Case from: Rory O’ Hanlon, Sanjay Prasad, Royal Brompton Hospital, London. UK
Clinical 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.
Angiography: Normal coronaries, normal LVgram, normal transthoracic echo
Cine CMR: Preserved LV function but subtle focal infero-lateral hypokinesis without thinning. Contrast CMR: Matching transmural MI with central dark microvascular obstruction*
Based on CMR, it was recommended to investigate for a potential source of paradoxical embolism and thrombophilia. The thrombophilia screen was normal.
Contrast Echo: (agitated saline): A large PFO was visualized with complete opacification of the LV cavity within one cycle on Valsalva.
1. Percutaneous closure of PFO was performed based on clinical presentation and presumed diagnosis of MI secondary to paradoxical embolism
2. CMR in this case made a significant contribution to establishing a diagnosis and directing relevant subsequent investigations.
3. Imaging modalities are complementary: LV angiography and echo may miss subtle RWMA, CMR would not easily detect a PFO.
*MVO, The often found dark core of an acute MI caused by capillary occlusion – the tissue equivalent of ‘no-reflow’