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Sample Site Stress/Rest Myocardial Perfusion Patient Name: Cta fv3d, Pet_cardiac Date of Study: 2003-11-21 FusedVision3D Age: 81 Sex: M Outpatient w ID Number: This letter reflects our overall impression of the results of the Stress/Rest Myocardial Perfusion study and the stress electrocardiogram combined with the patient’s age, sex, symptoms, and coronary risk factors. The study was performed in order to evaluate coronary artery disease in this 81 year old male with a history of prior myocardial infarction (2000), bypass, aortic valve surgeries with the most recent being done on (5/2001), previous positive treadmill, valve disease and coronary artery disease by referring physician. Symptoms include atypical chest pain. Risk factors include hypercholesterolemia and hypertension. At the time of testing, the patient was under the influence of a beta blocker. The patient is currently taking CA++ blockers and HMG CoA reductase inhibitor. Exercise duration was 5:15 minutes to a heart rate of 102 (73% of maximum predicted). Exercise was terminated because of achievement of adequate heart rate. Chest discomfort occured at 4 minutes into recovery. The resting blood pressure was 80/120 and maximum blood pressure was 90/130. The resting ECG showed atrial flutter, A/V sequential pacing, possible inferoposterior myocardial infarction, possible anteroseptal myocardial infarction, Early repolarization and left posterior fascicular block. The stress ECG revealed -2.5mm horizontal ST depression in lead V5 and -5.3mm downsloping ST depression in lead AVF. ● Exercise separate aquisition dual isotope gated myocardial perfusion SPECT (stress sestamibi/rest thallium) demonstrated overall defects as follows: Vessel Reversible Nonreversible RCA small to medium (inferoseptal) LAD small to medium (anterior) There was transient ischemic dilation of the left ventricle (more enlargement of the LV at stress compared to rest) which is a marker of severe and extensive coronary artery disease. Sestamibi SPECT was performed in the supine position. ● Resting gated SPECT revealed an ejection fraction of 50% with end-diastolic volume of 120 ml. Post Exercise resting gated SPECT revealed a mildly reduced left ventricular ejection fraction of 45% with end-diastolic volume of 120 ml. Left ventricular wall motion demonstrated severe dyskinesis of the interventricular septum with normal thickening, consistent with prior sternotomy or paced rhythm. Furthermore, there was dyskinesis in the septal wall and moderate hypokinesis in the anterior wall. ev ie ● Pr In conclusion, the test results are as follows: Clinical Response: Ischemic ECG Response: Ischemic Perfusion: Abnormal (Reversible and Nonreversible) Gated Function: Abnormal These test results indicate a high intermediate (70-89%) likelihood for the presence of exercise induced ischemia. The type and distribution of the scintigraphic abnormalities are most consistent with the following: in the RCA territory, a small to medium amount of severe ischemia in the inferoseptal wall; in the LAD territory, a small to medium sized prior myocardial infarction involving the anterior wall. In view of the normal perfusion and function and electrocardiogram at peak exercise, the development of chest pain during exercise is of uncertain significance. Thank you for referring this patient to us. Sincerely yours, -Preview Only- Stress ECG interpreted by Sample Physician Date printed: 2005-3-9 11:40 Cardiology Fax (800) 555-1212 Phone (800) 555-1212 Sample Site Myocardial Perfusion SPECT Patient Name: Cta fv3d, Pet_cardiac Date of Study: 2003-11-21 FusedVision3D Age: 81 Sex: M Short Axis Apical Level Outpatient Short Axis Mid-Ventricular Short Axis Basal Level 3 5 Infero Lateral 4 8 12 9 11 14 15 10 2. AnteroSeptal 3. InferoSeptal 4. Inferior 5. InferoLateral 6. AnteroLateral 3 0 0 0 0 0 S R 3 0 0 0 0 0 7. Anterior 8. AnteroSeptal 9. InferoSeptal 10. Inferior 17 20 3 0 3 0 0 0 3 0 0 0 0 0 S R 11. InferoLateral 12. AnteroLateral %SS : 15 (severe) Antero Apical 13. Anterior 14. AnteroSeptal 15. InferoSeptal 16. Inferior 0 0 3 0 0 0 0 0 0 0 0 0 17. InferoLateral 18. AnteroLateral Infero Apical Reversible Nonreversible S R 19. AnteroApical 20. InferoApical ev 1. Anterior 19 16 Inferior S R 18 ie Infero Septal 6 13 7 Antero