5. 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 antro-lateral fixed perfusion defect with no reversibility. Echocardiogram is satisfactory.
- What is the significance of the MYOVIEW scan finding?
- Would you proceed for transplantation provided all other investigations are satisfactory?
Chose the correct answer(s) regarding coronary angiogram
A. Indicated for any potential recipients
B. Indicated for all diabetics regardless of the duration of DM, the type (1 or 2) and the age.
C. Indicated for all those who have symptoms of IHD
D. Indicated for all who have a fixed perfusion defect on MPI
E. Indicated for all who have wall motion abnormalities on stress ECHO
Please justify your answer
Chose the correct answer(s) regarding coronary angiogram
A. Indicated for any potential recipients-> NO,
B. Indicated for all diabetics regardless of the duration of DM, the type (1 or 2) and the age-> NO, not in all in type 2 diabetes macrovascular complications may be at the time of diagnosis or later, but in type 1 it needs 10 years to experience .
C. Indicated for all those who have symptoms of IHD -> Yes
D. Indicated for all who have a fixed perfusion defect on MPI- > NO, it is indicated if they have reversible defect.
E. Indicated for all who have wall motion abnormalities on stress ECHO-> NO as it has low sensitivity and specificity detects event epicardial disease and the patient needs to be well dialysed (reaching dry wt), if he is symptomatic will go MPI if reversible defect for angio.
correct answers:
B ,C .and E.
As by KDIGO guideline all diabetes patient should have angiogram.
Fixed perfusion defect mean old infarction ,no benefit with intervention reverse of wall
motion abnormality which amenable to both stenting or CABG.
C is the main indication for this study. Not indicated for every patient or diabetic because will be not cost effective, hazard of contrast and complications, no much gain. Also not indicated in cases of fixed perfusion defect as we already knew that there is infarct and it will not change the management. Wall motion abnormalities may be seen in fixed perfusion defect
C only correct
Chose the correct answer(s) regarding coronary angiogram
A. Indicated for any potential recipients: Not indicated in all donors
B. Indicated for all diabetics regardless of the duration of DM, the type (1 or 2) and the age. (Not indicated in all diabetic patients; depends on the H&E and the result of
noninvasive testing.
C. Indicated for all those who have symptoms of IHD True.
D. Indicated for all who have a fixed perfusion defect on MPI. With a fixed defect it is already late, the defect will not be corrected.
E. Indicated for all who have wall motion abnormalities on stress ECHO. Not in All cases depend on the severity.
Answer: C
c is the correct answer
answer C
Stress echocardiography is a powerful prognostic tool in chronic coronary disease, after myocardial infarction, . It is an accurate test for prediction of functional recovery of dyssynergic zones after revascularisation,
The only mainstream marker of ischaemia is abnormal wall motion, and the need to induce ischaemia in the metabolic sense limits the accuracy of stress echocardiography in detecting coronary artery disease in patients who exercise submaximally or who are on antianginal treatment.
refernce
Marwick TH. Stress echocardiography. Heart. 2003 Jan;89(1):113-8
C E
ICA is not indicated for any potential recipients.
Patient with ( DM + More then fourty ) should undergo MPI . Then if MPI refer to reversible ischemia, patient should perform ICA.
Fixed perfusion indicates MI in the past and here there is no role of ICA
Thank you for the excellent answer
Thank you for answering this question. The correct answer is C and E
Definitely, when symptomatic, a coronary angiogram is indicated. Wall motion abnormality on stress ECHO also indicates reversible ischaemia, exactly like reversible ischaemia on MPI. This also should warrant a coronary angiogram.
A- No
B-No
C-yes
d-No
E-yes
C,e
The answer: C and E
coronary angiography is
not indicated in all potential KTRs nor diabetic below the age 50 y unless there are symptoms of IHD. Although fixed and irreversible perfusion defect is indicative
of MI, it’s mostly related to scarring and fibrosis as a sequalae of old MI and reperfusion therapy in this regard may harm rather offering a benefit. In the case of mild and moderate fixed perfusion defect, it may represent a hibernating and viable myocardium which may likely benefit form coronary angiography
and revascularization therapy.
C and E
C and D
A- NO
B- NO
C- YES
D- NO
E- YES
correct answer Band C
C and E
Stress echocardiography detects myocardial ischemia with good sensitivity (+-80%), helping to define a more specific examination. She is not able to quantitatively assess blood flow.
