myoview scan shows reversible antero-lateral perfusion defect, I would request a coronaro angiogram. He will also need a cardiology review. He need dual antiplatelets also Beta blockers and ACE-inhibitor. his patient will require
Please choose the correct answer regarding reversible ischaemia on MPI
A. Needs a coronary angiogram: yes correct (as above explained)
B. These patients need to be on dual antiplatelets: yes (correct as above indicated)
C. Need better control of blood sugar and blood pressure (Yes correct
D. Need stress ECHO to characterize the ischaemic area No Incorrect (he would require ECHO only if there was a fixed defect on MPI)
E. Lose weight yes correct
What is the significance of the MYOVIEW scan finding?
This 62 years old diabetic patient with CKD stage 5 on HDx.
The MYOVIEW scan showed reversible antero-lateral perfusion defect.
MYOVIEW scan is important tool that is used assess myocardial viability and cardiac condition.
Nuclear stress myocardial perfusion imaging (MPI) is a nuclear cardiology test that shows how well blood flows to the myocardium.
This test is used to diagnose coronary heart disease and evaluate the extent of the disease where its presence is already known.
It’s also used to analyse injury to the heart following a heart attack.
By scanning the heart during exercise and at rest, it detects any reduction to the blood supply to the heart wall
This patient needs control of risk factors
And adopt healthy life style, stop smoking, weight control, adequate dialysis, control CKD-MBD,PTH ,control of diabetes and hypertension.
Referral to cardiologist because this is reversible ischemia to evaluate ghe need for coronary angiography or CABG .
The patient considers at risk for cardiovascular disease: being male > 50 years, DM, on dialysis.
MYOVIEW scan (cardiac scintigraphy) * non-invasive nuclear imaging done as part of his cardiovascular assessment reported Reversible antro-lateral perfusion defect which need coronary angiogram before proceed to transplantation.
Indications of the scan include.
1. Diagnosis of cardiac disease
2. Assessment of treatment
3. Risk stratification
4. To assess myocardial viability before PCI/CABG
In this case, I would proceed for coronary angiography given the age of the patient, the presence of co-morbidity (DM), & the fact that there is a reversible defect on Myoview scan. Reversible defect indicates the presence of viable myocardium.
PCI may indicate a significant narrowing that may be amenable to stenting or otherwise needs CABG
If the lesion was small, not amenable to revascularization, then maximum medical management with dual antiplatelet, statin and proper control of HTN and DM may be the way to go.
references Hand book of kidney transplantion
Myoview in kidney transplantation
the most common cause of death in kidney transplant recipients is cardiovascular death so, the extensive cardiac evaluation showed be done. Some patients are considered as high risk if: Patients ≥ 45 years, Diabetic patient, have any symptoms of CAD, Past history or strong family history of coronary heart disease, past history of hypertension, or History of hemodialysis for > 1 year.
There are no standard guidelines for high-risk patients’ evaluation. most the transplant centers use noninvasive function testing either stress echo or cardiac scintigraphy for screening high-risk patients and if it’s positive, the patient should be referred to an expert cardiologist for better evaluation and for possible angiography
Myoview: is a very good procedure for evaluation of myocardial perfusion, LVEF
with trusted sensitivity and specificity 81-88%,75- 85% respectfully, and regarding the evaluation of wall motion abnormality sensitivity 80-92% and specificity 68- 86%.
Perfusion defects detected by MYOVIEW are classified according to 3main categories (size, reversibility, and location).
Size: small: less than 10% of LV myocardium, medium: 10-20%, and large: greater than or equal to 20%.
Reversibility: irreversible (fixed): perfusion defect appears at rest and stress. it represents an area of fibrosis or scarring due to old MI.
reversible: perfusion defect appears after stress and disappears at rest (ischemia).
Location: related to the site of the lesion
In our case:
We have a high-risk patient whose cardiac evaluation was done with Myoview and showed reversible ischemia so, cardiology consultation by an expert cardiologist is needed, mostly he will need to do PCI for diagnosis and maybe for treatment purposes, if he needed stenting and dual antiplatelet then the operation should be postponed for 6m. his vascular tree especially his iliac blood vessels need to be evaluated carefully mostly duplex will not be enough and he needs to be evaluated by CT angiography.
