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Cases of the Week 2010

Number 10-18: Aortic Coarctation Repair with associated Bicuspid Aortic Valve History: 3D MRA demonstrating pre and post stenting of descending thoracic aorta coactation in addition to a bicuspid aortic valve with dilated aortic root.

Number 10-17: Clinical role of perfusion CMR History: A patient with chest pain had echocardiography suspicious for HCM - CMR resolved the true diagnosis of multivessel CAD.

Number 10-16: Improvement in Image Quality in Atrial Fibrillation by using a Novel Prospective Reconstruction Method History: Presentation of alternative techniques for improving image quality in patients with arrhythmia.

Number 10-15: T2* CMR to tailor chelation therapies History: A 35 year old male with beta-thalassemia major, regularly transfused since the age of 30 months, started chelation treatment with subcutaneous desferrioxamine at the age of 4 years.

Number 10-14: Persistent Left SVC and AF Ablation History: Electrical Activation of Atrial Fibrillation via persistent left SVC

Number 10-13: Cardiac Metastasis of the Renal Cell Carcinoma Diagnosed by CMR History: A 59 year old male with history of pleuritic chest pain and pulmonary embolism presenting with painless hematuria

Number 10-12: Spiral Hypertrophic Cardiomyopathy History: This is a case of HCM with asymmetrical hypertrophy which is distributed in a spiral or helical way from base to apex.

Number 10-11: Cardiac Sarcoidosis History: A 32-year-old man presented with chest pain, fever, erythema nodosum of the lower extremities and swelling of both ankles. ECG showed ST-elevation in leads I and aVL and troponin was raised 40-fold.

Number 10-10: The Case of Three Ventricles History: Large left ventricular basilar aneurysm with thrombus secondary to infarct

Number 10-09: Acute Pulmonary Edema in an Active Duty Officer in Iraq History: A 27-year-old female active duty soldier with no significant past medical history was evacuated from Iraq for flash pulmonary edema.

Number 10-08: Perfusion Abnormalities in Cardiac Amyloidosis History: A 68 year-old hypertensive male patient presented with typical chest pain. The ECG showed new characteristic ischemic changes and troponin dosage was positive. An urgent coronary angiogram revealed unobstructed epicardial coronary arteries. The echo showed a significant degree of septal wall thickening, out of proportion with his well-controlled blood pressure profile, suggesting possible hypertrophic cardiomyopathy.

Number 10-07: Sludge infarcts due to homozygous sickle cell anemia History: 16 y/o male with homozygous sickle cell anemia presenting with a history of chest pain and normal coronary angiography.

Number 10-06: Common Trick, Uncommon Application History: An incorrect diagnosis of Gerbode defect by CMR clarifed by echocardiography with agitated saline.

Number 10-05: Dobutamine inducible ischaemia: Case 2 History: An 48 year old male was admitted to hospital with 6 hours of crushing central chest pain.

Number 10-04: Hemorrhagic myocardial infarction History: Case demonstrating CMR sequences which can aid in the effective diagnosis of hemorrhagic infarct

Number 10-03: Unicuspid aortic valve and associated anomalies History: A 24-year-old male underwent a subclavian flap repair for aortic coarctation at the age of 1. A recent echocardiogram had been reported as showing mild aortic regurgitation and a dilated aortic root.

Number 10-02: Dobutamine inducible ischaemia: Case 1 History: 62 year old asthmatic male presented to the cardiologists with worsening atypical chest pain and breathlessness on exertion.

Number 10-01: Myofibroblastic tumor of the right atrium in a 2-year old boy History: A 2 year-old male with a history of one week febrile illness and cough was evaluated by his pediatrician

Cases of the Week 2009

Number 09-19: Pulmonary embolism by CMR History: A 34-year-old white female with a history of anxiety, mild asthma, and allergic rhinitis was recently hospitalized with an episode of SVT

Number 09-18: Traumatic interventricular septal dissection History: A 15-year-old boy fell down into a 10 meters gutter, he was found spleen bleeding and pansystolic cardiac murmur at the left sternal border without rib fracture.

Number 09-17: Characterization of a left atrial anomaly with CMR History: A 67-year-old female with hypertension presented with a 5-month history of exertional chest pain and dyspnea.

Number 09-16: A large and mysterious mass in the LV History: A 59 y/o female with history of breast CA s/p right lumpectomy and ovarian CA was referred for CMR

Number 09-15: Peripartum Cardiomyopathy? History: CMR in possible Peripartum Cardiomyopathy demonstrates Duchenne muscular dystrophy in a carrier - scar burden reinforces decision for ICD implantation

Number 09-14: CMR in Systemic Sclerosis History: A 28 years old female with Scleroderma (SSc) for 11 years and acute angina and elevated creatine kinase (CK).