If symptoms are present at rest or after stress echocardiography, there is a need for more specific tests for cardiac assessment due to the high risk.
B, C, E are the correct answers because fixed perfusion defects cant be further managed with angiogram and if ECG, ECHO is normal and there is no history chronic illness like hypertension, obesity, hyperlipidemia then there is no role of angiogram in all potential recipients.
Sir diabetes is a hypercoagulable state and in most cases is associated as a part of metabolic syndrome which increases the risk of atherosclerosis and MI. So can B option be also considered
C and E
C & E are correct answers.
MPI is aged diagnostic tool in detecting adverse CV outcome in patients with known or suspected CVD. Presence of reversible defect on MPI associated with 3 fold increased risk of post transplant cardiac events & 2 world increase in death when compared to normal result of MPI.
It was found that the incidence of cardiac ischemia was low in high risk renal transplant recipients when assessed by non invasive cardiac stress test (normal test or fixed defect).
Fixed perfusion defect can be due to artifact or an old myocardial infarction especially in absence of wall motion abnormality on ECHO. If wall motion abnormality found or there was no history of previous infarction, further test needed to confer myocardial viability as FDG-PET viable image.
The patient in above scenario had fixed defect with satisfactory ECHO, therefor no need for another investigation & can precede to transplantation.
References:
C,E
C and E
C and E
Indicated for all those who have symptoms of IHD true
It is not indicated in all recipient, or all diabetic patients as vascular complications are related to long duration.
Indicated for patients with reversible perfusion defect not fixed
And not in all wall motion abnormalities
Assalamu Alaikum Sir
Correct answer is C
ICA is not indicated for any potential recipients.
Patient with ( DM + More then fourty ) should undergo MPI . Then if MPI refer to reversible ischemia, patient should perform ICA.
Fixed perfusion indicates MI in the past and here there is no role of ICA
answer C.
According to Cardiac Evaluation Sheffield Protocol
• Very high risk (symptomatic): Coronary angiogram
Professor Halawa
C & E
*C &E because; CA is indicated in all recipients with symptoms of IHD and for recipient with reversible perfusion defect not in fixed perfusion.
Chose the correct answer(s) regarding coronary angiogram
A. Indicated for any potential recipients –> Not required
B. Indicated for all diabetics regardless of the duration of DM, the type (1 or 2) and the age.–> not always required
C. Indicated for all those who have symptoms of IHD –> Required
D. Indicated for all who have a fixed perfusion defect on MPI –> Not required
E. Indicated for all who have wall motion abnormalities on stress ECHO –> Required
This recipient can proceed for transplantation provided all other investigations are satisfactory
Kotta PA, Elango M, Papalois V. Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review. J Clin Med. 2021 Jun 7;10(11):2525. doi: 10.3390/jcm10112525. PMID: 34200235; PMCID: PMC8201125.
Those with potential benefit from CAG need angiography (symptomatic patients and those with stress testing showing reversible ischemia
Dear Professor,
C&E are the correct answers
Chose the correct answer(s) regrading reversible ischaemia on MPI
A. We need to do a coronary angiogram only
B. We need to do an ECHO only
C. We need to do both, a coronary angiogram and ECHO?
D. It indicates MI in the past
E. It may indicates correctable coronary artery disease
A E
A, E
C and E
A and E
C&E
A &E
We need to do both coronary angiograms and echocardiography to assess the EF% and cardiomyopathy after achieving dry BWT
reversible ischemia in MPI may indicate correctable CAD ( PCI,vs BYPASS Surgery)
the correct answers
C &E
c&e
B, D
D
A&E
C and E
A. We need to do a coronary angiogram only: False
B. We need to do an ECHO only: False
C. We need to do both, a coronary angiogram and ECHO?: True
D. It indicates MI in the past: False
E. It may indicates correctable coronary artery disease: True
C and E
Well done
Thank you to everybody who answered this question. The right answer is C and E
For the following reasons:
It is reversible ischemia; therefore, requires a coronary angiogram for potential treatment, which could be Percutaneous angioplasty of bypass graft. ECHO is an essential investigation to evaluate the myocardium.
thank you Prof. but it is mentioned clearly that is fixed defect and irreversible in the question stem !!
antro-lateral fixed perfusion defect with no reversibility!!