Also, regarding his related donor (his son) he needs OGTT for a better evaluation risk of DM with this strong positive family history.
References:
KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020 April; 104: 4S.
Myocardial perfusion imaging is an imaging test used to show if there is adequate blood flow to the heart and if the heart is pumping well. It is important for the diagnosis and management of patients with known or suspected coronary artery disease (CAD).
Magnetic resonance myocardial perfusion imaging (stress CMR) is frequently used to assess patients with symptoms most associated with ischemia, such as breathlessness or chest pain. This technique is also used to evaluate the physiologic importance of coronary artery lesions to determine whether patients will need to be medically treated, or will need coronary artery stenting or bypass surgery. In addition, heart muscle damage caused by underlying CAD can also be discovered by using this technique.
The patient in this scenario has high risk for cardiovascular events as he old age, male , CKD on HD due to diabetic nephropathy.the Myoview scan shows reversible perfusion defect which indicate ischemia, So the next step must be referral to cardiologist in order to continue his work up by doing coronary angiography , maximize his treatment by putting him on dual anti platelets, ACEi or ARAB , statin with firm control of DM and BP.
Reference:
What Is Myocardial Perfusion Imaging?
November 2, 2021
What is the significance of the MYOVIEW scan finding?
Our pt is high cardiological risk as :
Age more than 50 , DM , ESRD on Dialysis
So needs full cardiac evaluation by cardiologist
This scan revealed reversible ischemia which may need coronary angio
Also needs dual anti platelets
Good control of blood sugar and blood pressure
Life style modifications
Stop smoking
Efficient dialysis
Normalizing ca, phosph
Control of hyperparathyroidism
What is the significance of the MYOVIEW scan finding?
This 62 year old patient with CKD 5 due to diabetic nephropathy is a high risk for cardiovascular disease.
The MYOVIEW scan has shows REVERSIBLE antero-lateral perfusion defect ( not due to artefact). Echo is satisfactory.
MYOVIEW scan is an important non invasive cardiac investigation.
Indications of the scan include.
1. Diagnosis of cardiac disease
2. Assessment of treatment
3. Risk stratification
4. To assess myocardial viability before PCI/CABG
I will adopt a multimodality approach and refer him to Cardiology team.
As this is reversible ischemia he will need coronary angiography and proceed.
He should be started on dual anti platelet therapy. He will need to modify life style.
I will make sure that hypertension and diabetes are strictly controlled.
Reference.
Golzar Y, Doukky R. Stress SPECT Myocardial Perfusion Imaging in End-Stage Renal Disease. Curr Cardiovasc Imaging Rep. 2017;10(5):13.
Yes, Dr Abdul Rahim Khan,
I like your plan for risk stratification.
Ajay
What is the significance of the MYOVIEW scan finding?
It is a valuable non-invasive screening test.
The ASN & the AST recommend myocardial perfusion imaging as part of the pre-operative evaluation; depending on results, the patient could require revascularization.
On the other hand, the ACC & the AHA recommend no preoperative cardiac evaluation if the patient has good functional status (equal to or more than 4 metabolic equivalents without cardiac symptoms); kidney transplantation poses an intermediate risk.
Examples of activities equivalent to 4 metabolic
equivalents include:
– Walking up a flight of stairs
– Walking at 4 miles/hour on level ground
– Heavy housework & activities(scrubbing, moving furniture, bowling, or golfing).
If the functional status is not 4 or more metabolic equivalents, & if a person has a H/O heart disease, HF, DM, cerebrovascular disease or renal disease, can go for operation with heart rate control, or consider noninvasive testing if the test will change management (recommendations based on a consensus of expert opinion after thorough review of current scientific evidence).
There is no consensus determining which patients require no testing, non-invasive cardiac testing or invasive interventions prior to kidney transplantation.