Number 09-13: Severe AI in a bicuspid AV assessed with CMR History: A nice example of how CMR can be used to evaluate the severity of AI using cine and phase contrast CMR imaging.

Number 09-12: Role of CMR in acute myocardial infarction, primary angioplasty, and autologous stem cell therapy History: 50 y/o male with a 3 week history of accelerated angina...

Number 09-11: Gerbode Ventricular Septal Defect after Ross Procedure History: A 26-year-old male patient with past medical history of aortic coarctation repair...

Number 09-10: An unusual complication of the Ross procedure and the role of CMR in its assessment History: A 26 year old male had previously undergone a Ross procedure for a stenosed bicuspid aortic valve when aged 17yrs.

Number 09-09: Left Atrial Appendage Clot and Atrial Fibrillation History: Atrial appendage thrombus post thoracoscopic atrial appendage amputation imaged with CMR.

Number 09-08: Syncopal Event in a Case of Kawasaki's History: Kawasaki's Disease and Atrial Septal Aneurysm. Single imaging modality for complete assessment.

Number 09-07: All That Elevates Is Not Plaque Rupture History: A 75-year-old woman with atrial fibrillation

Number 09-06: Heterogeneous etiologies affecting a patient with cardiac amyloidosis History: 81 year-old male with history of atrial fibrillation

Number 09-05: Locating the leaks History: 61 year old female with endocardial cushion referred for CMR to measure shunt flow.

Number 09-04: Diagnosing RV dilatation by CMR (2) History: A 52 year old male with a dilated right ventricle and elevated pulmonary artery pressures on echocardiography.

Number 09-03: Coincident Hypertrophic Cardiomyopathy and Left Ventricular Non-Compaction History: Woman, 44 y/o, diagnosed by echocardiography of Non-Obstructive Hypertrophic Cardiomyopathy (HCM)

Number 09-02: Giant LV Pseudoaneurysm by CMR History: A 79 year old male with late-presentation lateral STEMI 3days earlier..

Number 09-01: Is it or isn't it coronary artery disease? History: A 46-year-old man presents with breathlessness, heart failure and chest pain. Troponin borderline

Cases of the Week 2008

Number 08-23: A tricky diagnostic challenge History: A man in his 40s presenting to respiratory medicine with 6 months breathlessness and hemoptysis.

Number 08-22: A Segmented thoracic mass History: A 32 yrs old man was referred for assessment of iron loading by measurement of cardiac T2*. Past medical history of transfusion dependent thalassaemia (thalassemia) major and chronic iron chelation therapy.

Number 08-21: Myocardial scarring from 2 distinct pathologies History: Asymptomatic 62 yr ?. Diagnosed with HCM more than 20 with an abnormal ECG. Recent echo demonstrated concentric LVH. CMR to further assess this.

Number 08-20: Imaging Restrictive cardiomyopathy by CMR History: A 23 year old male presented with increasing dyspnea, abdominal distension, pedal edema and orthopnea over 18 months.

Number 08-19 Diagnosing RV dilatation by CMR History: ** Case of the year winner, 2008

Number 08-18 'Bystander' ST elevation MI in DCM History: A 52 yr old lady, previously asymptomatic with no previous medical history, underwent a primary PCI for acute chest pain with inferior STEMI and LBBB. The left coronary system was unobstructed and RCA was occluded distally. PCI successfully established flow into the postero-lateral branch but not posterior descending branch of the RCA.

Number 08-17: Isolated Left Ventricular Apical Hypoplasia History: 35yr male. Known previous DCM diagnosed via echocardiography. Currently stable, NYHA Class I, and well controlled. No significant arrhythmias noted. Referred for CMR.

Number 08-16: Advanced late gadolinium enhancement optimisation History: 48 Y/O male from Kuwait presented with dyspnea and palpitations. Holter shows 2:1 heart block episodes. PMH: severe asthma.

Number 08-15: Danon Disease - A rare cause of LV hypertrophy History: 20 years old male, history of RF ablation for WPW syndrome, without prior history of heart failure.

Number 08-14: Erdheim-Chester Disease by CMR History: 41 year old black female admitted for chest pain, malaise, weakness and increasing peripheral edema. Tibial biopsy had demonstrated typical findings of Erdheim-Chester disease (ECD) 8 years earlier. She has previously documented involvement of the long bones, pancreas, pericardium and thoracic aorta with her ECD. Cardiac biomarkers were negative for myocardial necrosis.