Dear Ahmed,
I got confused, about which case we are talking about? Assignment 1, there is nothing about cardiology assessment and in this case, the patient has fixed defect.
C and E
answer C and E.
E is the answer
A&E
A and E
C,E
C and E
C and E
C and E
For reversible ischemia, we need CAG as a diagnostic and treatment tool. D is consistent with non-reversible ischemia. eCHO is necessary to evaluate the ejection fraction
This scenario is related to assignment 1. More focus on cardiac assessment. Please chose the correct answer(s)
A. We need to do a coronary angiogram
B. We need to do an ECHO?
C. We need to do both, a coronary angiogram and ECHO
D. It indicates MI in the past
E. It indicates reversible ischaemia
B and D
Answers are (B&D).
B and D
D
B and D
B and D
B,D
b and d
b and d
B & D
C
sorry, C and D
D
B (BUT ECHO WAS ALREADY DONE)
B,d
B, D
The answer is B and D
the correct answer is D it indicate previous MI , echo already done
B&D
A. We need to do a coronary angiogram: False
B. We need to do an ECHO?: True
C. We need to do both, a coronary angiogram and ECHO: False
D. It indicates MI in the past: True
E. It indicates reversible ischaemia: False
Non-reversibility implies infarcted area in the myocardium
B and D
Answer D ,Indicate old MI
B&D
D
B and D
B and D
Band D true
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.
Yes, because only situations in which revascularization surgery are indicated absolutely contraindicate kidney transplantation. The patient’s persistence in HD can bring more risks for her from the cardiovascular point of view than the transplant.
Donor has high CVS risk as per his myoview
A fixed perfusion defect mean an already damaged myocardium, no benefit from re-vascularization .
I think we can proceed to transplantation if other long term complications of diabetes are assessed
High risk patient :
62 years old
DM
CKD 5 on Hemodialysis
MYOVIEW scan (cardiac scintigraphy) reported antro-lateral fixed perfusion defect with no reversibility >> indicate old MI with no reversibility so no indication for coronary angiography
So I will proceed after cardiology consultation with high risk for CVD
ICU admission post operation
Close follow-up of cardiac condition
Cautious fluid replacement after KTx
What is the significance of the MYOVIEW scan finding?
MYOVIEW scan is consistent with old Myocardial Infarction with no need for coronary angiography.
.
Would you proceed for transplantation provided all other investigations are satisfactory?
This is a high risk patient above the age of 50 years , uncontrolled diabetes and old Myocardial Infarction detected by MYOVIEW , so this patient needs cardiology assessment, ECHO , and if all other investigations are normal and satisfactory, we shall proceed with transplantation.
MYOVIEW scan suggestive of an old MI in view of perfusion defect with no reversibility
Considering no DSA, negative CDC and FCXM,i will proceed for transplant in this case
Myocardial scintigraphy (MS) is a cornerstone in the evaluation of patients with suspected CAD due to its high diagnostic accuracy, as well as being able to define the extent, severity and location of myocardial perfusion abnormalities, greatly assisting in clinical management . Currently, there is strong evidence for using MS in the diagnosis, follow-up, risk stratification and prognosis of symptomatic patients with known or suspected CAD. However, MS indication in asymptomatic patients or patients with atypical symptoms, even with known CAD, is yet to be defined, since in addition to the fact that benefits in this population are not fully established, the examination involves the inherent risks of physical or pharmacological stress, as well as exposure to ionizing radiation. MS was considered normal if the radiotracer concentration was homogeneous in both phases (basal and stress); suggestive of ischemia, if the low uptake was reversible after stress; suggestive of fibrosis, if the low uptake was fixed after the stress phase in relation to baseline; and suggestive of ischemia and fibrosis, if there was fixed and reversible low uptake of the radiotracer in one or more myocardial segments at the baseline and stress phases(2).
