Cardiac sympathetic denervation in coronary artery fistula
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Department of Radiology, Faculty of Medicine, Kagawa University, Kagawa, Japan
Received Sep 3, 2020; accepted Sep 3, 2020 doi:10.1007/s12350-020-02374-z
INTRODUCTION 123
CASE PRESENTATION 123
Cardiac I-metaiodobenzylguanidine ( I-MIBG) scintigraphy is clinically used to differentiate Parkinson’s disease and Lewy body disorders from atypical parkinsonism. The heart-to-mediastinum ratio (H/M) and the washout rate (WOR) are considered useful for diagnosis; hence physicians may tend to pay attention only to those values. We present a case of giant coronary artery fistula (CAF) with abnormal findings on 123IMIBG scintigraphy.
Reprint requests: Takashi Norikane, MD, PhD, Department of Radiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2020 American Society of Nuclear Cardiology.
A 71-year-old woman with suspected Parkinson’s disease was referred to our hospital. 123I-MIBG scintigraphy was performed for the assessment of cardiac sympathetic innervation. The early planar image (anterior projection) of 123I-MIBG scintigraphy showed almost normal uptake in the myocardium, but the uptake in the inferior wall was relatively lower than that in the anterior wall (Figure 1A). Furthermore, a focal decreased area at the right lower lung field was depicted
Mitamura et al Cardiac sympathetic denervation in coronary artery fistula
Journal of Nuclear CardiologyÒ
on the planar image. On late phase 123I-MIBG image, myocardial accumulation was decreased, and a significant increase in WOR was observed, suggesting cardiac
A
B
Figure 1. Anterior planar images of 123I-MIBG scintigraphy. (A) Early image showed almost normal uptake in the myocardium, but the uptake in the inferior wall was relatively lower than that in the anterior wall. Furthermore, a focal decreased area at the right lower lung field was depicted on the planar image (s). (B) On late phase (4hrs) 123I-MIBG image, myocardial accumulation was decreased, and a significant increase in WOR was observed. The values of the heart-tomediastinum (H/M) ratio in the early and late phases were 2.56 and 1.86 (normal range is [ 2.20), respectively. The washout rate was 48% (normal range is \ 22%).
Early phase
Late phase
sympathetic nervous dysfunction (Figure 1B). 123IMIBG polar map showed decreased accumulation and high washout especially in the apical to basal inferior wall (Figure 2). She underwent coronary computed tomography angiography (CCTA) for morphological evaluation. CCTA images demonstrated a tortuous right coronary artery (RCA) with marked diffuse aneurysmal dilation draining into the basal inferolateral wall of the left ventricle (Figure 3). These findings confirmed a diagnosis of coronary artery fistula (CAF). Chest CT volume rendering image showed giant RCA at the right lower lung field consistent with a focal decreased area on 123I-MIBG scintigraphy (Figure 4). On hybrid 123IMIBG single photon emission computed tomography/ CCTA image, a red
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