Number 10-17: Clinical role of perfusion CMR
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Number 10-17: Clinical role of perfusion CMR

Case from: Daniel M Sado, Steven White, Juan Gimeno, James C Moon.
The Heart Hospital Imaging Centre, (part of UCLH and UCL), London.

Clinical history: A 73 year old man with exertional chest pain, hypertension and an abnormal ECG underwent echocardiography as part of his clinical work-up (Movie 1).  This revealed a basal septal bulge and regional hypertrophy suspicious for hypertrophic cardiomyopathy (HCM). 
CMR with perfusion was performed to assess HCM and exclude coronary artery disease with angulated (sigmoid) septum, the other differential.


Movie 1


CMR Findings: Short axis cine imaging revealed marked basal septal hypertrophy (maximum 1.8cm) (Movie 2).  This degree of hypertrophy would support HCM more than hypertension typically - although here the angulated septum meant that hypertensive heart disease was not ruled out.


Movie 2


First pass adenosine stress perfusion images were obtained following a 4 minute adenosine infusion.
This showed extensive stress induced perfusion defects from base to apex in a territorial distribution of multivessel disease (Movie 3).  (stress, top row; matching rest images, bottom row).


Movie 3


Late gadolinium enhancement (LGE) imaging was performed. This also showed multi-territory subendocardial infarction - but its extent was substantially less than the perfusion defects (Figure 1).


Figure 1


An imaging diagnosis was made of multivessel coronary artery disease with angulated septum and hypertensive cardiac changes - with no need to invoke HCM as a third diagnosis.  Coronary angiography was performed.



Movie 4                                                         Movie 5


This showed severe left system disease (Movie 4) and likely RCA occlusion (unable to selectively cannulate) (Movie 5).  The patient was referred for coronary artery bypass grafting.

Clinical perspective
Common things are common.  Hypertensive heart disease and 3 vessel disease with infarction was here masquerading as Hypertrophic cardiomyopathy. CMR using cine, perfusion and late gadolinium enhancement resolved the diagnostic dilemma in one simple step leading to the right treatment choice for the patient. 

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COTW handling editor: Chiara Bucciarelli-Ducci 

Forum comments on this case.

Re: Number 10-17: Clinical role of perfusion CMR
well done dan. interesting and refreshing style of presenting. ...
On: 02/10/2011 By: moon Read more?

Number 10-17: Clinical role of perfusion CMR
Many congratulations to Dr Dan Sado and his colleagues! This case is the winner of the COTW Best Case of the Year 2010!Well done Dan, your presentation was excellent! ...
On: 02/08/2011 By: chiarabd Read more?

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