True myocardial perfusion defect should be described with reference to (1) the defect size or extent (small, medium and large), (2) severity of perfusion defect (mild, moderate and severe), (3) extent of reversibility (reversible, irreversible or reverse redistribution) and (4) location (based on 17 segment model and coronary artery territory if possible). Initial interpretation is usually visual (quantitative) analysis followed by semiquantitative and quantitative analysis. Both rest and stress images must be evaluated carefully for any recognized artifacts before visual interpretation. In normal myocardial perfusion study, there is homogenous radiotracer distribution in both stress and rest images . There is, however, slightly diminished activity in the apex accounted for by physiological apical thinning, which is usually localized to the apex and does not extend to the anterior wall. Normal thinning of the basal membranous septum and basal inferior wall causes perfusion defect in the corresponding segments. Focal increase activity in and at insertion of papillary muscle (about 2 and 6 o’clock positions) may give a false impression of a defect adjacent to or between them; reviewing these in long-axis images will demonstrate homogenous normal distribution in these region. The degree of reversibility of a perfusion defect is identified on post-stress images as an area of decreased radiopharmaceutical activity that improves or disappears on rest or redistribution images. 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. Reverse redistribution has been reported after myocardial infarction especially after revascularization or thrombolytic therapy. Some postulate that a regional hyperemic response to exercise may mask hypoperfusion in this region. Location of the perfusion defect can be characterized as they are located to specific myocardial wall’s segment based on 17-segment model. Standardization of segment nomenclature is highly recommended(1)
This donor has high risk of CVS events. In one study, the group with normal myocardial scintigraphy showed longer period of time free of major cardiac events, non-fatal myocardial infarction and death. Fibrosis in the myocardial scintigraphy determined a 2.4-fold increased risk of non-fatal myocardial infarction and five-fold higher risk of death (2). So. I would not proceed with this donor.
Ref:
1- 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.
2- Smanio PE, Silva JH, Holtz JV, Ueda L, Abreu M, Marques C, Machado L. Myocardial scintigraphy in the evaluation of cardiac events in patients without typical symptoms. Arq Bras Cardiol. 2015 Aug;105(2):112-22. doi: 10.5935/abc.20150074. Epub 2015 Jul 3. PMID: 26176186; PMCID: PMC4559119.
Question 1
MYOVIEW scan reported antro-lateral fixed perfusion with no reversibility, which is consistent with old MI, no need for coronary angiography.
Question 2
Yes, I will proceed for transplantation, acceptable mismatch, no DSA.
The cardiac finding of the patient is not contraindicated for transplantation.
Cardiac assessment in kidney transplant recipients is based on each center’s experience and there are no standard guidelines although 50% of graft loss is caused by cardiac death with a functioning graft. according to shieffled protocol, they divided patients into 3 main categories according to symptoms, age, and risk factors like diabetes and smoking. the high-risk patient needs to be assessed by MYOVIEW scan which may show a fixed perfusion defect which means old MI and the patient will not gain benefits from coronary angiography or reversible defect related to ischemia and will respond to intervention.
fixed perfusion means old MI and as long as the ECHO heart is satisfactory and after cardiology clearance yes, I will proceed with transplantation
References:
Kotta PA, Elango M, Papalois V. Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review. J Clin Med. 2021 Jun 7;10(11):2525.
as it shows a fixed perfusion defect with no reversibility, it indicates an old MI.
no need for coronary angiography, he needs Echo to assess the function (EF)
Yes, will proceed. taking in consideration other risk factors with counselling the patient about risk factors modification
What is the significance of the MYOVIEW scan finding?
Fixed perfusion defect points to old myocardial infarction.
Would you proceed for transplantation provided all other investigations are satisfactory?
I will proceed for transplantation
What is the significance of the MYOVIEW scan finding?
Scintigraphy revealed a fixed perfusion defect that indicates an old MI. Therefore, no revascularization is required but only a an ECHO to assess the EF and RWMA
Would you proceed for transplantation provided all other investigations are satisfactory?
Yes, I will proceed for transplantation after adjustment of the modifiable risk factors including DM, smoking, obesity and hyperlipidemia. The history of CVD will put this patient at high-risk.
MDT approach with the cardiologist is crucial in such case.
coronary angiogram
C-Indicated for all those who have symptoms of IHD
E-Indicated for all who have wall motion abnormalities on stress ECHO
References
1-Renal transplant recipient Evaluation. Lecture by Prof Ahmad Halawa
· Q1: This scan showed a myocardial infarction. Therefore, there is no place for angiography.
· Q2: this patient had a myocardial infarction but echocardiogram is satisfactory. Thus, I will proceed for TX.
MYOVIEW indicate fix defect which a result of old ischemia
I will proceed for transplant after coronary angiogram putting in mind the patient age more than 60 years with diabetes
The significance of MYOVIEW revealing anterolateral fixed perfusion defect without reversibility ,indicates the existence of previous old MI ,the patient already has tendency for IHD (age exceeding 50 years, haemodialysis ,DM accelerates cardiac events and atherosclerotic events as well).
