|Case of the Week|
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CASES OF THE WEEK 2016
Cases of the Week 2015
Number 15-17: unenhanced cmr for suspected pulmonary embolism during the first trimester of pregnancy. when avoiding ionizating radiation and iodine contrast media really matters.
History: An 85 year old male veteran had an incidental discovery of a large aneurysm in the region of a ductus diverticulum on a CT chest 2 years prior.
History: A 64-year-old male, a diabetic and a smoker, with no relevant cardiovascular history presented with a syncope during sexual intercourse after using sildenafil, with complete recovery after 10 minutes.
History: A 70-year-old female residing in a remote, rural part of Pakistan presented with several days of chest pain and dyspnea concerning for acute coronary syndrome.
History: A 46 year old woman was referred to our hospital for investigation of vaginal blood loss.
History: A 64 year old male presented one year after cardiac transplant for routine follow up. A 2D transthoracic echocardiogram revealed a mobile, echogenic lesion along the inferior wall of the right atrium.
History: A symptomatic 50 year old woman previously diagnosed as congenitally corrected transposition of great arteries (L-TGA) was referred to our department.
History: An 8-year old girl presented with clinical signs of low cardiac output after symptoms of fever and emesis during a few days. ECG revealed a complete atrio-ventricular (AV) block with a ventricular rate of 35 bpm and wide QRS complexes (120 ms) with variable axis deviation and bundle branch block morphology.
NUMBER 15-09: are myocardial crypts a genetic phenonmenon related to hypertrophic cardiomyopathy?
History: A teenager who collapsed during athletic activity, has T wave inversion on ECG.
NUMBER 15-08: granulomatosis with polyangiitis (churg-strauss syndrome)
History: A 23 year-old gentleman presented to the coronary care unit with “dull aching” central chest pain without pleuritic or pericarditic features.
History: An 84 year-old man presented after an out-of-hospital cardiac arrest and was successfully resuscitated.
History: A 63 year old healthy man was seen in consultation for chest pain and an abnormal electrocardiogram (EKG).
History: An asymptomatic 42 year-old male is submitted for a CMR study after an echo scan showing asymmetric hypertrophy involving the apical segment of the left ventricle. A noticeable highly echogenic signal is described at the endocardial border of the thickened apical region.
History: 49-year-old gentleman diagnosed with T3aN0M1 metastatic renal cell carcinoma in September 2010, underwent a right-sided nephrectomy the same month. He presented to our emergency department with complaints of constant chest pain, which waxes and wanes in intensity and sharp in characteristic.
History: A 70 year-old male had presented approximately 6 months prior to another hospital with fatigue, weakness, chest pain and dyspnea. At that time, left heart catheterization showed non-obstructive coronary artery disease and elevated left ventricular end-diastolic pressures with a restrictive filling pattern.
History: A 15-year-old boy presented with progressively worsening exertional dyspnea following balloon aortic valvotomy in infancy for congenital aortic stenosis.
History: A 16-year-old boy was found to have an abnormal ECG during his appendectomy surgery. His background was remarkable for a small muscular VSD which had undergone spontaneous closure on an echocardiogram performed two years prior.
Cases of the Week 2014
History: 15 year old boy with Tetralogy of Fallot (TOF) status post a valve-sparing repair who was referred for a cardiac MRI due to pulmonary valve insufficiency.
History: A 17 year-old male with a history of d-transposition of the great arteries status post arterial switch operation at age 3 days presented with increasing exercise intolerance.
History: A 34 year-old female with a 2-month history of shortness of breath and new onset lower extremity edema presented to the emergency department for assessment.
History: A three year old child presents with hemitruncus. This case illustrates the importance of an XMR facility for clinical decision-making in pediatric cardiology.
History: A 58 year-old man was admitted to hospital with a short history of rapidly progressive breathlessness, haemoptysis, weight loss and fatigue.
History: An example of a false (pseudo) aneurysm and a true aneurysm in two different patients.
History: A 75-year-old Caucasian female, diagnosed with intestinal carcinoid tumor presented with a syncopal episode.
History: A 77-year-old man presented with a 2-week history of low-grade fever and dyspnea. Chest X-ray revealed large pleural effusions on the right side.
