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Question 8
   The patient is a 57 year old white male who underwent double vessel coronary artery bypass graft surgey 8 years ago. Comorbidities include hypertension and hyperlipidemia. He did well until three months prior to his presentation to the office wit recurrance of his pre-op angina pectoris.
    A Tc-99M Sestamibi treadmill stress test was performed. His resting ECG revealed a sinus mechanism with diffuse nondiagnostic low voltage T waves. The resting BP was 170/100 mm Hg. The patient completed six minutes of the Bruce treadmill protocol at a workload of 7 METS and achieved 85% of his maximal predicted heart rate when he developed mild throat tightness which resolved within two minutes of the recovery phase. He had a flat BP response to exercise and the ECG demonstrated shallow T wave inversion in the mid precordial leads with 1 mm ST segment depression in the lateral leads. There were no exercise induced arrhythmias.
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     The post-stress and resting single-photon emmision tomographic (SPECT) images are shown above in the vertical long axis (VLA), horizontal long axis (HLA) and short axis views (SA) The bullseye reconstructed images and 2.5 standard deviation blackout plots are shown below.
Select ONE of the following statements that BEST describes the study:

A. Reversible anterior wall ischemia
B. Reversible posterolateral wall ischemia
C. Reversible infreior and posterolateral wall ischemia
D. Posterolateral wall photopenia with minimal reversiblity
E. Inferior wall photopenia with minimal reversibility

Answer A 

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Answer B  

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Answer C 

    You selected the correct answer.
  The post-stress images in the VLA view (top row) shows mild to moderate photopenia of the apex, infero-apical and distal inferior wall and severe photopenia of the basilar half of the inferior wall. This is best seen in the 10th frame.
In comparison, the resting images reveal near complete reversibility within the inferior wall with
mild persistent apical photopenia.
  The 10th frame of the post-stress SA view (fifth row of images) shows severe photopenia of the posterolateral wall with near complete reversibilty in the resting phase (last row).

   Thus, the study demonstrates reversible photopenia or ischemia of the inferior and posterolateral wall.
There is also a mild area of fixed apical photopenia. One would expect to find disease within the circumflex artery (which was not grafted) PLUS the saphenous vein graft to the RCA (or the RCA diatal to the anastamosis).
  The bulls-eye reconstructed images and the 2.5 standard deviation blackout plots, shown below, confirms the above findings.

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Answer D

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Answer E 

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