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Number 11-08: Innovative Viability Study for an Uncommon Complication of Myocardial Infarction
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Number 11-08: Innovative Viability Study for an Uncommon Complication of Myocardial Infarction

Case from: G Cooper, R Shifrin & J Peterson.
Institute: University of  Florida Cardiac Imaging Group, Gainesville, Florida, USA.

Clinical history:
A 64 year old female with acute myocardial infarction 20 years earlier and CABG 10 years previously, was admitted with 2 episodes of syncope. Physical examination was positive for a well healed median sternotomy and an S4. Cardiac markers were twice negative.
EKG shows normal sinus rhythm at rate of 62 bpm, loss of R wave anteriorly and T wave abnormalities in DI, aVL and the anterior precordial leads (Figure 1).

 

 

Figure 1

 

SPECT Regadenoson stress perfusion study (not shown) demonstrated  a large, severe, fixed, anterior perfusion defect.
Transthoracic echocardiography showed a dysfunctional LVEF of ~40%, with anteroseptal and apical hypokinesis.
CMR was ordered in consideration of  bi-ventricular pacing therapy.

CMR Findings: except as noted, images were obtained prior to the injection of Gadolinium.

 

 

Figure 2 - Axial Localiser showing apical thinning with an area of increased signal intensity from the ventricular septum

 

The first transaxial localiser images already show apical thinning of the LV with an area of increased signal intensity in the interventricular septum (Figure 2).

 

 


Movies 1 & 2

4 & 2 chamber steady-state free precession (SSFP) cines (Movies 1 & 2) demonstrate an area of high signal intensity in the septum (previously seen on the axial localiser - Figure 2) with anterior and apical wall thinning and dyskinesis.

 

Movie 3

On the short axis SSFP cines (Movie 3), the anterior and anteroseptal dyskinesis and thinning is well observed. The area of increased signal in the interventricular septum is noted once again.

 


                                                                                            

Movie 4                                                                                     Movie 5

 

 

 

Movie 6

Resting Gadolinium perfusion images were obtained in 3 short axis slices (Movies 4 [base], 5 [mid-cavity level] and 6 [apex]).  The septal area with increased signal intensity was once again noted before the injection of Gadolinium. There is a thin rim of hypoperfused subendocardial myocardium seen on all three stress slices. 

A standard set of multi-plane late gadolinium-enhanced  (LGE) images was obtained (Movie 7 [short axis stack] & Movie 8 [4-chamber view]). It was evident that the preexisting septal area of increased signal intensity would make assessment of concomitant LGE in the same area problematic.

 


                                    

Movies 7 & 8                                                                                       Movies 9 & 10

Look-Locker scouts were then obtained in a short axis orientation (Movie 9), 2chamber view (not shown) and the 4 chamber view (Movie 10). The same difficulty in differentiating between the pre-existing area of increased signal intensity is again encountered. However, there is early nulling of the septum.

 

 

Figure 3 - right click to enlarge

Finally, T2-weighted post Gadolinium images in the the 4 chamber view (Figure 3 upper panel) and in the short-axis orientation (Figure 3 lower panel) without fat saturation (Figure 3 left panel) and with fat saturation (Figure 3 right panel)were obtained. This demonstrated that the area of increased signal intensity in the interventricular septum is fat, localised in the area of the previous myocardial infarction.
 

Perspective: Fatty metamorphosis is a complication of acute myocardial infarction. There exist sporadic reports(1,2) of fatty change following myocardial infarction. In a series of  25 post myocardial infarction patients, 18 of which had CMR-demonstrable fatty changes, there was a high prevalence of fatty metamorphosis in patients with large infarct volume, decreased LV EF, increased LV ESV index, and increased LV Mass(3).
Autopsy studies (4,5) have demonstrated a high incidence of fatty change following myocardial infarction. Fatty metamorphosis such as demonstrated here may be more common than previously appreciated.
It may be difficult to identify areas of  late gadolinium enhancement in the presence of fat, since both have high signal intensity.  The judicious use of multi-plane Look-Locker series at various TIs may demonstrate early nulling in the infarct area. T1 pre Gadolinium or T2 pre or post Gadolinium images without and with fat saturation can confirm the diagnosis of fatty metamorphosis. The fatty metamorphosis was largely in the mesocardium. The dark line encircling the fatty area is likely to represent a chemical shift artifact.

