Tricked by transient ischemic dilation: A case of hypertrophic cardiomyopathy
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Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland
Received Aug 14, 2020; accepted Aug 17, 2020 doi:10.1007/s12350-020-02350-7
INTRODUCTION Transient ischemic dilation (TID) on PET stress testing is highly specific for multi-vessel coronary artery disease (CAD). However, it is important to note that TID can occasionally be seen in the absence of significant underlying CAD. The present case demonstrates an example of TID in the setting of hypertrophic cardiomyopathy (HCM). CASE SUMMARY A 75-year-old female presented to the hospital with recurrent episodes of chest pressure relieved by nitroglycerin. Medical history was notable for HCM with systolic anterior motion of the mitral valve (Figure 1). Cardiac biomarkers were negative, and
Reprint requests: Ajay Bhargava, MD, Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2020 American Society of Nuclear Cardiology.
electrocardiogram demonstrated no acute ischemic changes (Figure 2). A gated 82Rb regadenoson PET stress test was ordered for further evaluation. This revealed a small scar at the apex, moderate ischemia in the territory of the left anterior descending (LAD), and mild ischemia in the territory of the left circumflex (LCx). Furthermore, there was a drop in ejection fraction post stress and striking TID of the left ventricular cavity, with a TID ratio of 1.41 (Figures 3, 4, and 5). Based on these findings, the patient underwent coronary angiography. This unexpectedly showed nonobstructive coronary artery disease. Her symptoms were thus attributed to HCM, and cardiothoracic surgery was consulted for myectomy. TID is widely acknowledged as a potential marker of severe CAD, but is also common in HCM with an estimated prevalence around 50%.1 TID in these patients
Pristera and Bhargava Tricked by transient ischemic dilation
Journal of Nuclear CardiologyÒ
Figure 1. Parasternal long axis view of the transthoracic echocardiogram demonstrating (A) severe concentric left ventricular hypertrophy, with a markedly thickened interventricular septum measuring 2.1 cm, and (B) systolic anterior motion of the mitral valve with septal contact (arrow).
Figure 2. 12-lead electrocardiogram showing normal sinus rhythm and left ventricular hypertrophy with secondary repolarization abnormalities.
Journal of Nuclear CardiologyÒ
Pristera and Bhargava Tricked by transient ischemic dilation
Figure 3. PET images showing a small (\ 10%) fixed perfusion defect at the apex, moderate (1020%) ischemia in the territory of the LAD, and mild (\ 10%) ischemia in the territory of the LCx. Most striking is the presence of TID with a ratio of 1.41. On PET imaging, a TID ratio C 1.1 is considered abnormal.
is thought to reflect microvascular dysfunction and decreased capillary density, leading to subendocardial hypoperfusion in the setting of a hypertrophied left ventricle.2 While studies have consistently demonstrated worse outcomes in patients with TID and CAD,3 it is
unclear if TID in HCM carries s
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