Donataccio Maria Pia, Reverberi Claudio, Gaibazzi Nicola
Parma University Hospital , Parma , Italy ; Verona University Hospital , Verona , Italy.
Parma University Hospital , Parma , Italy.
Echo Res Pract. 2014 Sep 1;1(1):K1-4. doi: 10.1530/ERP-14-0013. Epub 2014 May 29.
A 52-year-old man presented after one episode of effort angina, normal treadmill electrocardiogram (ECG), and clearly positive adenosine cardiac magnetic resonance (aCMR) for reversible perfusion defects in the left anterior descending (LAD) coronary artery territory. Contrast high-dose dipyridamole (0.84 mg/kg per 6 min) stress echocardiography (cSE) demonstrated normal myocardial perfusion (MP) and wall motion at rest, while perfusion defects were shown in the lateral and apical segments after dipyridamole. Wall motion at stress was completely normal and stress/rest Doppler diastolic velocity ratio on the LAD demonstrated reduced flow reserve. In this case, cSE was the provocative test detecting both the LAD and circumflex obstructive lesions, thanks to MP analysis, while wall motion assessment was negative, not different from treadmill ECG, and aCMR highlighted only the LAD disease.
In spite of the low sensitivity of wall motion assessment during stress-echocardiography to detect coronary artery disease (CAD) in patients with multivessel disease and balanced ischemia, the addition of cSE with myocardial perfusion assessment, is not only able to overcome this limitation of false negative rate on a per-patient basis, but may also depict multivessel myocardial perfusion defects more efficiently than aCMR, as in the reported case, thanks to high spatial resolution.Myocardial perfusion assessment during cSE, although not always technically feasible, has a very high spatial and temporal resolution which can easily demonstrate multivessel subendocardial perfusion defects during maximal vasodilation, which is often the only detectable marker of multivessel, balanced CAD.It is known that wall motion analysis during pharmacologic stress may result in falsely negative multivessel disease; in these cases perfusion imaging or Doppler measurement of coronary flow reserve may be helpful to detect multivessel obstructive CAD, which is a significant and dismal prognostic finding. aCMR is assumed as the perfect imaging modality for CAD detection, but in selected cases, such as the one presented, an advanced echocardiographic method in experienced hands can provide even more comprehensive results.
一名52岁男性在出现一次劳力性心绞痛后就诊，平板心电图（ECG）正常，腺苷心脏磁共振成像（aCMR）显示左前降支（LAD）冠状动脉区域存在明显的可逆性灌注缺损，结果呈阳性。对比剂增强高剂量双嘧达莫（每6分钟0.84毫克/千克）负荷超声心动图（cSE）显示静息时心肌灌注（MP）和壁运动正常，而双嘧达莫给药后外侧和心尖段出现灌注缺损。负荷时壁运动完全正常，LAD上的负荷/静息多普勒舒张速度比值显示血流储备降低。在该病例中，由于MP分析，cSE是检测LAD和回旋支阻塞性病变的激发试验，而壁运动评估为阴性，与平板ECG无异，aCMR仅突出显示了LAD疾病。
尽管负荷超声心动图期间壁运动评估检测多支血管疾病和均衡性心肌缺血患者冠状动脉疾病（CAD）的敏感性较低，但增加cSE并进行心肌灌注评估，不仅能够在个体基础上克服假阴性率这一局限性，而且如本病例所示，由于高空间分辨率，其描绘多支血管心肌灌注缺损可能比aCMR更有效。cSE期间的心肌灌注评估虽然并非总是在技术上可行，但其具有非常高的空间和时间分辨率，能够在最大血管扩张时轻松显示多支血管心内膜下灌注缺损，这通常是多支血管、均衡性CAD唯一可检测到的标志物。已知药物负荷期间的壁运动分析可能导致多支血管疾病出现假阴性结果；在这些情况下，灌注成像或冠状动脉血流储备的多普勒测量可能有助于检测多支血管阻塞性CAD，这是一个重要且预后不良的发现。aCMR被认为是检测CAD的理想成像方式，但在某些特定情况下，如本文所述病例，经验丰富的人员采用先进的超声心动图方法可提供更全面的结果。
