Serial Changes of 99m Tc-Sestamibi Washout Due to Coronary Spasm Captured by Dynamic Myocardial Perfusion Imaging With Cardiac Dedicated CZT-SPECT: a Case Report

HomeCirculation: Cardiovascular ImagingVol. 15, No. 3Serial Changes of 99mTc-Sestamibi Washout Due to Coronary Spasm Captured by Dynamic Myocardial Perfusion Imaging With Cardiac Dedicated CZT-SPECT: a Case Report Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBSerial Changes of 99mTc-Sestamibi Washout Due to Coronary Spasm Captured by Dynamic Myocardial Perfusion Imaging With Cardiac Dedicated CZT-SPECT: a Case Report Yue Chen, MD, MS, Ze-kun Pang, MD, MS, Jiao Wang, MD, PhD, Rui-fei Yang, MD, MS, Rui Jing, MD, MS, Hong-xin Chu, MD, MS, Bailing Hsu, PhD, Wen-hua Lin, MD, MS and Jian-ming Li, MD, PhD Yue ChenYue Chen Department of Nuclear Medicine (Y.C., Z.-k.P., J.W., H.-x.C., J.-m.L.), TEDA International Cardiovascular Hospital, China. , Ze-kun PangZe-kun Pang Department of Nuclear Medicine (Y.C., Z.-k.P., J.W., H.-x.C., J.-m.L.), TEDA International Cardiovascular Hospital, China. , Jiao WangJiao Wang Department of Nuclear Medicine (Y.C., Z.-k.P., J.W., H.-x.C., J.-m.L.), TEDA International Cardiovascular Hospital, China. , Rui-fei YangRui-fei Yang Department of Cardiology (W.h.L; R.-f.Y., R.J.,.), TEDA International Cardiovascular Hospital, China. , Rui JingRui Jing Department of Cardiology (W.h.L; R.-f.Y., R.J.,.), TEDA International Cardiovascular Hospital, China. , Hong-xin ChuHong-xin Chu Department of Nuclear Medicine (Y.C., Z.-k.P., J.W., H.-x.C., J.-m.L.), TEDA International Cardiovascular Hospital, China. , Bailing HsuBailing Hsu Correspondence to: Jian-ming Li, MD, PhD, Department of Nuclear Medicine, TEDA International Cardiovascular Hospital, Tianjin 300457, China, Email E-mail Address: [email protected] or Wen-hua Lin, MD, MS, Department of Cardiology, TEDA International Cardiovascular Hospital, Tianjin 300457, China, Email E-mail Address: [email protected] or Bailing Hsu, PhD, Nuclear Science and Engineering Institute, University of Missouri-Columbia, E2433 Lafferre Hall, University of Missouri-Columbia, Columbia, MO 65211, Email E-mail Address: [email protected] Nuclear Science and Engineering Institute, University of Missouri-Columbia (B.H.). , Wen-hua LinWen-hua Lin Department of Cardiology (W.h.L; R.-f.Y., R.J.,.), TEDA International Cardiovascular Hospital, China. and Jian-ming LiJian-ming Li https://orcid.org/0000-0002-2585-4753 Department of Nuclear Medicine (Y.C., Z.-k.P., J.W., H.-x.C., J.-m.L.), TEDA International Cardiovascular Hospital, China. Originally published23 Feb 2022https://doi.org/10.1161/CIRCIMAGING.121.013687Circulation: Cardiovascular Imaging. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 23, 2022: Ahead of Print A 64-year-old man with a history of smoking and known coronary artery disease underwent percutaneous coronary intervention in left anterior descending artery 4 years ago. Recently, he was admitted to hospital after experiencing intermittent retrosternal pain for 3 days. A blood test for biochemical indices came back negative. His electrocardiography showed T-wave changes, and his echocardiogram showed a normal left ventricular ejection fraction, 63%. The patient was further instructed to undergo dynamic myocardial perfusion imaging (MPI) on a cardiac single photon emission computed tomography (SPECT) using cadmium zinc telluride detector scanner to measure myocardial blood flow over a one-day period. As part of the dynamic SPECT imaging protocol, a rest scan was performed immediately before the first intravenous injection of 99mTc-sesetami (MIBI) tracer, and an hour later, a stress scan was conducted 3 minutes following the intravenous infusion of adenosine (0.14 mg/kg per minute) and immediately before the second MIBI injection. Serial ECGs were recorded during the stressing process to monitor patient safety. The patient complained of chest pain and shortness of breath throughout the adenosine infusion and developed coronary spasms (CS) 2.5 minutes after the infusion. His SPECT