Provided all the investigations are satisfactory, cardiological consultation approval to proceed with minimal to moderate risk, proper selection of therapy for IHD,
Postoperatively, tight glycemic control is mandatory, lifestyle modification, diet control, avoid obesity are important in the future plan and follow up.
Fluids post operatively should be guided by the clinical volume status to avoid serious cardiac events and electrolyte balance as well as replacement when required.
Pre operatively, adjusting the dry weight is a must, correction of anaemia if existed, careful dialytic support regarding the pump and blood flow.
Vascular access examination and close frequent clinical assessment should be carried out regularly to avoid infective endocarditis and hemodynamic instability.
regarding dr Halawa’s question C&D are correct.
The cardiac scintigraphy scan has a good sensitivity and moderate specificity for identifying coronary ischemia (Stress echo has better specificity). Nevertheless they give a good idea of the severity of the lesion and guide in planning the revascularization procedures….Mild to moderate reversible defect need not mean coronary atherosclerosis but also can be seen in hibernating myocardium also….A fixed reversible lesion in cardiac scintigraphy is an indication of CAG to identify and reverse the lesion….But a Fixed irreversible defect on Cardiac scintigraphy represents a area of fibrosis and will not be repaired by revascularization as in this patient….We need to assess the LV function and improve it by optimal medical management….The patient needs adequate dialysis and ultrafiltration…Anemia correction is warranted to optimize the LV function…The 2D echo should also be performed after the patient has achieved the dry weight on dialysis as false positive on the 2D echo can be seen due to the pre load and the after load effects….
I would proceed with the transplant in this patient as he has a suitable donor with good HLA match and no DSA…He needs antiplatelets and Statins after the transplant to optimize the IHD management…
▪︎What is the significance of the MYOVIEW scan finding?
In this scenario MYOVIEW scan* of the recipient revealed antero-lateral perfusion defect with no reversibility. This means that there an old infarct in the myocardium.
The MYOVIEW * 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.
▪︎Would you proceed for transplantation provided all other investigations are satisfactory?
Yes, I will proceed after consulting a cardiologist. But this patient need proper consultation about his risk (he is diabetic with an old IHD).
Management plan:
– Diet control
– Control of DM & dyslipidemia.
– Stop smokingif he is smoker.
chose the correct answer(s) regarding coronary angiogram
A. Indicated for any potential recipients >> NO
B. Indicated for all diabetics regardless of the duration of DM, the type (1 or 2) and the age. >> YES
C. Indicated for all those who have symptoms of IHD>> YES
D. Indicated for all who have a fixed perfusion defect on MPI >> NO
E. Indicated for all who have wall motion abnormalities on stress ECHO >> YES
1) Not reversible myoview scan indicated old infaction. PCI may not indicated.
2) Yes after optimizing diabetic and blood pressure control with medication.
C, E correct
Chose the correct answer(s) regarding coronary angiogram
A. Indicated for any potential recipients –> Not required
B. Indicated for all diabetics regardless of the duration of DM, the type (1 or 2) and the age.–> not always required
C. Indicated for all those who have symptoms of IHD –> Required
D. Indicated for all who have a fixed perfusion defect on MPI –> Not required
E. Indicated for all who have wall motion abnormalities on stress ECHO –> Required
This recipient can proceed for transplantation provided all other investigations are satisfactory
Kotta PA, Elango M, Papalois V. Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review. J Clin Med. 2021 Jun 7;10(11):2525. doi: 10.3390/jcm10112525. PMID: 34200235; PMCID: PMC8201125.
· The patient considers at risk for cardiovascular disease: being male > 50 years, DM, on dialysis *although not clear for how long.
· MYOVIEW scan (cardiac scintigraphy) * non-invasive nuclear imaging done as part of his cardiovascular assessment reported Fixed defect no reversiblility antro-lateral indicate myocardial scarring or chronic hypo perfusion ischemia not requiring coronary angio before transplantation
· the patient is high risk cardiac need extensive cardiac assessment and follow up even during and post-surgery.
· MDT approach with the cardiologist is crucial in such case
*The significance of the MYOVIEW scan finding: It showed fixed perfusion defect which means old MI , No revascularization will be needed.
