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.

Presenting Author(s)

Zakariye Ashkir, MD

Specialty Registrar (Resident)
Imperial College Healthcare NHS Trust

Disclosure: Disclosure information not submitted.

Primary Author(s)

Zakariye Ashkir, MD

Specialty Registrar (Resident)
Imperial College Healthcare NHS Trust

Disclosure: Disclosure information not submitted.

Co-Author(s)

CP

Carla Plymen, MD

Imperial College Healthcare NHS Trust

Disclosure: Disclosure information not submitted.
BA

Ben Ariff, MD, PhD

Imperial College Healthcare NHS Trust

Disclosure: Disclosure information not submitted.
Tushar Kotecha

Cardiology Research Fellow
University College London

Disclosure: Disclosure information not submitted.
Graham Cole, MD, PhD

Consultant Cardiologist
Imperial College London

Disclosure: Disclosure information not submitted.