References:

1) J Estornell, R Jimenez, F Ridocci: In Vivo Demonstration of Lipomatous Metaplasia in Left Ventricular Scar Following Myocardial Infarction. Eur Heart J 2006, 27(15): 1766.

2) Sung Soo Ahn1, Young-Jin Kim, Jin Hur, Hye-Jeong Lee, Tae Hoon Kim, Kyu Ok Choe and Byoung Wook Choi : CT Detection of Subendocardial Fat in Myocardial Infarction. AJR 2009; 192:532-537.

3) JW Goldfarb, M Roth, J Han: Myocardial Fat Deposition after Myocardial Infarction. Radiology 2009;253(1):65-73.

4) Baroldi G, Silver MD, De Maria R, Parodi O, Pellegrini A: Lipomatous Metaplasia in Left Ventricular Scar. Can J Cardiol 1997;13:65-71.

5) L Sul, JE Siegel, MC Fishbein: Adipose Tissue in Myocardial Infarction. Cardiovasc Pathol 2004;13:98-102.

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Have your say: What do you think? Latest posts on this topic from the forum


Re: Number 11-08: Fatty Metamorphosis of Myocardial Infarcti
There is an apical thrombus. The focus was on the fatty metamorphosis so I did not emphasize that aspect of the study. ...
On: 06/21/2011 By: gcoop01 Read more?

Re: Number 11-08: Fatty Metamorphosis of Myocardial Infarcti
James, that is quite an distracting victim of satisfaction of search example you have shared . I do agree with you about the apical thrombus. ...
On: 06/07/2011 By: vikasrathi Read more?

Re: Number 11-08: Fatty Metamorphosis of Myocardial Infarcti
Gary, I am not sure, but is there an apical thrombus here?Could we be victim of satisfaction of search?http://www.radswiki.net/main/index.php?title=Satisfaction_of_search ...
On: 06/06/2011 By: moon Read more?

Re: Number 11-08: Fatty Metamorphosis of Myocardial Infarcti
Nice case. Remember one at the Brompton back in 2008. Should we search for these complication in every infart? ...
On: 04/22/2011 By: pmazcarate Read more?

Re: Number 11-08: Fatty Metamorphosis of Myocardial Infarcti
Very beautiful case of adipous metaplasia of a scar.Radiologists involved in chest CT already know the chanche to find an intramyocardial hypodense area in very old myocardial scars. CMr can charachterize fat with a more robust approach. However, very...
On: 04/20/2011 By: montilor Read more?

Re: Number 11-08: Fatty Metamorphosis of Myocardial Infarcti
Very nice case. While I have seen fatty metamorphosis in myocardial infarction, the well defined distribution in the entire coronary territory is rather unusual. Can anyone speculate why fat deposition occurs in some infarctions? Any relation to the reperfusion of...
On: 04/20/2011 By: KADIYALA2000 Read more?

Re: Number 11-08: Fatty Metamorphosis of Myocardial Infarcti
Have only seen this once before. On original case I did not do as good job in tissue characterization as with this one. Based on that experience had a better opportunity to plan this acquisition.This has stimulated some...
On: 04/18/2011 By: gcoop01 Read more?

Re: Number 11-08: Fatty Metamorphosis of Myocardial Infarcti
Ive seen this a number of times now although Gary's case is a beautiful example of fatty metaplasia. I think it highlights the importance to scan all types of infarct both acutely and late as the information is prognostic.
On: 04/12/2011 By: rohanlon Read more?

Number 11-08: Fatty Metamorphosis of Myocardial Infarction
Nice case Gary! How often have you seen this happen? ...
On: 04/12/2011 By: chiarabd Read more?

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