In this case, I would opt to proceed for coronary angiography given the age of the patient, the presence of co-morbidity (DM), & the fact that there is a reversible defect on Myoview scan. Reversible defect indicates the presence of viable myocardium.
PCI may indicate a significant narrowing that may be amenable to stenting or otherwise needs CABG.
Reference
Rowena B. Delos Santos, Aleksandra Gmurczyk, Jagdeep S. Obhrai, and Suzanne G. Watnick.Cardiac Evaluation prior to Kidney Transplantation. Semin Dial. 2010 ; 23(3): 324–329.doi:10.1111/j.1525 139X.2010.00725.x.
Thanks, Dr Mahamed,
Ajay
This patient is consider as high risk : age >50 years , DM, CKD on HD
MYOVIEW scan reported reversible antro-lateral perfusion defect, not due to artefact. + Echo is satisfactoy:Multidisciplinary team + cardiology consultation
And such patient with this findings may benifit from Coronary angiogram
Medical managment to start dualAntiplatelets and maximum control of diabetis and hypertension
Please choose the correct answer regarding reversible ischaemia on MPI
A. Needs a coronary angiogram correct
B. These patients need to be on dual antiplatelets correct
C. Need better control of blood sugar and blood pressure correct
D. Need stress ECHO to characterize the ischaemic area No
E. Lose weight correct
Thanks, Dr Mahamed, I agree with your answers.
Ajay
This 62 yrs old, male, diabetic patient who has a Myoview scan which reported antrolatetal perfusion defect (this finding goes with significant ischemia). So, this pt has a high cardiovascular risk
Study reported that, post-transplant survival of high-CV risk patients (with known CAD) is lower than that of low-risk recipients but remains acceptable. Cardiac interventions may reduce perioperative risk but do not reduce the probability of post-transplant cardiac events to that of low-risk group [1].
From the above finding, this patient need a cardiologist consultation and good evaluation.
strict control of his blood sugar, blood pressure and lipid profile is needed.
Control of his lifestyle and his weight is essential. He must stop smoking if he is smoker.
Statins, antiplatelets (dual antiplatelet), ACE Inhibitor and B- blockers is needed.
_________________________
Ref:
[1] Tarun K Jeloka et al.
Renal transplant outcome in high-cardiovascular risk recipients. Clin Transplant. 2007 Sep-Oct.
Many thanks Dr Tahni
MYOVIEW scan (cardiac scintigraphy) has been one of the most important and common non-invasive diagnostic cardiac test
The major indications for MYOVIEW scan (cardiac scintigraphy) are diagnosis of coronary artery disease (CAD), risk stratification in patients with known CAD, assessment of therapy and intervention and myocardial viability before percutaneous intervention or bypass surgery.
The excellent accuracy in detection of coronary artery disease (CAD) in patients with undiagnosed chest pain and no known CAD The sensitivity was 87% with specificity somewhat lower than 73%.
Non-reversible defect (fixed) shows no significant changes in activity between post-stress or rest images.
Severe fixed defect most likely represents scarring or fibrosis from prior MI, but a mild or moderate fixed defect may indicate hibernating myocardium or prior nontransmural MI
reversible perfusion deficit (stress ischemia) when the radiotracer’s activity is reduced during the stress examination, but not during the rest examination
Patients with significant reversible stress-induced ischemia should be considered for early coronary angiography and possible intervention as they considered higher risk scan .
As our patient is > 50 y/o diabetic ESRD on HD so considered high risk for cardiovascular diseases and need to be fully assessed before transplantation and give data of MYOVIEW scan (cardiac scintigraphy) reported reversible antro-lateral perfusion defect, not due to artefact. Echocardiogram is satisfactory so he needs to be evaluated with cardiologist and vascular surgeon.
And as we say above Patients with significant reversible stress-induced ischemia should be considered for early coronary angiography and possible intervention
Beside medical treatment with dual with dual antiplatelet, statins
Strict control for BP and glycemic control
Look for life style modification and obesity
Encourage smoking sensation
work up for PAD and iliac vessels
Reference
Myocardial Perfusion Scintigraphy: Techniques, Interpretation, Indications and Reporting
Ahmed Fathala, MD
Dear Dr Huda,
I like scientific contents. I would , however, suggest that you should use headings and subheadings (either in bold or underlined) to make it easier everyone to read.