History: A 77-year-old immuno-competent man was referred to our emergency room for onset of dyspnea, orthopnea and paroxysmal nocturnal dyspnea.
History: A 16 year old male previously dilated from congenital post-ductal aortic coarctation (AoCo) through balloon angioplasty at age of 1 year-old, was referred to cardiovascular imaging to rule out any possible complications derived from high-performance and continuous physical activity as a professional soccer player.
History: A 70 year old man with hepatitis B, solitary kidney and remote coronary artery bypass grafting from 17 years prior presented with an inferior myocardial infarction.
History: A 62 year-old Caucasian man presented to the Cardiology Clinic for a routine perioperative evaluation prior to juxtarenal abdominal aortic aneurysm repair.
History: A 3 year old girl was evaluated in clinic with a history of a previously diagnosed right aortic arch and a patent ductus arteriosus.
History: A 22 year old female was seen for a routine follow up of her apical muscular ventricular septal defect (VSD).
History: An asymptomatic 3 year old was evaluated for a murmur. Physical examination was significant for a widely split second heart sound with an ejection systolic murmur in the left upper sternal border.
History: Cardiac aspergilloma is a very rare entity. The diagnosis is usually made by direct observation of the fungal mass during surgery, biopsy, or pathology. We report the CMR findings in a patient with cardiac aspergilloma.
History: A 44 year old male status-post repair of dextro-transposition of the great arteries presented with atypical chest pain in the context of hypertension and hypercholesterolaemia.
Cases of the Week 2013
History: A 33-year-old man was suspected of having a regurgitant quadricuspid aortic valve on the basis of transthoracic echocardiography following the incidental discovery of a diastolic murmur.
History: A 70-year male presented with gradual deterioration, breathlessness, and peripheral oedema as well as bilateral pleural effusions. He had previous CABGx4(LIMA LAD, VG to OM, Diagonal and RCA).
History: A 23 year-old morbidly obese female presented with dyspnea on exertion. Shw was born with Down Syndrome, double outlet right ventricle, complete atrioventricular septal defect and pulmonary stenosis and underwent surgical correction at age 5. She also has a reported history of myocarditis at age 19 with resultant systolic dysfunction (EF 35-40%).
History: Clinical History: A 40 year-old male with no significant past medical history was referred for a chest CT due to the discovery of an enlarged pulmonary artery on routine chest x-ray.
History: This case report describes a case of co-incidental coronary disease, Takotsubo cardiomyopathy and hypertrophic cardiomyopathy, where cardiac magnetic resonance imaging (MRI) was crucial in establishing the diagnoses.
History: 19yo asymptomatic male with an abnormal left ventricular finding and ectopy.
History: A six year old girl was referred to pediatric cardiology for evaluation of a heart murmur.
History: A fifteen years old girl with known bicuspid aortic valve was admitted with ineffective endocarditis due to Strept. Agalactiae and treated with antibiotic therapy.
History: A 53 year-old man with no significant past medical history presented to our hospital reporting severe substernal chest pressure with associated diaphoresis that woke him up from sleep. A standard 12-lead electrocardiogram (figure 1) showed marked ST-segment elevation in leads V1, V2, and V3 and in the inferior leads II, III, and aVF, with ST depression in leads I, L, with T wave inversion in V5 and V6.
History: Progressive aortic root dilatation after repair of tetralogy of Fallot is a rare but recognized complication.The cardiovascular magnetic resonance in this case report represented a key tool for the surgical approach before a tetralogy of Fallot reoperation.
History: An asymptomatic fifteen-year-old boy with dextrocardia and complete transposition of the great arteries (CTGA) who had arterial switch operation and closure of ventricular septal defect (VSD) during infancy.
History: A previously healthy 18-year-old woman presented to an outside medical facility with fever and left scapular pain and was found to have an elevated D-dimer.
History: A 52 year old asymptomatic male affected by hypertension and without other remarkable past medical history presented to the outpatients clinic for check-up.
History: 74 year old gentleman was discharged after an uneventful recovery following four vessel coronary artery bypass grafting, which was done for worsening angina pectoris and triple vessel disease.