Number 08-13: Viral Myocarditis by CMR History: A 22-year-old college student noted chest pain one week after recovering from flu-like symptoms. His ECG revealed inferolateral ST-elevation and his cardiac biomarkers were elevated.

Number 08-12: Congenital Bicuspid Aortic Valve with Ascending Aortic Dilatation History: 35 year old man. Known congenital bicuspid aortic valve. Recently noted ascending aortic dilatation on routine echocardiogram. Referred for a cardiac MRI for LV functional and morphologic assessment and contrast MRA for aortic evaluation.

Number 08-11: CMR for RA Mass characterization History: A 37 yr female had an echocardiogram for chest pain showing a possible mass in the right atrium. CMR was performed to further characterise this.

Number 08-10: Interrupted Aortic Arch History: 2 day old female, mild respiratory distress

Number 08-09: Lipomatous Hypertrophy of the Interatrial Septum (LHIAS) History: 73 year male. 1 year hx of myalgia and weight loss. RA mass on echo.

Number 08-08: Incidental chest findings - is CT needed? History: A 54 yr old man with abnormal ECG and apical obliteration on LVgram but normal echo, was referred for CMR (possible apical hypertrophic cardiomyopathy).

Number 08-07: Left Ventricular Trabeculae, Non-Compaction and DCM History: 18 Y/O male presented with dyspnea and palpitations. His father had died suddenly at age 32.

Number 08-06: Coarctation & aortic stenosis? History: A 46 year old male with 6 months breathlessness. Previous patch repair of “adult type” CoA.

Number 08-05: Acute MI, normal coronaries History: A 44 yr old lady transferred for primary PCI for chest pain with lateral ST elevation. Troponin I 26, CK 1233. Normal lipids (TC:HDL 3.17). Only risk factor for IHD was hypertension: non-smoker.

Number 08-04: Where is the murmur from? History: A 20 year-old Hispanic male with a murmur since childhood presented with worsening exertional chest pressure and dyspnea. CMR was ordered for further evaluation.

Number 08-03: Primary Pericardial Echinococcosis History: A 47 year male previously admitted with a severe pericardial effusion which was drained and an associated left pleural effusion. Subsequently referred for a CMR scan with as a structure “like a cyst” was noted near the heart on echocardiography.

Number 08-02: Apical HCM, fibrosis and sustained VT History: An 82 yr man admitted with palpitations, presyncope and sustained monomorphic VT. Family history, his brother died age 6 of unknown cause.

Number 08-01: Measuring Dyssynchrony in Pulmonary Hypertension History: A stable, idiopathic pulmonary artery hypertensive (IPAH) 38 year old female (PAP 110 mmHg, WHO functional class III) underwent CMR.

Cases of the Week 2007

Number 07-22: LV Thrombus History: A 59 year old man with previous anterior MI presented with a 6 hour history of acute dyspnoea without chest pain

Number 07-21: An unexpected cause of ascites History: A 31 year old male with a 2 year History of recurrent ascites, peripheral oedema and deranged LFTs. Budd-Chiari syndrome suspected. Proteinuria noted so Renal MRA requested to exclude renal vein thrombosis

Number 07-20: ASD First pass contrast bolus tracking History: A 28 year old white male with incidental CXR abnormalities: cardiomegally, right heart enlargement and R pleural effusion ECG: RVH

Number 07-19: CMR guided revascularisation History: 72 yr old man with a 3 week history of chest pain and shortness of breath presented in cardiogenic shock with pulmonary edema, acute renal failure and VT

Number 07-18: Right Atrial Tumour - or not? History: An incidental mass was identified in the right atrium of a middle aged female on pre-operative trans thoracic echocardiography (top left). CMR requested for further characterization.

Number 07-17: ARVC mimic - congenital partial absence of the pericardium History: Family screening implemented for ARVC after a 1st degree relative died of cardiomyopathy with ventricular dilatation. In this individual, and abnormal ECG with right pre-cordial T wave inversion and a shift of the transition zone to V5 was found suggesting possible ARVC. Echo normal but with poor windows.

Number 07-16: Late Mediastinal malignancy treatment complications History: Increasing Breathlessness. Past medical history included a thymoma removal with subsequent mediastinal radiotherapy. Previous successful PCI to the LAD for radiation induced coronary artery disease.

Number 07-15: Sarcoidosis Masquerading as ARVD/C History: A 46 year old African American presenting with VT of LBBB morphology.