myocardial blood flow quantitation showed an abnormally low myocardial flow reserve of 1.39, in combination with an abnormal myocardial flow capacity of 38.19% extent of moderately and severely anomalous flow statues, an indication of myocardial ischemia (Figure 1). Additionally, stress dynamic MPI data further divided into sequences of perfusion images revealed MIBI washout gradually in the inferoseptal, inferior and apical myocardium, which ultimately led to large stress perfusion defects in regions (from 0% to 31%) and diminished left ventricular ejection fraction (from 64% to 48%; Figure 2). Serial electrocardiograms showed progressive development of CS and remission after treatment with high-concentrated oxygen and sublingual nitroglycerin (Figure 3). Figure 4 shows the time sequence from the peak stress stage to the end of the stress dynamic SPECT scan. He was transferred to receive an urgent coronary angiography, which revealed only mild hyperplasia in the previously implanted stent in the proximal left anterior descending and 99% spastic occlusion in the middle left anterior descending. Following the infusion of 200 μg of nitroglycerin through the catheter, the spasm was controlled, and no residual abnormality in the coronary intima was observed on coronary angiography and confirmed by optical coherence tomography (Figure 5).Download figureDownload PowerPointFigure 1. Single photon emission computed tomography myocardial blood flow (MBF) quantitation from dynamic myocardial perfusion imaging. LAD indicates left anterior descending; LCX, left circumflex; LV, left ventricle; MFR, myocardial flow reserve; and RCA, right coronary artery.Download figureDownload PowerPointFigure 2. Serial change of 99mTc-Sestamibi washout and diminished left ventricular ejection fraction (LVEF) starting from the completion of adenosine infusion. LAD indicates left anterior descending; LCX, left circumflex; and RCA, right coronary artery.Download figureDownload PowerPointFigure 3. Real-time ECG monitoring during the adenosine-stress dynamic single photon emission computed tomography acquisition. A, Baseline ECG at rest stage. B, Peak-stress ECG at 3 min post the adenosine infusion. C, ECG in the early stage of spasm showing obvious ST-segmental and T-wave elevation in the anterior wall leads at 2.5 min post the end of adenosine infusion. D, ECG in the peak of spasm showing ST-segmental elevation in multiple leads, ST-segmental elevation above R waves in the anterior wall leads (V2, V3, and V4), and T-wave fusion with tombstone-like change at 4.3 min. E, Progressive ECG showing short bursts of VA during the peak of spasm at 5.1 min. F, The frequency of short bursts of VA became slower during the control period of spasm after sublingual 0.5 mg nitroglycerin at 7 min. G, Early remission of spasm showed a tendency of ST-segmental regression in the anterior wall leads at 7.5 and 7.75 min. VA indicates ventricle and atrium.Download figureDownload PowerPointFigure 4. The time sequence of coronary spasm event from the peak stress stage (3 min post the adenosine infusion) to the end of stress dynamic single photon emission computed tomography scan. LVEF indicates left ventricular ejection fraction; MIBI, 99mTc-sesetami; MPI, myocardial perfusion imaging; NTG, nitroglycerin; and VA, ventricle and atrium.Download figureDownload PowerPointFigure 5. Coronary angiography of coronary spasm observed before and after intracoronary nitroglycerin treatment, and the transparent intima reconfirmed by optical coherence tomography (OCT). LAD indicates left anterior descending; LCX, left circumflex; NTG, nitroglycerin; and RCA, right coronary artery.CS is a transient constriction of the coronary artery that may lead to myocardial ischemia downstream as a result of partial or complete occlusion. Clinically, this event cannot be measured in real-time without an intracoronary provoking procedure (eg, Ergometrine test). Nonetheless, some previous studies have observed MIBI washout in the myocardium caused by CS in delayed SPECT imaging.1 