History: A 60-year-old man, originally from Sardinia, with diabetes and hypertension presented with sporadic, nonspecific precordial discomfort of short duration.
History: A 65 year old, non-diabetic, normotensive and obese female complained of exertional angina of four years’ duration. She had a transient ischemic attack 15 days ago. Physical examination was unremarkable.
Cases of the Week 2012
History: 59 yo female two months post abdominal hysterectomy, bilateral salpingo-oophorectomy for a high grade endometrial leimyosarcoma.
History: A 61 year old gentleman presented with worsening breathlessness for 2 years. He had a past history of COPD and idiopathic pericardial constriction which had been treated many years earlier by pericardial stripping through a median sternotomy.
History: We present a case of a 27 year old Native American male with a past medical history of complex congenitally corrected transposition of great arteries (CCTGA) with associated double outlet right ventricle (DORV), dextrocardia, subpulmonary stenosis, subpulmonary VSD and PDA.
History: 69 year-old male with history of endovascular abdominal aortic aneurysm repair, COPD, and metastatic lung cancer status post resection on radiation therapy was referred to a cardiothoracic surgeon for consideration of aortic valve replacement (AVR) after a routine transthoracic echocardiography (TTE) at an outside facility revealed evidence of severe aortic stenosis (AS) with a peak gradient of 105 mmHg and aortic valve area (AVA) of 0.78 cm2.
History: A four week old male infant was noted to be dysmorphic including hypertelorism, bilateral inguinal herniae, umbilical hernia and bilateral club feet. A right axillary mass was noted on examination; ultrasound revealed the mass to be a dilated and tortuous vessel but could not conclude definitively whether it was venous or arterial.
History: History: A 46-year-old man with history of Hodgkin’s lymphoma treated with radiation 20 years ago. Four years previously he had undergone pleurodesis for recurrent pleural effusions. He recently developed worsening dyspnea, lower extremity edema, and ascites. At another facility, he was treated initially for interstitial lung disease with bronchodilators without improvement of his symptoms. He was referred to our center for further evaluation.
History: The patient is a previously healthy 9 year old child who presented to her primary care doctor with complaints of her feet turning white.
History: Patient presenting with constitutional symptoms and right atrial mass. Several differential diagnosis and CMR helped to point the correct diagnosis and plan treatment
History: 27 year-old male with the history of heterotaxy syndrome, Tetralogy of Fallot with pulmonary atresia, and right aortic arch.
History: A 51 year old man was referred for a CMR study. He had repair of Tetralogy of Fallot in childhood.
History: A 49 year-old male presented with a 10-day history of worsening shortness of breath, paroxysmal nocturnal dyspnea and orthopnea
History: 68 year old female, smoker, with a history of hyperlipidemia, and type 2 diabetes mellitus. In 2007 she suffered from a myocardial infarction with incomplete revascularization.
Cases of the Week 2011
History: a 18 year old male with tuberous sclerosis presents for cardiac MR after an abnormal echogenic foci was identified on echocardiogram.
History: 53yo male with dyspnea and left atrial prolapsing sarcoma.
History: A 28 year old woman with history of Wolf-Parkinson-White syndrome status-post ablation of a right posterolateral bypass tract in four years earlier who was referred to us for evaluation of an abnormal transthoracic echocardiogram.
History: A 65 year old patient presented with symptoms of worsening right heart failure. Transthoracic echocardiography showed right heart dilatation and severe tricuspid regurgitation with grossly abnormal, thickened and retracted tricuspid valve leaflets.
History: 63 year old male patient initially presented to the outpatient clinic with fatigue and progressive shortness of breath.
History: 69-year-old male with a history of previous myocardial infarction developed increasing exertional dyspnoea and angina four years after initial presentation. CMR demonstrated a left ventricular aneurysm with thrombus.
History: A 43-year old man with no remarkable past medical history presented with progressive dyspnea and peripheral edema. ECG showed frequent polymorphic ventricular ectopic beats Echocardiogram showed LV systolic dysfunction.
