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Volume 18 Supplement 1

19th Annual SCMR Scientific Sessions

  • Poster presentation
  • Open Access

Role of adenosine Stress CMR before Chronic Total Occlusion reopening

  • 1, 2,
  • 3,
  • 4,
  • 2,
  • 1 and
  • 2
Journal of Cardiovascular Magnetic Resonance201618 (Suppl 1) :P80

  • Published:


  • Late Gadolinium Enhancement
  • Perfusion Abnormality
  • Chronic Total Occlusion
  • Perfusion Stress
  • Adenosine Infusion


Conflicting data exists on the usefulness of a perfusion stress test prior to reopening a chronically occluded coronary artery (CTO). We sought to test whether a stress MR may improve patient selection for Chronic Total Occlusion (CTO) reopening over a conventional LGE study.


70 CTO patients without any other relevant coronary artery stenosis (or already treated if present at baseline angiography), underwent an adenosine stress CMR before a reopening attempt. ECG and echocardiographic (echo) data were available for all. Patients were considered suitable for the reopening procedure in case of myocardial ischemia and / or viable myocardium subtended to the CTO.

Presence of a previous myocardial infarction (MI) was defined at ECG: Q waves > 40 msec; at echo: akinetic areas with reduced wall thickness; at stress MR: presence of ischemic Late gadolinium Enhancement.

Presence of myocardial ischemia was defined as a subendocardial perfusion defect lasting for at least 4 heart beats during adenosine infusion in a segment without LGE.


ISCHEMIA: adenosine stress MR showed a perfusion abnormality in 100% of CTO territory. Inducible ischemia was observed in 71% of cases, with a perfect concordance with CTO occlusion.

PREVIOUS MI: using CMR as the gold standard for the diagnosis, the prevalence was globally high: 69% in our series. Both ECG and echo significantly underestimate this data (36% and 53% respectively). Presence of LGE in different sites from the CTO territory was often observed: in fact, only 58% of patients with LGE had it exactly in the CTO territory. At echo, 82% of pts with wall motion abnormality (WMA) had it described in CTO segments: this can be explained with a portion of patients with viable, non-ischemic myocardium. The true prevalence of LGE in CTO segments was 40% for the whole population, but only 13% (n = 9) of patients showed a mean LGE transmurality >50%, contraindicating a reopening attempt. These patients were not identified by echo that identified 30 patients with akinetic areas subtended to a CTO.


Perfusion stress MR did not show any additional diagnostic value in our population of patients with CTO and known coronary anatomy, since a perfusion abnormality was observed in all patients.

LGE analysis showed a 13% prevalence of transmural MI in CTO territories: this important information can't be obtained with a baseline diagnostic approach and should encourage the use of LGE MR before a CTO reopening.
Table 1

Previous MI in CTO patients


ECG (Q waves)

ECHO (akinesia + wall < 6 mm)

Ischemic LGE pattern

Global prevalence of diagnostic criterion

36% (n = 25)

53% (n = 37)

69% (n = 48)

Correct site of a positive criterion

80% (n = 20)

81% (n = 30)

58% (n = 28)

Previous MI in the CTO territory

29% (n = 20)

43%(n = 30)

40% (n = 28)

Authors’ Affiliations

Radiology, Humanitas Research Hospital, Rozzano (MI), Italy
Cardiology department, Istituto Clinico Humanitas, Rozzano, Italy
Cardiology, Ospedale di Novara, Novara, Italy
Cardiology, IRCCS Ospedale Maggiore Policlinico di Milano, Milano, Italy


© Monti et al. 2016

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.