2 - CMR identification of flush occlusion as a cause of MINOCA
Thursday, February 13, 2020
2:55 PM – 3:05 PM
Location: Salon J2
Description of Clinical Presentation: A 68 year-old male with a background of hypertension, diabetes and previous percutaneous coronary intervention (PCI) to the left main coronary artery (LMCA) and left anterior descending artery (LAD) presented with a two-day history of chest pain. His electrocardiogram showed lateral T-wave inversion and he had a markedly elevated serum troponin I of 17,598ng/l (normal range 0-34ng/l). A transthoracic echocardiogram showed an anteroapical wall motion abnormality and moderate left ventricular systolic dysfunction. A coronary angiogram subsequently showed patent stents in his LMCA and LAD with mild-moderate lesions in the RCA and circumflex arteries but no clear culprit lesion.
Diagnostic Techniques and Their Most Important Findings: A CMR was performed with T2 mapping and dark-blood late gadolinium enhancement. This showed moderate systolic impairment (LVEF 40%) with anterolateral and apical lateral akinesis. T2 mapping showed elevation in the anterolateral and apical septal segments (Figure 1). Late gadolinium imaging showed extensive >75% thickness late gadolinium enhancement in the same territory (Figure 2). There was also a small subendocardial basal inferior infarct, but T2 mapping values were normal here, indicating this was old.
Learning Points from this
Case: The patient returned to the catheter laboratory where focussed reassessment of the proximal LAD identified a flush occlusion of D1. A PCI was subsequently undertaken with good result (Figure 3). This case highlights the importance of CMR in myocardial infarction with apparently “non-obstructed” coronary arteries, which frequently identifies infarction due to recanalisation or embolism, myocarditis, Takotsubo or other cardiomyopathies. In this case, the identification of a flush occlusion and targeting of subsequent PCI is likely to have been important given the large territory being infarcted.