Microvascular obstruction complicating acute myocardial infarction

Case contributed by Dr Azza Elgendy

Presentation

Chest pain, elevated troponin, status post cardiac catheterization and angioplasty.

Patient Data

Age: 60 years
Gender: Male

There is delayed myocardial enhancement involving the anteroseptal , anterior, anterolateral and lateral walls extending from base to apex consistent with the recent extensive LAD occlusion. Additional non enhancing foci in LAD distribution, is highly suspicious for microvascular obstruction with underlying hemorrhage. Significant T2 prolongation in this region is likely due to wall edema.

The first image was taken early after giving the GAD at Ti of 600 shows intra-myocardial, non enhancing foci in LAD distribution,  highly suspicious for microvascular obstruction and intra-myocardial hemorrhage. The second image shows set of 2 images the one on the right was taken 4 min after contrast injection, the left one was taken 14 min after the injection, the area of the hypo enhancement with the central dark zone marked by the green arrows, indicating myocardial infarction with central zone of MVO, the extent of the MVO is less on the left image  due to contrast penetration over time. 

Case Discussion

There is acute myocardial infarction the distribution of LAD, constitutes 40-50% of LV mass. It is dominant left circulation that is why the apex is involved as well. A dark zone of mesocardial non enhancement in this distribution is suggestive for microvascular obstruction with underlying haemorrhage. Significant prolongation on native T2 mapping in this region is likely due to wall oedema in keeping up with acute ischaemia.  Severely decreased left ventricular systolic function with LVEF = 25% (contouring not included).

Diffuse  pericardial enhancement seen in the setting of Dressler's syndrome.

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Case Information

rID: 48566
Case created: 14th Oct 2016
Last edited: 27th Oct 2016
System: Cardiac
Tag: mvo
Inclusion in quiz mode: Included

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