European Journal of Heart Failure 2007 9(9):959-961; doi:10.1016/j.ejheart.2007.06.002
© 2007 European Society of Cardiology
Severely impaired left ventricular function: Tissue characterization by cardiovascular magnetic resonance in a clinical dilemma
Chiara Bucciarelli-Duccia,b,*,
Didier Loccaa,
Rory O'Hanlona,
Paul Oldershawc and
Sanjay K. Prasada,b
a Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital London, UK
b National Heart and Lung Institute, Imperial College London, UK
c Cardiology Division, Royal Brompton Hospital UK
* Corresponding author. Cardiovascular Magnetic Resonance Unit Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK. Tel.: +44 20 7351 8812; fax: +44 20 7351 8816. E-mail address: c.bucciarelli-ducci06{at}imperial.ac.uk
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Abstract
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In patients with symptoms of heart failure, identifying the
underlying cause of cardiomyopathy is helpful to establish the
diagnosis and to guide therapy. The differential diagnosis of
cardiomyopathy can be challenging based on clinical findings.
We report the case of a patient who represented a clinical dilemma
(cardiac sarcoidosis or ischaemic heart disease), in whom cardiovascular
magnetic resonance was a clinically valuable tool to distinguish
dual cardiac pathology due to its unique, non-invasive, tissue
characterization capabilities.
Key Words: Cardiac sarcoidosis • Cardiovascular magnetic resonance • Imaging • Ischaemic heart disease
Received February 6, 2007; Accepted June 4, 2007
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1. Case report
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A 54-year-old man presented with symptoms of heart failure (NYHA
class III), palpitations and a transient episode of chest pain
which had occurred 3 weeks previously. His past medical history
was notable for sarcoidosis 15 years earlier, with no clinical
evidence of active disease in recent years. Electrocardiogram
showed left bundle branch block. Chest X-ray showed cardiothoracic
ratio at the upper limit of normal, some unfolding of the aorta,
slightly prominent hilum and clear lung fields. His echocardiogram
showed significant impairment of left ventricular (LV) function
but notably with an akinetic inferior wall and apex.
Diagnostic X-ray coronary angiography confirmed regional akinesia of the inferior wall but surprisingly showed non obstructed coronary arteries with the right coronary artery (RCA) widely patent (movie 1, see Appendix A), normal circumflex coronary artery and a diminutive left anterior descending artery in its distal portion without discrete stenosis (movie 2, see Appendix A). These findings raised a diagnostic dilemma: Did the patient have recanalisation of the RCA or cardiac sarcoid involvement? Contrast-enhanced cardiovascular magnetic resonance (ce-CMR) imaging was performed to assess the aetiology of his left ventricular dysfunction-ischaemic heart disease [1] or another cardiomyopathic process such as cardiac sarcoidosis [2,3]. Spin-echo images showed extensive mediastinal lymphadenopathy (Fig. 1). Cine images confirmed the presence of markedly dilated LV with severely impaired systolic function (end-diastolic volume: 372 ml, end-systolic volume: 266 ml, calculated EF: 28%). Early inversion-recovery segmented gradient-echo imaging following gadolinium-DTPA contrast administration showed absence of contrast uptake in the septum (Fig. 2, panel A), suggesting the presence of microvascular obstruction (MVO), pathognomonic of recent myocardial infarction [4]. On delayed images, there was extensive transmural enhancement of the mid cavity inferior wall with right ventricular involvement (Fig. 2, panel B). However, CMR also showed subendocardial enhancement of the septum and lateral wall from the base to the apex of the LV (Fig. 2, panel C). No signs of myocardial inflammation and/or oedema were observed on the T2-weighted turbo spin-echo images indicating no detectable active inflammation (Fig. 2, panel D). The presence of cardiac sarcoidosis was therefore excluded and in the context of his coronary anatomy these findings were consistent with coronary recanalization. However, such extensive involvement of myocardial necrosis is an unusual finding with a recanalized RCA. A second evaluation of the coronary angiography showed a dominant and prominent RCA whose branches extended to the apex, which was in accordance with the CMR findings.
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Fig. 2 Panel A: four-chamber view, presence of MVO (white arrow) indicating acute myocardial infarction. Mid cavity short axis (panel B) and four-chamber (panel C) views, IR T1-weighted gradient echo images. Late gadolinium enhancement is present in the inferior wall, inferior septum and extending to the right ventricle (black arrow). Panel D: four-chamber view, STIR T2-weighted spin echo sequence.
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2. Discussion
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Overall, according to the pattern of contrast distribution,
the CMR findings were consistent with ischaemic aetiology with
an unusually prominent RCA. CMR was a clinically valuable tool
to distinguish dual cardiac pathology by providing information
on the presence of a recent infarct that suggested prompt re-evaluation
of the coronary angiography and subsequent appropriate clinical
management.
In 20-50% of patients with sarcoidosis at autopsy there is evidence of cardiac involvement, which produces symptoms in only 5% of patients [5]. The granulomatous infiltrations most commonly affect the left lateral wall, papillary muscles, right ventricle free wall and subendocardial surface. Cardiac sarcoidosis has a typical appearance on CMR: active sarcoidosis with myocardial inflammation appears as a bright signal on T2-weighted images, a typical pattern on Ce-CMR that does not correspond to any particular epicardial coronary artery distribution but rather matches the fibrogranulomatous involvement of the myocardium [6]. While more work has to be carried out, CMR has the potential to offer incremental value in both the detection of cardiac sarcoidosis and represents a potential therapeutic marker [7,8].
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Notes
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All authors disclose any personal or financial support or any
conflicts of interest related to this manuscript.
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References
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Abstract
1. Case report