Inshalla
thank you for your kind advice
MYOVIEW scan (cardiac scintigraphy) is important in diagnosis of cardiovascular disease, estimating prognosis, risk stratification in CAD cases , evaluating the usefulness of therapy, and myocardial viability before percutaneous intervention or bypass surgery.
The reversibility degree of a perfusion defect as in the current case reporting reversible antro-lateral perfusion defect, not due to artefact can be noticed on post-stress images as an area of reduced radiopharmaceutical activity that improves on rest or redistribution images.
Transient ischemic dilatation from rest to stress due to subendocardial hypoperfusion at stress leads to an apparent increase in LV cavity at stress, categorizing it as with high-risk scan, necessitating referral for early coronary angiography and cardiologist assessment for possible intervention.
Reference
Fathala A. Myocardial perfusion scintigraphy: techniques, interpretation, indications and reporting. Ann Saudi Med. 2011 Nov-Dec;31(6):625-34.
Hi Dr Doaa,
I wish you could write a list recommendations for managing this situation.
MYOVIEW scan shows reversible antro-lateral perfusion defect. So, it demands coronary angiogram followed by necessary steps like PTCA or CABG. Then proceed towards renal transplantation.
What else?
Will you do something else?
Here Myoview scan showed, reversible ischaemia. He needs further evaluation like coronary angiogram and revascularization if required.
By this test we can understand that, whether it is reversible or irreversible ischaemia.
What else?
Will you do something else?
Cardiac scintigraphy is an effective tool when exploring cardiovascular pathologies. It plays a role in the diagnosis of cardiovascular diseases, establishing prognosis, assessing the effectiveness of therapy and evaluate the myocardial viability. The radiopharmaceuticals that s normally used are 201TI-chloride, 99mTc-tetrafosmin and 99mTc- sestamibi. Once the test has been performed, it gives the quality of the image and based on the defect size may be quantify as small, medium or large. Small defects are about 10%, medium 10-20% and large defect is greater than 20%. The degree of reversibility of the perfusion defect is identified on post stress images as an area of decrease radiopharmaceutical activity that improves or disappear on rest. Images that is not reversible has no significant changes in activity between post stress and rest images. When there is severe defect, it likely represents scarring or fibrosis from prior myocardial infarction. It is to be noted that mild to moderate fixed defect may indicate hibernating MI or prior no transmural MI. There is also a possibility of reverse redistribution after MI especially after revascularization or thrombolytic therapy.
Knowing the above, we can see the patient has risk factors and they are”
1) Age
2) Male gender
3) Diabetic
4) On HD
Due to the report made from the scan, it shows reversibility and as such the patient must be further studied. The patient must be seen by a cardiologist, to evaluate and ask for studies like ECHO, angiography and evaluate for possible stent placement.
Medications must commence that the patient may benefit like the ACEI and ARBs. Antiplatelet are also needed. The patient must be monitored to see the progression.
References:
Fathala, A., REVIEW (2011), Myocardial perfusion Scintigraphy: Techniques, Interpretation, Indications and reporting. 2011; 31(6): 625-634.
Hi Dr Marius Badal,
You have suggested, ‘Antiplatelet are also needed”. How many and for how long if and when planning transplant operation?
Stress-induced perfusion abnormalities in regions that exhibit normal perfusion at rest are termed reversible perfusion defects, and such regions represent viable, ischemic tissue with blunted coronary blood flow reserve.
When both viable myocardium and scarred myocardium are present, the defect may be characterized as mild-moderate fixed, which connotes non-transmural infarction, and can also be seen after percutaneous coronary intervention in the setting of acute coronary syndrome. However, if the viable component of the admixture of viable and scarred myocardium is reversible (stress-induced ischemia), then the defect will appear partially reversible (a region of non-transmural infarction sub-served by significantly narrowed coronary artery).
This patient will require cardiology evaluation including coronary angiography.