*He has risk factors for CVD: old male have DM and ESRD.
Echo: must be done to evaluate EF% ,wall motion abnormalities, valvular diseases.
* Yes, I will proceed for transplantation if the patients cardiac condition is stabilized now but to take into consideration that he considered high risk patient with IHD with managing of risk factors : DM, stop smoking , diet control , dyslipidemia management.
Answer
a. no
b. no
c. yes
d. no
e. yes
The MYOVIEW scan used for detection of perfusion defect.
Second question there is high risk of worsening of heart failure and cardiac associated death post transplantation. so he should have a ECHO if any wall motion abnormality should be corrected accordingly, if low EF% then should proceed with angiogram and correction if possible to prevent ICMP, but I will proceed for transplantation but keeping the risk in mind.
References:
Kotta PA, Elango M, Papalois V. Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review. J Clin Med. 2021 Jun 7;10(11):2525.
What is the significance of the MYOVIEW scan finding?
As long as he is asymptomatic with normal Echo I will not go for further cardiac evaluation.
· In High risk (>50 and diabetic): MPI, if showed reversible ischaemia, coronary angiogram is indicated. If irreversible ischaemia (fixed perfusion defect), just ECHO
· The presence of fixed defects associated with five-fold increased risk of cardiac death
· Advanced kidney disease may impair diagnostic accuracy, as Left ventricular hypertrophy and a large left ventricular cavity may increase attenuation defects in the inferior wall
· Endothelial dysfunction in the absence of CAD (common in diabetic patients with ESRD), could decrease the specificity of MPI.
Would you proceed for transplantation provided all other investigations are satisfactory?
Yes. But I will manage him as high risk patient with IHD with aspirin, statin, and beta blocker.
A myoview scan show a fixed perfusion defect. This indicate an old lesion (e.g. fibrosis followin an MI). Therefore he does not need a coronaro angiogram. Only if there was a reversible ischaemia than coronaro angiogram is required. Myocardial perfusion scan compared to stress echo have the same sensitivities to detect coronary artery disease. However, stress echo has higher specificity compared to Myocardial perfusion scan. ECHO is useful to assess EF, wall motion abnormalities, valvular disease etc.
Even if the ECHO is satisfactory he is an high risk patient in view of his age, diabetes and on hemodialysis. This patient will need an MDT with cardiology involvement in view of his high cardiovascular risk also considering that a fixed perfusion defect is associated with increase risk of cardiac death.
MYOVIEW scan showed fixed perfusion defect which means old myocardial infarction,so he needs no revascularization
He has many risk factors for CVD,
Male ,old age ,diabetes, ESRD
Echocardiogram must be done to evaluate EF% ,as there old scare in the anterolateral part of the heart so he is high risk patient.
I would proceed with the transplant if the patients cardiac condition now is stable after full cardiac evaluation.
fixed perfusion defect indicates old MI, needs only echocardiography to assess cardiac status.
Yes, I will proceed keeping in mind the history of CVD will put this patient at high-risk group, good control of risk factors is needed as DM, hyperlipidemia, smoking, and obesity.
MYOVIEW scan showed fixed perfusion defect which means old myocardial infarction,so he needs no revascularization
He has many risk factors for CVD,
Male ,old age ,diabetes, ESRD
Echocardiogram must be done to evaluate EF% ,as there old scare in the anterolateral part of the heart so he is high risk patient.
I would proceed with the transplant if the patients cardiac condition now is stable after full cardiac evaluation.
Myoview significance:
It indicates old MI
So, to proceed for transplantation: no symptoms, other investigations are satisfactory with MDT approach including cardiology care.
Reference:
Evaluation of the cardiovascular prior to transplantation; Course lectures.
# What is the significance of the MYOVIEW scan finding?
The main problems are:
Old age, CKD on HD, DM, MYOVIEW scan showed antro-lateral fixed perfusion defect with no reversibility.
The antro-lateral fixed perfusion defect with no reversibility mean permanent perfusion defect due to old scar which indicated previous myocardial infarction.
# Would you proceed for transplantation provided all other investigations are satisfactory?
Yes, I will proceed for transplantation as there is no symptoms of IHD and the Echocardiogram and other investigation are satisfactory, also we need to involve the cardiologist , with regular follow up of the patient after transplantation.
C& E are correct
Those with reversible ischemia should have ICA.
No role of ICA in irreversible defect.
