Case Session
SCMR 22nd Annual Scientific Sessions
Austin Robinson, MD
Fellow
University of Virginia
Adrián Löffler, MD
Cardiac Imaging Fellow
University of Virginia Health System
Roshin Mathew, MD
Cardiovascular Advanced Imaging Fellow
University of Virginia Health System
Michael Ragosta, MD
Professor of Medicine (Cardiology)
University of Virginia
Gorav Ailawadi, MD
Professor of Surgery
University of Virginia
Christopher Kramer, MD
Ruth C. Heede Professor of Cardiovascular Medicine
University of Virginia Health System
Michael Salerno, MD
Associate Professor of Medicine (Cardiology), Radiology, and Biomedical Engineering
University of Virginia
Description of Clinical Presentation:
A 70 year old male with CAD, including LAD aneurysm s/p recent hybrid management with coronary bypass grafting with LIMA to LAD and ligation of the proximal LAD, followed by percutaneous covered stent-exclusion of the native LAD, presented to the hospital after a syncopal event. EKG demonstrated new loss of R wave progression in precordial leads and echocardiography showed subtle hypokinesis of the septum that was new since the intervention. Patient was referred for cardiac MRI to evaluate LV segmental function and burden of myocardial scar.
Diagnostic Techniques and Their Most Important Findings:
CT coronary angiography:
A Siemens 128 detector dual source cardiovascular CT scanner was used to obtain EKG-gated images of the coronary arteries. This demonstrated severe coronary calcification with a proximal LAD aneurysm, measuring 44 mm in diameter with severe stenosis in the proximal and mid LAD. (Figure 1) There was aneurysm along much of the RCA course.
Cardiac MRI:
A Siemens 3T Prisma was used to obtain the following sequences: axial HASTE, T1/T2 weighted imaging, steady state free precession (SSFP) short and long axis cine images, and phase sensitive inversion recovery images. This demonstrated LV ejection fraction of 35% and his known, excluded large LAD aneurysm with evidence of thrombus (Figure 2). The inferoseptum was hypokinetic and demonstrated subendocardial late gadolinium enhancement (LGE) (Figure 3). There was also LGE in the basal inferolateral wall consistent with a chronic RCA infarct. There was no other evidence of infarction in the LAD territory. Given syncopal event, low EF and scar burden, patient underwent ICD placement for prevention of sudden cardiac death.
Learning Points from this Case:
The patient appeared to have had a clinically stable loss of a septal perforator as the result of hybrid intervention for a large LAD aneurysm, which likely resulted in VT causing the syncopal event. CMR nicely demonstrated evidence of new subendocardial scar in this case. The optimal management strategy of coronary artery aneurysms has not been well established. One proposed solution is hybrid surgical bypass and percutaneous exclusion, as was performed in this case (1). However, the outcomes related to this approach have not been described. Magnetic resonance imaging has the potential to provide important information about the size of aneurysm and nature, including thrombotic content, as well as evidence of myocardial injury related to management strategies.