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The role of imaging in evaluating revascularised patients

Non-Invasive Imaging



The role of imaging in evaluating revascularised patients is a challenging topic in the clinical decision making. The main purpose of this session was to point out the role of cardiac imaging in these  patients.

When is imaging useful in asymptomatic patients?

In this presentation, Prof. M.J. Zellweger  focused on the importance of silent ischemia detection.  Event free survival in patients post- PCI/Stenting is a function of the presence of (silent) ischemia and the extent of residual CAD. Independent predictors of silent restenosis after PCI are: 1) male sex; 2) greater reference diameter at follow-up; 3) lesser lesion severity. After CABG, independent predictors of cardiac-death, in asymptomatic patients, are: 1) the number of non reversible segments at cardiac radionuclide imaging; 2) the extent of ischemia. Therefore, symptomatic status alone does not predict outcome. Prof. M.J. Zellweger concluded  that silent ischemia is frequent in revascularised patients, even though silent ischemia generally has a smaller extent of symptomatic ischemia and it is of prognostic relevance. Chest pain is not a reliable sign of restenosis of a graft occlusion.

Coronary computed tomography for evaluating stents and bypass grafts

Professor P.A. Kaufmann, in this presentation, highlighted the current main advantages and limitations of CT scan technique in revascularised patients evaluation. He focused on the importance of energy resolution and multiple approaches, and other technological aspect that play a key role in improving image quality.  He showed that B46f is the best kernel in CT 64 slices and this reconstruction protocol is recommended for proximal stent assessment. He concluded that MSCT is not yet ideal for stents, while it is accurate to evaluate CABGS, but anastomosis may remain difficult to study. Combination with ischemia test is preferable (combined imaging, hybrid imaging).

Is single-photon emission computed tomography predicting prognosis in revascularised patients?

Professor S.R. Underwood underlined the role of myocardial perfusion scan (MPS) in revascularised patients. Prognostic value of MPS is maintained after CABG. Perfusion reserve may return slowly after successful PCI and this may not be predictive of restenosis. Abnormal MPS findings after PTCI are mainly due to: 1) inability of coronary arterioles to autoregulate following prolonged epicardial stenosis; 2) release of vasoactive substances by platelets at the time of dilatation; 3) distal embolisation of microcirculation. Silent ischemia after revascularization is predictive of restenosis. Therefore MPS is appropriated in: symptomatic revascularized patients; 5 years after CABG in asymptomatic patients; 2 years after PCI even in the absence of symptoms.

Anatomy, function or both for evaluating patients after revascularisation?

Professor H. Sochor in his presentation showed that the anatomic evaluation (luminology) is not enough in patients with coronary disease (either revascularised or not) in order to establish accurate clinical decisions as well as to risk stratification. Functional evaluation is crucial in these patients, because prognosis does often not correlate with anatomy. Diagnosis of a given lesion does not implicate ischemia. Test and tools might/should embrace multiple aspects. Hybrid imaging (i.e. CT/PET) can provide such unique information, which not only improves diagnostic assessment and risk stratification, but may also guide decision making with regard to revascularised patients.

In conclusion, all presentations were very interesting and provided useful information for daily clinical practice.




The role of imaging in evaluating revascularised patients

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.