Number 07-14: ARVC with LV involvement History: A 59 year old with an 8 year history of asymptomatic ARVC diagnosed through family screening. A disease causing mutation in plakophilin was found. Type 1 diabetes since childhood. Recent echo showed a possible new LV apical aneurysm. Coronary angiography normal.

Number 07-13: Cine Artefact History: A 55 y.o. male admitted with new heart failure. No acute coronary syndrome. Past medical history includes type I Diabetes, hypertension, chronic renal insufficiency and anaemia of chronic disease. After stabilization, transthoracic echo showed an EF of 40%, no significant valvular disease. CMR was requested.

Number 07-12: Troponin +ve Chest pain, normal coronaries History: 6 months ago, a 48 year old body builder had troponin positive chest pain with inferior T wave inversion on ECG and normal coronary angiography. Echo had suggested possible inferior hypokinesia. Ongoing clinical uncertainty

Number 07-11: Valvular disease by CMR History: A 74 year old female with increasing breathlessness. Known rheumatic heart disease and LVH.

Number 07-10: Tumor or Thrombus? History: 61 year old male, known renal cell carcinoma with renal venous thrombosis.

Number 07-09: Tako-tsubo or Infarction History: ***Winner, case of the Year, 2007.

Number 07-08: Acquired VSD by CMR History: An 80 year old man with STEMI and cardiogenic shock.

Number 07-07: HCM with LVOT obstruction by CMR History: 62 year old man with HCM with obstruction referred for alcohol septal ablation (ASA) refractory symptoms of angina and dyspnea. This was a baseline study done prior to ASA.,

Number 07-06: Microvascular Obstruction by CMR History: A 41 year-old man admitted with 3 hours of chest pain with initial thrombolysis (tenecteplase) and salvage angioplasty one hour later.

Number 07-05: Double chambered Right Ventricle History: 34-yr-old male, recurrent syncope and dyspnea

Number 07-04: Delayed enhancement-targeted biopsy History: A 53-yr-old male with 2 types of symptomatic VT. One VT with LBBB and superior axis suggested origin from RV inflow, likely from IVS. Rest ECG shows inverted T waves inferiorly and no epsilon wave.

Number 07-03: HCM with multi-level obstruction History: A 69 yr-old female, increasing breathlessness.

Number 07-02. Coarctation, MS and bicuspid AoV History: A 17-yr-old female, referred with hypertension.

Number 07-01: `Ringing bell' sinus of valsalva aneurysm History: A 42-yr-old male, recent onset breathlessness.

Cases of the Week 2006

Number 06-10: Myocarditis History: A 42 year-old male admitted with 3 days of chest pain and diarrhoea

Number 06-09: Isolated RV infarction History: A 61-year-old male, 24 hours of chest pain, CK raised, normal ECG.

Number 06-08: Great vessel pathology History: A 16 year old male, known coarctation + dysplastic aortic valve.

Number 06-07: Infective cardiomyopathy History: A 55 year old male presented with breathlessness and palpitations

Number 06-06: What course the RCA? History: A 56 year old female, atypical chest pain and collapse.

Number 06-05: Apical HCM by CMR and echo History: A 64 year old women presented with chest pain and palpitations. The ECG showed Extensive T wave inversion. Echocardiography (L) was reported as showing diastolic dysfunction and an akinetic apex. Cine CMR confirmed the clinical suspicion of apical hypertrophic cardiomyopathy (aHCM).

Number 06-04: Thrombus or tumor? History: An 84 year old women presented breathless. Earlier in the year, she had undergone coronary artery bypass from which she had made a full recovery. Echocardiography demonstrated a left atrial mass, of uncertain aetiology.

Number 06-03: Pericardial constriction History: A 59 year old presented with paroxysmal atrial fibrillation, breathlessness, ankle oedema and disturbed liver function tests.

Number 06-02: High Risk HCM History: A 33 year old man with HCM with a family history of sudden death. Seven years previously, a single Holter had shown 3 beats of NSVT. Cine CMR shows HCM with ASH, no SAM, no LVOTO (left or right), and normal systolic function. After gadolinium, there was very extensive late enhancement, (44% of LV myocardium, arrowed). The scan triggered re-evaluation of cardiac risk, and the patient was offered an ICD.

Number 06-01: Left Atrial Myxoma History: An 80 year old men presented with dyspnea. Echo showed a LA mass. Cine CMR (left) showed a large (7x7x4cm) tumor attached to the fossa ovalis, prolapsing through the mitral valve. Signal intensities: low T1 and high T2 (middle, top and bottom) were also compatible with myxoma, subsequently confirmed at surgery (right). The patient was discharged 6 days after surgery.