Lateral 1 2 Vertical Long Axis Normal Anterior Antero Septal w ID Number: 0 0 0 0 0 = Normal 1 = Mildly reduced/ Equivocal 2 = Moderaty Reduced 3 = Severely Reduced 4 = Absent Uptake S = Stress R = Rest %RS : 8 (mild) %DS : 8 (moderate) Exercise separate aquisition dual isotope gated myocardial perfusion SPECT using Tc-99m sestamibi (35.9 mCi) at stress and thallium-201 (2.6 mCi) at rest was performed using the rest/stress sequence. Sestamibi SPECT was performed in the supine position. Pr Findings: overall defects as follows: Vessel Reversible RCA small to medium (inferoseptal) LAD Nonreversible small to medium (anterior) There was transient ischemic dilation of the left ventricle (more enlargement of the LV at stress compared to rest) which is a marker of severe and extensive coronary artery disease. Myocardial perfusion test result: Definitely abnormal with both reversible and nonreversible defects. %SS (Percent Stress) Normal Mild Moderate Severe 0-4% 5-9% 10-14% >14% Date printed: 2005-3-9 11:40 %RS (Percent Fixed) Normal Mild Moderate Severe 0-4% 5-9% 10-14% >14% %DS (Percent Ishemic) Normal Mild Moderate Severe 0-2% 3-5% 6-9% > 9% Vessel Descriptions RCA (Right Coronary Artery) LAD (Left Anterior Descending) LCX (Left Circumflex) DIAG (Diagonal) Sample Site Ventricular Function Gated SPECT Patient Name: Cta fv3d, Pet_cardiac Date of Study: 2003-11-21 FusedVision3D Age: 81 Sex: M Short Axis Apical Level Outpatient Short Axis Mid-Ventricular Short Axis Basal Level 6 3 5 4 13 7 Antero Lateral Infero Lateral 8 12 9 11 14 15 10 2. AnteroSeptal 3. InferoSeptal 4. Inferior 5. InferoLateral 6. AnteroLateral 2 5 5 0 0 0 2 5 5 0 0 0 S R 7. Anterior 8. AnteroSeptal 9. InferoSeptal 10. Inferior 17 20 2 5 5 0 0 0 2 5 5 0 0 0 S R 13. Anterior 14. AnteroSeptal 15. InferoSeptal 16. Inferior 0 5 5 0 0 0 0 5 5 0 0 0 ev 1. Anterior 19 16 Inferior S R 18 11. InferoLateral 12. AnteroLateral LV Ejection Fraction Rest: 50% Post Stress: 45% Antero Apical ie Infero Septal 1 2 Vertical Long Axis Normal Anterior Antero Septal w ID Number: 17. InferoLateral 18. AnteroLateral Infero Apical Moderate / Severe Hypokinesis Akinesis Dyskinesis S R 19. AnteroApical 20. InferoApical 0 0 0 0 0 = Normal 1 = Mild Hypokinesis 2 = Moderate Hypokinesis 3 = Severe Hypokinesis 4 = Akinesis 5 = Dyskinesis S = Stress R = Rest End-diastolic volume Rest: 120 ml Post Stress: 120 ml Pr Findings: Definitely Abnormal Resting gated SPECT revealed an ejection fraction of 50% with end-diastolic volume of 120 ml. Post Exercise resting gated SPECT revealed a mildly reduced left ventricular ejection fraction of 45% with end-diastolic volume of 120 ml. Left ventricular wall motion demonstrated severe dyskinesis of the interventricular septum with normal thickening, consistent with prior sternotomy or paced rhythm. Furthermore, there was dyskinesis in the septal wall and moderate hypokinesis in the anterior wall. Date printed: 2005-3-9 11:40 Sample Site Stress Electrocardiography Patient Name: Cta fv3d, Pet_cardiac Date of Study: 2003-11-21 FusedVision3D Age: 81 Sex: M Outpatient w ID Number: A standard 12 LEAD ELECTROCARDIOGRAM was recorded with continous ECG monitoring throughout exercise and recovery. Additionally, 12 LEAD ELECTROCARDIOGRAMS were recorded every minute. Stress Physiology Exercise Duration 5:15 Heart Rate Rest: 80 Blood Pressure Rest: 80/120 Exertional Hypotension No Discomfort Yes Pain location Chest Arrthythmia None Reason for termination achievement of adequate heart rate ie % Maximal Predicted Heart Rate: 73% Exercise: 90/130 Onset of Pain: Stress minute 3.6 ev Resting Electrocardiogram Exercise: 102 atrial flutter, A/V sequential pacing, possible inferoposterior myocardial infarction, possible anteroseptal myocardial infarction, Early repolarization and left posterior fascicular block V5 AVF III Maximum Abnormality: -2.5mm horizontal ECG First became Abnormal:Recovery minute 3 Maximum Abnormality-5.3mm downsloping ECG First became Abnormal:Exercise minute 2 Maximum Abnormality: None ECG First became Abnormal: No. of leads with significant S-T depression: 0 Impression Pr Clinical response to Stress: Ischemic due to chest discomfort ECG response to Stress: Ischemic due to the development of significant ST segment depression Stress ECG interpreted by Sample Physician Date printed: 2005-3-9 11:40