Papillary muscle ischemia on high-resolution cine imaging of nitrogen-13 ammonia positron emission tomography: Association with myocardial flow reserve and prognosis in coronary artery disease



The evaluation of papillary muscle (PM) perfusion through existing perfusion imaging, including single-photon emission computed tomography and magnetic resonance imaging, is not possible. Therefore, this study sought to investigate the detection of PM ischemia in coronary artery disease (CAD) using nitrogen-13 (N-13) ammonia positron emission tomography (NH3 PET) and its association with global myocardial flow reserve (MFR) and major adverse cardiac events (MACE).


Data of adenosine-stress NH3 PET for 263 consecutive patients with known or suspected CAD were retrospectively analyzed. PM ischemia was defined as the absence of PM accumulation under stress conditions and PM presence at rest on high-resolution cine imaging derived from PET-computed tomography scanner with time-of-flight technology. The primary outcome was MACE.


Of 263 patients, 30 experienced mean follow-up period of 910 days (MACE), while 31 (11.8%) presented PM ischemia. Compared to patients without PM ischemia, those with PM ischemia reported a significantly lower global MFR and a significantly higher rate of MACE (P < .0001).


NH3 PET enables the detection of PM ischemia in approximately 10% of patients with known or suspected CAD. PM ischemia is associated with reduced global MFR and is an important sign in predicting prognosis.

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Papillary muscle


Positron emission tomography

13 N-NH3 PET:

N-13 ammonia PET


Coronary artery disease

Global MFR:

Global myocardial flow reserve


Major adverse cardiac events


Myocardial perfusion imaging


Left anterior descending artery


Left circumflex artery


Right coronary artery


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Correspondence to Michinobu Nagao MD, PhD.

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Nakao, R., Nagao, M., Yamamoto, A. et al. Papillary muscle ischemia on high-resolution cine imaging of nitrogen-13 ammonia positron emission tomography: Association with myocardial flow reserve and prognosis in coronary artery disease. J. Nucl. Cardiol. (2020).

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  • Microvascular dysfunction
  • PET
  • myocardial blood flow
  • diagnostic and prognostic application
  • perfusion agents
  • vasodilators