This 45-year-old patient’s coronary angiogram confirms a discrete mid-LMS lesion with a possible ostial RCA lesion following a recent admission with a minor troponin-positive episode of acute pulmonary oedema. Type 2 diabetes is the only risk factor. Echocardiography is difficult to assess because of obesity, but LV function is probably only mildy impaired. How would you proceed based on the MPS shown below?
The LMS is flow limiting, as evidenced by the large area of anterior and septal ischaemia with stress-induced LV cavity dilatation. The apex is a small non-viable infarct. The RCA is not flow limiting and needs no further assessment.
This 75-year-old woman has undergone an MPS to risk stratify before a total hip replacement (shown below).
Adenosine stress was performed without symptoms. Her past medical history includes hypertension, hypercholesterolaemia, and atrial fibrillation.
Which one of the following statements is true?
This is a normal low-risk scan. The ‘warranty period’ in a non-diabetic patient is approximately 7 years in the absence of new symptoms (less so in diabetics). Tracer activity is noted in the GI tract in the rest study. This is not a sign of GI pathology.
Which one of the following statements about the study shown in Figure below is incorrect?
The inferior wall demonstrates a predominantly non-viable infarct apart from the basal segment which is viable at rest and ischaemic with stress. The anterior and inferolateral walls demonstrate reversible ischaemia. The inferior septum is also infarcted (non-viable). This is a high-risk scan, and an ICD should be considered if LVEF is sufficiently impaired by the IHD.
The three-dimensional (3D) transesophageal echocardiographic (TEE) image in Figure below
demonstrates a patient with:
Abnormal mechanical MVR. Figure in question is a 3D echo image showing a malfunctioning bileaflet mechanical MVR. This image demonstrates one leaflet that is open (to the right of the image), while the other remains shut. You can see the sewing ring of the prosthesis well. This is most likely due to thrombus although impingement by a chord or piece of valve could do this as well.
The images in Figure below A–E come from an 18-year-old young man with marked shortness of breath (SOB).
The most appropriate course of action would be
Percutaneous mitral valvuloplasty (PMV) because he has a split score of 4 to 8 and minimal MR. The MV “split score” as it pertains to “ splittability” of a rheumatic MV with MS is derived by grading four features of the stenotic valve. The features, which are graded on a scale of 1 to 4, include leaflet thickening, leaflet calcification, leaflet mobility, and involvement of the subvalvular apparatus. Grade 1 denotes the least abnormality while 4 denotes the most severe abnormality. Because each feature is graded on a scale of 1 to 4, the total score can range from 4 (more splittable) to 16 (least splittable). A valve with a score of ≤8 is considered amenable to PMV as long as there is no significant MR. Of note, the degree of MR typically increases by 1 grade when a patient undergoes balloon mitral valvuloplasty. A score of >8 denotes a valve that would not be amenable to PMV and if the patient is symptomatic or has significant pulmonary hypertension or other indication for an intervention (other than maximizing medical therapy), the patient would undergo a surgical valve replacement as long as they were considered a surgical candidate. The images presented for this example show a patient with severe MS due to rheumatic disease with minimal leaflet thickening or calcification, and no subvalvular involvement with preserved mobility. The stenosis is due almost entirely to commissural fusion and as such has a split score of 4. In addition, the color Doppler still frame in systole showed only trivial MR. For these reasons, the patient is an ideal candidate for PMV. The images in Figure below A and B were taken following the balloon inflations during the PMV.
A. Three-dimensional images of the mitral valve showing a larger orifice and the split commissures compared with the pre-PMV image. B. The transmitral gradient post balloon inflation. The mean mitral gradient has decreased from 30 to 9 mmHg.
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