History: Myocardial contusion is a ubiquitous cause of hospitalization. The most common etiologies are auto-pedestrian accident, CPR, fall from heights>20’, and motor vehicle accidents.The majority of patients will have a troponin leak and may have EKG changes. Since the right ventricle is the most anterior portion of the heart it is commonly traumatized.
History: An 42 y/o asymptomatic male underwent CMR for screening.
History: We describe two cases with known and previously documented mitral valve (MV)prolapse on transthoracic echocardiography.
History: Anterior Mitral Valve Cleft in the Presence of a Primum ASD.
History: A 38 year-old man without symptoms. His father was diagnosed with right ventricular arrythmogenic cardiomyopathy after heart transplant for ventricular arrhythmias and dilated cardiomyopathy.
History: 72 yo female with susceptibility artifact from oral iron ingestion.
History: An 18-year-old African American male was admitted to our Emergency Department after developing sudden and severe chest pain.
History: A 24 year old man underwent surgical repair of tetralogy of Fallot (TOF) at the age of 10 months.
History: A case of non-ST elevation myocardial infarction presenting with out of hospital VF arrest where CMR played a key role in establishing the underlying diagnosis.
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.
History: Management of a 5-year old girl with tricuspid valve dysplasia.
History: A previously healthy 23 year old military recruit presented to an outside hospital for a routine physical examination and a murmur was noted on exam.
History: A case of severe LV dilatation and systolic dysfunction, where CMR (in particular the pattern of LGE), together with ECG abnormalities pointed towards the correct diagnosis: cardiac sarcoidosis.
History: A 79 year old man with a recent episode of non-sustained ventricular tachycardia.
History: Unsuspected post-traumatic aortic pseudoaneurysm in a patient presenting with acute coronary syndrome.
History: A 65 year old female patient with severe, symptomatic mitral regurgitation underwent mitral valve repair for posterior mitral valve leaflet restriction (type IIIb). At surgery, the left atrial wall appeared abnormal and a left atrial biopsy was performed. Surprisingly, histological examination of this biopsy showed chronic, non-caseating granulomatous changes suggestive of sarcoidosis.
History: A 43 year old male presented with history of dyspnea on exertion and family history of sudden cardiac death. Initial workup.
Cases of the Week 2010
History: A 74-year old white male with previous history of CAD and CABG and chronic renal failure on hemodialysis, presented to our institution after a spontaneous fall while lawn mowing.
History: MRI evaluation of a double outlet right ventricle with a giant systemic venous collateral.
History: A 56-year old male underwent heart transplantation (HTX) 8 years ago.
History: A 58-year old man, free from any previous medical history, presented to the emergency department with retrosternal oppressive chest pain, varying with inspiration and posture, of rapid installation and evolution after prolonged direct exposure to cold airflow from an air-conditioner.
History: A 57 year old woman with a family history of premature coronary artery disease and a prolonged history of exertional chest pain underwent an exercise stress test and multislice CT coronarography which were negative for myocardial ischemia and obstructive coronary artery disease.
History: Multimodality imaging of an anomalous right coronary artery arising from the pulmonary arterial trunk.
History: A 78 year old patient was admitted to the Accident and Emergency department with a syncope. The ECG showed a broad complex tachycardia (left bundle-branch morphology with superior axis) with a rate of 230 bpm. The patient received DC cardioversion under sedation, which resulted in sinus rhythm.
History: A 19-year old Caucasian female with documented ventricular tachycardia was referred to electrophysiology service.
History: A 49-year old male patient with previous history of inferior infarction treated with angioplasty and stenting of the RCA, was admitted for new onset angina at rest.
History: 3D MRA demonstrating pre and post stenting of descending thoracic aorta coactation in addition to a bicuspid aortic valve with dilated aortic root.
History: **best case of the week in 2011. A patient with chest pain had echocardiography suspicious for HCM - CMR resolved the true diagnosis of multivessel CAD.
History: Presentation of alternative techniques for improving image quality in patients with arrhythmia.
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.
History: Electrical Activation of Atrial Fibrillation via persistent left SVC.
History: A 59 year old male with history of pleuritic chest pain and pulmonary embolism presenting with painless hematuria.
History: This is a case of HCM with asymmetrical hypertrophy which is distributed in a spiral or helical way from base to apex.