The present study, to our knowledge, is the first to report the kinetic of myocardial MIBI washout induced by CS during the adenosine-stress dynamic SPECT scan. According to this patient's dynamic perfusion and ECG, MIBI washout was instantaneous when acute myocardial ischemia occurred. MIBI washout is explained by local Ca+2 accumulation causing depolarization in the transmembrane of mitochondria, resulting in the loss of MIBI cation to be indicative of mitochondrial dysfunction.From our study, 3 points can be learned as follows:The progressive development of myocardial ischemia leading to mitochondrial dysfunction can be very rapid during severe CS episodes. It is vital to seek immediate medical treatment at the onset of CS to prevent further acute injury to myocytes.Provocative tests with acetylcholine or ergometrine have been proposed to diagnose CS, but their safety remains a major concern.2 Adenosine as a vessel dilatator has been widely used in MPI with a well-accepted safety profile, and cases of CS following an adenosine-stress test have been reported.3 The results of this study demonstrate that dynamic MPI with adenosine is an effective method to monitor CS progression and reflect the pathophysiological characteristic by measuring the MIBI washout kinetics.CS often coexists with coronary microvascular dysfunction, as this patient population has a strikingly increased risk of cardiac events.4 In this case, myocardial flow reserve and myocardial flow capacity in 3 vessel territories were overall abnormal to additionally indicate diffuse coronary microvascular dysfunction. SPECT myocardial blood flow quantitation is, therefore, valuable for assessing the coexistence of CS and coronary microvascular dysfunction.In conclusion, serial changes in MIBI washout in dynamic MPI with cardiac dedicated SPECT using cadmium zinc telluride detector can be useful to evaluate the mitochondrial dysfunction and the severity of myocardial ischemia when CS occurs. Further quantification of myocardial blood flow reveals clinical insight on whether CS and coronary microvascular dysfunction coexist.Article InformationSources of FundingNone.Disclosures None.FootnotesFor Sources of Funding and Disclosures, see page 186.Correspondence to: Jian-ming Li, MD, PhD, Department of Nuclear Medicine, TEDA International Cardiovascular Hospital, Tianjin 300457, China, Email [email protected]com or Wen-hua Lin, MD, MS, Department of Cardiology, TEDA International Cardiovascular Hospital, Tianjin 300457, China, Email [email protected]com or Bailing Hsu, PhD, Nuclear Science and Engineering Institute, University of Missouri-Columbia, E2433 Lafferre Hall, University of Missouri-Columbia, Columbia, MO 65211, Email [email protected]comReferences1. Ono S, Takeishi Y, Yamaguchi H, Abe S, Tachibana H, Sato T, Kubota I. Enhanced regional washout of technetium-99m-sestamibi in patients with coronary spastic angina.Ann Nucl Med. 2003; 17:393–398. doi: 10.1007/BF03006607CrossrefMedlineGoogle Scholar2. Kaski JC. Testing for coronary artery spasm noninvasively: potentially ideal, but safe?JACC Cardiovasc Imaging. 2020; 13:1888–1890. doi: 10.1016/j.jcmg.2020.04.002CrossrefMedlineGoogle Scholar3. Han PP, Tian YQ, Wei HX, Wang Q, He ZX. Coronary spasm after completion of adenosine pharmacologic stress test.Ann Nucl Med. 2011; 25:580–585. doi: 10.1007/s12149-011-0493-zCrossrefMedlineGoogle Scholar4. Suda A, Takahashi J, Hao K, Kikuchi Y, Shindo T, Ikeda S, Sato K, Sugisawa J, Matsumoto Y, Miyata S, et al. Coronary functional abnormalities in patients with angina and nonobstructive coronary artery disease.J Am Coll Cardiol. 2019; 74:2350–2360. doi: 10.1016/j.jacc.2019.08.1056CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails March 2022Vol 15, Issue 3 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.121.013687PMID: 35290080 Originally publishedFebruary 23, 2022 Keywordsmyocardial perfusion imagingnitroglycerincoronary angiographyelectrocardiographyspasmPDF download Advertisement SubjectsCoronary Artery DiseaseNuclear Cardiology and PET