Transcript Case of the week 08-XX: A tricky diagnostic challenge

Case of the week 09-01: Is it or isn’t it coronary artery disease: (page 1 of 2)
History: A 46-year-old man presents with breathlessness, heart failure and chest pain. Troponin borderline
Past medical history: Diffuse coronary artery disease 3 year previously; systemic lupus with persistent pleural
effusion and joint pains.
Echo: globally poor systolic function, borderline AV dyssynchrony
SPECT: ‘minimal inducible ischaemia’
Angiography: delayed as too unwell.
CMR requested, question: ischaemic cardiomyopathy?
Cine CMR: Marked dilatation and regional dysfunction*
(inferior and infero-lateral dyskinesis with preserved
myocardial thickness)
Contrast CMR: absence of LGE suggests viability of all
territories
CMR diagnosis: Likely stunning of infero-septal and inferior
wall. Consider angio. The possibility of thrombus in a
dominant RCA exists…
Dr Anna Herrey, Ajay Suri, Andrew Flett, Simon Woldman
The Heart Hospital, London, UK
* note: cine artefact was determined to be
due to the surface coil connection)
Case of the week 09-01: is it or isn’t it coronary artery disease: (page 2 of 2)
coronary angiography: A dominant RCA with thrombus – treated with successful PCI
PRE
POST
PRE
POST
Follow-up CMR: six weeks later: significant regional
and global LV recovery (+20% ef) confirming stunning of
the inferior and infero-septal wall. No infarction from the
procedure
Conclusion: CMR accurately predicted the presence of
acute coronary disease as well as recoverability of the
affected coronary territories.