A 45-year-old man presents with chest pain radiating to his left arm of duration 2 hours. There is no relevant past medical history. Troponin levels were measured at 1434 ng/L. The ECG is shown below.
Video below shows the CMR long-axis cine images
Video below shows the short-axis cine images.
The late myocardial enhancement images are shown below
What is the diagnosis?
The ECG shows global ST elevation. The late gadolinium images show myocardial fibrosis in a non-ischaemic distribution (epicardial and mid-wall). Given the history, this would be consistent with acute myocarditis. Ischaemic insults cause late myocardial enhancement to spread from the endocardium to the epicardium.
A 65-year-old man presents with angina to the outpatient clinic. There is a past history of myocardial infarction 10 years earlier. You list him to have an angiogram. The angiogram demonstrates an occluded left anterior descending artery and a 90% stenosis of the right coronary artery. A CMR is requested to assess viability prior to any potential intervention. Video below shows the CMR long axis cines
Video below shows the short axis cines.
The late myocardial enhancement is shown below
Which of the following statements is correct?
The septum and anterior wall is LAD territory. This is where there is late myocardial enhancement (white appearance of myocardium). The enhancement is >50% of the wall thickness; therefore the territory is classed as non-viable.
A 42-year-old man presents to the outpatient clinic with Canadian class 2 angina symptoms. His only risk factor is hypercholesterolaemia and he is on a statin. He is referred for an adenosine perfusion stress CMR to assess for inducible ischaemia. Video below shows the long-axis cines,
Video below shows the short-axis cines,
Video below shows the perfusion images (stress, top row; rest, bottom row).
The late myocardial enhancement is shown below in the four-chamber view (top left), three-chamber view (top right), and two-chamber view (bottom).
Which one of the following statements is correct?
There is no late myocardial enhancement present on the late gadolinium images and therefore there is no myocardial infarction. There is an inducible perfusion defect in the anterior wall/septum (LAD territory).
A 63-year-old man presents with a non ST-elevation acute coronary syndrome. His troponin is elevated at 650 ng/L. The ECG is unremarkable. He has a past medical history of familial hypercholesterolemia but is taking no medication. His cholesterol level is 11.3 mmol/L.
He undergoes coronary angiography which reveals triple-vessel disease. A CMR is undertaken to assess myocardial viability. z Video below shows the long-axis cines,
and Video below shows the stress perfusion images at the basal (top left), mid (bottom left), and apical (top right) levels.
The late myocardial enhancement images are shown ibelow (top row, left to right: basal, mid, and apical short axis; bottom row, four-chamber view).
There is late myocardial enhancement in the lateral wall which represents <50% wall thickness and therefore is viable. This distribution of late gadolinium enhancement is within the circumflex (Cx) territory.
A 73-year-old male presents with breathlessness on exertion. His current medication consists only of amlodipine 5 mg od. His ECG demonstrates voltage criteria for left ventricular hypertrophy. A TTE reveals LVH so he is referred for CMR. Video below shows the long-axis cines
and Video below shows the short-axis cines.
Figure below shows the late myocardial enhancement of the four-, three-, and two-chamber views (top row, left to right) and the short-axis views at the basal, mid, and apical levels (bottom row, left to right).
What is the most likely diagnosis?
There is asymmetrical LVH up to 20 mm with systolic anterior motion (SAM) at rest. There is replacement fibrosis of the regions of increased wall thickness. This is a case of hypertrophic cardiomyopathy.
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