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.
History: Large left ventricular basilar aneurysm with thrombus secondary to infarct.
History: A 27-year-old female active duty soldier with no significant past medical history was evacuated from Iraq for flash pulmonary edema.
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.
History: 16 y/o male with homozygous sickle cell anemia presenting with a history of chest pain and normal coronary angiography.
History: An incorrect diagnosis of Gerbode defect by CMR clarifed by echocardiography with agitated saline.
History: An 48 year old male was admitted to hospital with 6 hours of crushing central chest pain.
History: Case demonstrating CMR sequences which can aid in the effective diagnosis of hemorrhagic infarct.
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.
History: 62 year old asthmatic male presented to the cardiologists with worsening atypical chest pain and breathlessness on exertion.
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
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.
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.
History: A 67-year-old female with hypertension presented with a 5-month history of exertional chest pain and dyspnea.
History: A 59 y/o female with history of breast CA s/p right lumpectomy and ovarian CA was referred for CMR.
History: CMR in possible Peripartum Cardiomyopathy demonstrates Duchenne muscular dystrophy in a carrier - scar burden reinforces decision for ICD implantation.
History: A 28 years old female with Scleroderma (SSc) for 11 years and acute angina and elevated creatine kinase (CK).
History: A nice example of how CMR can be used to evaluate the severity of AI using cine and phase contrast CMR imaging.
History: 50 y/o male with a 3 week history of accelerated angina.
History: A 26-year-old male patient with past medical history of aortic coarctation repair.
History: A 26 year old male had previously undergone a Ross procedure for a stenosed bicuspid aortic valve when aged 17yrs.
History: Atrial appendage thrombus post thoracoscopic atrial appendage amputation imaged with CMR.
History: Kawasaki's Disease and Atrial Septal Aneurysm. Single imaging modality for complete assessment.
History: A 75-year-old woman with atrial fibrillation.
History: 81 year-old male with history of atrial fibrillation.
History: 61 year old female with endocardial cushion referred for CMR to measure shunt flow.
History: A 52 year old male with a dilated right ventricle and elevated pulmonary artery pressures on echocardiography.
History: Woman, 44 y/o, diagnosed by echocardiography of Non-Obstructive Hypertrophic Cardiomyopathy (HCM).
History: A 79 year old male with late-presentation lateral STEMI 3 days earlier.
History: A 46-year-old man presents with breathlessness, heart failure and chest pain. Troponin borderline.
Cases of the Week 2008
History: A man in his 40s presenting to respiratory medicine with 6 months breathlessness and hemoptysis.
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.
History: Asymptomatic 62 yr ?. Diagnosed with HCM more than 20 with an abnormal ECG. Recent echo demonstrated concentric LVH. CMR to further assess this.
History: A 23 year old male presented with increasing dyspnea, abdominal distension, pedal edema and orthopnea over 18 months.
History: ** Case of the year winner, 2008.
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.
History: 35yr male. Known previous DCM diagnosed via echocardiography. Currently stable, NYHA Class I, and well controlled. No significant arrhythmias noted. Referred for CMR.
History: 48 Y/O male from Kuwait presented with dyspnea and palpitations. Holter shows 2:1 heart block episodes. PMH: severe asthma.
History: 20 years old male, history of RF ablation for WPW syndrome, without prior history of heart failure.
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.
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.
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.
History: A 37 yr female had an echocardiogram for chest pain showing a possible mass in the right atrium. CMR was performed to further characterize this.
History: 2 day old female, mild respiratory distress.
History: 73 year male. 1 year hx of myalgia and weight loss. RA mass on echo.
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).
History: 18 Y/O male presented with dyspnea and palpitations. His father had died suddenly at age 32.
History: A 46 year old male with 6 months breathlessness. Previous patch repair of "adult type" CoA.
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.
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.
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.
History: An 82 yr man admitted with palpitations, presyncope and sustained monomorphic VT. Family history, his brother died age 6 of unknown cause.
History: A stable, idiopathic pulmonary artery hypertensive (IPAH) 38 year old female (PAP 110 mmHg, WHO functional class III) underwent CMR.
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