Case from: Giovanni Quarta, Caroline Coats, Ferdiando Pasquale, James Moon. The Heart Hospital, London UK 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.
Echocardiogram: Disproportionate LV dilatation, thinning and impairment for the size of the apparent infarct. With global dyscoordination and thinning, distinguishing infarcted and non-infarcted myocardium was impossible. CMR requested.
Cine CMR: (day 4) Confirms the echo: severely LV dilatation (LVEDd 8cm), dyscoordination, thinning and global hypokinesis. Prominent trabeculae noted.
CMR Tissue Characterization: After gadolinium, there was a clear, small, transmural myocardial infarction in the basal inferior wall, but not elsewhere. No LV thrombi on early gadolinium imaging.
Conclusions: CMR, by the virtue of its ability tissue characterization ability, confirmed two pathologies: a small transmural MI and severe non-ischemic dilated cardiomyopathy. Although the ST elevation MI was the presenting complaint, the DCM is the more important pathology here and is diagnosed by CMR even in the context of MI and proven coronary artery disease.