Case Report Utility of Fractional Flow Reserve to Determine Treatment After Recent Large Myocardial Infarction With Severe Left Ventricular Dysfunction Sumith Aleti, MD, Barry F. Uretsky, MD, and Rajesh Sachdeva, * MD Evaluation of ischemia and the extent of viable myocardium is required prior to consid- eration of revascularizing a lesion after a myocardial infarction in which there is hypo- or akinesis. We present a case in which we utilized fractional flow reserve (FFR) of a lesion in a patient whose nuclear study 7 days after infarction suggested minimal via- bility in the infarct zone. After FFR was positive, stenting was performed with recovery of a large amount of viable myocardium at 1 month as shown on nuclear study. This case illustrates that if ischemia is demonstrated by FFR in an infarct-related artery even with minimal viability by nuclear study, revascularization may result in significant myocardial recovery. V C 2011 Wiley Periodicals, Inc. Key words: fractional flow reserve; myocardial infarction; myocardial viability; percutaneous coronary intervention; angioplasty; nuclear stress testing INTRODUCTION The value of revascularization in coronary stenosis after acute myocardial infarction is related, in part, to the extent of myocardial ischemia and viability. The ACC AHA guideline recommends that in patients who sustain a myocardial infarction (MI) and are treated medically, stress testing should be used to risk stratify patients [1]. We present a case in which nuclear stress testing 7 days after MI showed minimal viability in the infarct zone suggesting the futility of revascularization of the infarct-related artery (IRA). During invasive evaluation, fractional flow reserve (FFR) suggested sig- nificant ischemia in the myocardium of the IRA and percutaneous coronary intervention (PCI) was per- formed. The patient’s myocardium 4 weeks later showed significant improvement in viability and sys- tolic function. This case demonstrates the potential de- cision-making value of FFR in the setting of a recent asymptomatic myocardial infarction with significant ventricular dysfunction. CASE REPORT Patient was a 64-year-old man with hypertension, di- abetes, and previous stroke with aphasia who presented to an outside hospital with dyspnea and anterior ST segment elevation. The patient declined invasive evalu- ation and was managed medically. Echocardiography showed moderately severe mid anterior wall hypokine- sis and anteroseptal and apical akinesis. Estimated ejection fraction was 26%. Thallium viability study 7 days after admission showed a large area of poor thal- lium uptake compatible with extensive infarction with only a small area read as viable in the anterior wall with additional mild inferior wall ischemia (Fig. 1). Catheterization was requested because of the small area of inferior ischemia as it was felt that the anterior wall was no longer viable. Coronary angiography 12 days post-infarction using quantitative coronary Division of Cardiovascular Medicine, Department of Medicine, Central Arkansas Veterans Healthcare System and University of Arkansas for Medical Sciences, Little Rock, Arkansas Conflict of interest: Dr. Sachdeva serves on the Speaker Burearu for Volcano Corporation. Co-authors have no conflict of interest to report *Correspondence to: Rajesh Sachdeva, MD, 4300 W 7th Street, Little Rock, AR 72205. E-mail: rrsachdeva@gmail.com Received 14 May 2011; Revision accepted 22 July 2011 DOI 10.1002/ccd.23324 Published online in Wiley Online Library (wiley onlinelibrary.com) V C 2011 Wiley Periodicals, Inc. Catheterization and Cardiovascular Interventions 00:000–000 (2011)