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Number 09-07 All That Elevates Is Not Plaque Rupture
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Number 09-07 All That Elevates Is Not Plaque Rupture

Case from: Ethan Ellis, Gregory Piazza, Emily Pilger, C. Michael Gibson. Institution: Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School

Clinical history: A 75-year-old woman with atrial fibrillation initiated warfarin without heparin "bridging".  Two days later she presented in sinus rhythm with chest pain, 1 mm ST-elevations inferiorly (Figure 1 - click to see in higher resolution), and elevated cardiac biomarkers. She received aspirin, clopidogrel, unfractionated heparin, and eptifibatide.




Figure 1


Coronary angiography was unremarkable (Figure 2A and Figure 2B).  Left ventriculography revealed focal mid-inferior wall hypokinesis (Movie 1) and cardiovascular magnetic resonance (CMR) demonstrated focal akinesis of the mid-inferolateral wall (Movie 2).



Figure 2A



Figure 2B



 Movie 1                                                Movie 2

Myocardial tissue characterization with CMR showed increased signal intensity in the mid-inferolateral wall on T2-weighted fast spin echo imaging, suggestive of myocardial edema (Figure 3A, white arrow). 3D high-resolution LGE imaging showed transmural increased signal intensity in the mid-inferolateral wall was consistent with a myocardial infarction (Figure 3B, white arrow).


Figure 3A


Figure 3B


Perspective: This patient's clinical presentation, angiographic findings, and CMR imaging are consistent with a myocardial infarction due to coronary artery embolus from the left atrium/left atrial appendage following spontaneous conversion from AF to SR.  Prompt treatment with antithrombotic and antiplatelet agents likely resulted in spontaneous thrombolysis.  In this case, CMR was useful to both establish an infarct diagnosis and to determine the location and extent of the infarction in support of the hypothesized etiology. 

1. Wessely R, Botnar RM, Vorpahl M, Schwaiger M, Schömig A, Ibrahim T. Images in cardiovascular medicine. Subacute thrombotic occlusion and spontaneous recanalization of the right coronary artery after percutaneous coronary intervention for ST-elevation myocardial infarction visualized by coronary angiography and cardiac magnetic resonance imaging. Circulation. 2007;116:e78-80.
2. Carlsson M, Wilson M, Martin AJ, Saeed M. Myocardial microinfarction after coronary microembolization in swine: MR imaging characterization. Radiology. 2009;250:703-13.  

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Case of the Week handling editor: Chiara Bucciarelli-Ducci


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