Myocardial scan shows a fixed defect possibly due to old infarct and Echo does not show any other wall motion abnormality. So I am in favor to proceed if no other complications out there.
C and E
Myocardial scan shows a fixed defect representing an old infarct. As Echo does not show any other wall motion abnormality I think it’s safe to proceed if otherwise no contraindication
A 62-year-old male, with stage 5 CKD, and history of DM nephropathy, received a kidney with 111 mismatches and no DSA. The cardiac study showed that patient has an anterolateral fixed perfusion defect with no reversibility.
Risk factors:
1) Age more than 45 years
2) DM patients
3) History of cardiovascular disease and or HTN
4) On HD for more than 1 year
5) Family of heart disease.
MYOVIEW is show that the patient has old myocardial disease/scarring possibly due to a history of myocardial infarction. This condition must be re-evaluated with an echocardiogram for a motion to see the viability of the muscles of the heart. An anterior-lateral defect will place the patient at high risk for having CVD, and as such further studies need to be conducted.
If further investigation is performed and there is adequate cardiac function, especially in the anterolateral part of the heart, then I would proceed with the transplant. I think the patient should do an ECHO and possibly an angiogram of the vessels of the heart. The patient has to be reviewed my the cardiologist for proper evaluation.
We can proceed for transplantation in this recipient with multidisciplinary team both cardiology and nephrology team work
The patient considered as risk group because
1-age more than 50
2-Diabetic
High risk (>50 and diabetic):
MPI, if showed reversible ischaemia, coronary angiogram.
If irreversible ischaemia (fixed perfusion defect), ECHO
• Very high risk (symptomatic): Coronary angiogram
So our patient need ECHO to detect EF and ventricular wall motion
No role for Coronary angiogram as it is irreversible ischemia
Left ventricular diastolic dysfunction and left atrial enlargement have been associated with worse outcomes after transplantation
So we can do transplantation with the following consideration:-
1-improve left ventricular compliance by more aggressive ultrafiltration on dialysis.
2-perform cardiac echocardiography when the patient is at their dry weight in order to avoid false positive results and to repeat echocardiography after dry weight reduction and after load control have been attempted.
3-control on HT
4-good glycemic control
5-treatment of hyperlipidemia
6-start anticoagulant therapy
Reference
Up to date 2022
non reversible fixed defect if sever most likely represent scaring or fibrosis from prior MI but mild or moderate fixed defect may indicate hibernating myocardium or prior non transmural MI.so that means this with is high CVS risk and need more evaluation if he smoke ,need doppler for LL extremities vessels ,ECHO to ass the EJ fraction of the heart,but coronary angiography not indicated in this case .
Discussion with and or review by cardiologist ,anaesthetists and the transplant MDT is recommended as part of the clinical assessment of donors with higher CVS and perioperative risk(D2).this recommendation by BTS guidelines and our case is high risk(Age more than 45 ys ,DM and ckd).
references
1-BTS/ guidelines donation for kidney transplant.
What is the significance of the MYOVIEW scan finding?
Cardiac scintigraphy detect old myocardial infraction
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among those with end-stage kidney disease and kidney transplant recipients . All major types of cardiovascular disease including coronary artery disease (CAD), valvular heart disease, arrhythmias, and pulmonary hypertension are prevalent among kidney transplant candidates.
Improvement of technology and increase experience of radiologist is important to evaluate peri operative to avoid cardiovascular complications during surgery which may lead to death.
Early detection of complications helps to reduce transplant failure and cardiovascular events.
Would you proceed for transplantation provided all other investigations are satisfactory?
I will proceed transplant because still no contraindications like advanced CAD or LVH or high right ventricle pressure
References:
Yes, i will proceed for the transplantation if all other investigations are satisfactory because MYOVIEW reporting of fixed perfusion defect indicates old MI which cant be corrected and doesnt require any active treatment.
Hence, if current cardiac functions are normal then one can proceed for transplantation.
Probably this alteration must be chronic, since the echocardiography does not show impairment of activity and dyskinesia does not occur.
After a thorough evaluation of the cardiac team, it will be able to confirm the availability to perform the transplant.
A 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 non-transmural MI.
Reverse redistribution has been reported after myocardial infarction, especially after revascularization or thrombolytic therapy.
For this diabetic patient with these cardiac scan findings, he should have angiography. If intervention could be done, then he can proceed with a transplant.