1. Dilsizian V. Interpretation and clinical management of patients with “Fixed” myocardial perfusion defects. Journal of Nuclear Cardiology. 2021 Apr;28(2):723-8.
2. Fathala A. Myocardial perfusion scintigraphy: techniques, interpretation, indications and reporting. Ann Saudi Med. 2011 Nov-Dec;31(6):625-34. doi: 10.4103/0256-4947.87101. PMID: 22048510; PMCID: PMC3221136.
What else?
Will you do something else?
Yes as you mentioned he will need to be on dual antiplatlets therapy, thanks
This finding of MAYOVIEW indicates the presence of cardiac ischemia, therefore;
– the patient needs coronary angiography for more evaluation
– Based on the result of angiography, he may need angioplasty with a stent or surgical intervention and all of that should be done in MDT including an expert cardiologist
– he needs good control of his blood sugar
– if he will go for surgery; CABG, so the transplant surgery will be a little bit delayed; 1 month or more as per the cardiologist’s evaluation
– if stenting, we need to evaluate the possibility of transplant surgery with the dual anti-platelet and the time of stopping one of them and restarting by a cardiologist
Hi Dr Farag,
When would you stop anti-platelets as you plan a transplant?
Ajay
The significance of MYOVIEW scan finding in this case scenario:
Reversible anterolateral perfusion defect after exclusion of artefact, represents viable, ischemic tissue with blunted coronary blood flow reserve. Coronary blood flow compromise in the setting of reversible ischemic defect is mostly related to narrowing or partial blockage of the coronaries.
This patient will benefit from revascularization therapy(PCI). Referral to cardiologist is crucial, for accurate and early on intervention to save the viable myocardium.
What else?
Will you do something else?
Significance of myoview scan revealed reversible anterior lateral defect means ischemia. So patient need evaluation by cardiologist regarding coronary angiogram, since patient is high risk of myocardial infraction during surgery because is diabetic with complications and old age more than 60 years.
This patient need good evaluation for control blood pressure and sugar and lipid profile and maintain his weight.
Dul anti platelets therapy and ACEI with B- blocker’s
Yes, well done. We should not forget aspirin and statin (dual antiplatelets)
-patient is considered high risk for cardiovascular discases:-
* age more than so.
* male gender.
* diabetic
*haemodialysis.
-the result of MYOVIEW showed reversible antero-lateral perfusion defect which means ischemia , this need to:-
* MDT with cardiologist for patient assessment.
* coronary angiography prior to transplantation.
* to be continued his cardiac medication, dual antic platelet therapy, ACEI or ARBS and statins.
* tight control of blood pressure, blood sugar and lipid profiles.
I agree, Dr Amal Anan.
With the advance and depending on the degree of control of diabetes, most patients are considered CAD patients clinically. In our scenario, the microvascular complications already exist; here, we have nephropathy that led to ESKD. as the patient is over 50 and has uncontrolled diabetes, we need MYOVIEW. we could be satisfied if the scintigraphy had been with irreversible findings because MI already happened. Still, a reversible defect means that this patient is at very high risk in terms of MI during or post-operation. So we need CAG (coronary angiogram), which may be therapeutic at this stage. LAD may need revascularization, after which the patient’s life is expected to be safer. Contrast nephropathy is considered very high risk in this patient due to advanced CKD on top of DM.
Dear Dr Mahmud Islam,
I like scientific contents of your short write-up.
However, please start a new sentence with a capital letter in first word.
Ajay
MYOVIEW;cardiac scintigraphy,(high risk considering age and having DM)revealed reversible antero lateral perfusion defect suggesting acute ischemia. Patient is in need for pretransplantation coronary angiography with stenting if needed,even with normal findings of ECHO based on reversibility nature of the lesion.Optimal medical management is required including dual antiplatelets, statin,b-blocker &ACEI.
Hi Dr Omran,
Rather than stating ‘stenting’ after coronary angiography, I would say coronary vascularization (percutaneous or surgical) after discussions in MDT with a cardiologist with a special interest in renal cases.
Ajay
OK…thanks