Ref: 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.
Chose the correct answer(s) regarding coronary angiogram
A. Indicated for any potential recipients
B. Indicated for all diabetics regardless of the duration of DM, the type (1 or 2) and the age.
C. Indicated for all those who have symptoms of IHD (yes)
D. Indicated for all who have a fixed perfusion defect on MPI
E. Indicated for all who have wall motion abnormalities on stress ECHO (yes)
What is the significance of the MYOVIEW scan finding?
MYOVIEW scan (cardiac scintigraphy) reported antro-lateral fixed perfusion defect with no reversibility that indicate old MI
Would you proceed for transplantation provided all other investigations are satisfactory?
Yes , I will proceed for transplantation provided all other investigation are satisfactory.
Which results at cardiovascular assessment prevent transplantation?
-Most centers currently will consider ischemia not responsive to revascularization as contraindication to transplantation.
-After revascularization of advanced coronary disease, severe left ventricular dysfunction considered contraindication to transplantation as it associated with high mortality .
-Some data suggest that high right ventricular systolic pressure considered as contraindication to transplantation till treated.
– It is mandatory to manage advanced valvular heart disease before transplantation
Reference:
-Tariq Zayan et al. Evaluation of the cardiovascular prior to transplantation; an endless debate. Urol Nephrol Open Access J 4(3): 00126. DOI: 10.15406/unoaj.2017.04.00126
Old patient 62 y/o diabetic With reversibility Perfusion defect MYOVIEW scan (cardiac scintigraphy) old ischemia and there is no benefit from other cardiac work up in such result and no indication for Coronary angioplasty
yes having suitable donor + no absolute contraindications for transplantation
What is the significance of the MYOVIEW scan finding?
The MYOVIEW scan findings of antero-lateral fixed perfusion defect with no reversibility is most likely representative of scarring or fibrosis from an old MI. Mild or moderate fixed defect may indicate hibernating myocardium or prior transmural MI. Hibernating myocardium can be identified by stress-based diagnostic techniques and may benefit from invasive coronary intervention and revascularization therapy to help saving the viable hibernating myocardium.
Studies of SPECT MPI demonstrated a mean sensitivity and specificity of 87% and 73%, respectively.
Would you proceed for transplantation provided all other investigations are satisfactory?
I will proceed for transplantation procedure provided all investigations are satisfactory. MDT is needed including cardiologist.
What is the significance of the MYOVIEW scan finding?
The cardiac scintigrophy finding indicate old MI
Would you proceed for transplantation provided all other investigations are satisfactory
Yes ,I go ahead to surgery .
Contra indication for kidney transplant :
1- advanced coronary disease
2- severe left ventricular dysfunction
3- pressure high right ventricular systolic till treated
Reference:
Evaluation of the cardiovascular prior to transplantation;
Tariq Zayan,1,2 Ahmed Aref,1,2 Ajay Sharma,2,3 Ahmed Halawa2
This patient with high risk:
Old age
DM
Male
CKD on HD
need full cardiac assessment starting from history and detailed examination.
Cardiac scintigraphy revealed antero-lateral fixed perfusion defect with normal echocardiography ,this mean old infarction and as it irreversible so no need to do ICA.but we can go for echocardiogram to assess the cardiac wall motion abnormalities,EF, LVD , valvular abnormalities,if it normal as our patient and no symptoms so we can go for transplantation after confirming CPAT status and if there’s any PAD as it mirror image for CAD .
In edition we must treated the cardiac problems optimally by ACEi ,BB,anti platelets,lipid lowering agents and proper glycemic control.
And follow up the patient by MDT including the cardiologist.
What is the significance of the MYOVIEW scan finding?
This patient need cardiac evaluation :
1-age >50 years
2- diabetic.
MYOVIEW scan (cardiac scintigraphy) reported antro-lateral fixed perfusion defect with no reversibility this is mean old ischemia.
Would you proceed for transplantation provided all other investigations are satisfactory?
Ø Yes ,procced for kidney transplant
Ø Contra indication for kidney transplant :
1- advanced coronary disease
2- severe left ventricular dysfunction
3- pressure high right ventricular systolic till treated
reference:
Evaluation of the cardiovascular prior to transplantation;
Tariq Zayan,1,2 Ahmed Aref,1,2 Ajay Sharma,2,3 Ahmed Halawa2