Disparity between Echocardiogram and Cardiac MRI Findings in a Patient with AMI. Who is Right, Echo Cardiologist or MRI Radiologist?

- Operator : Young-Guk Ko

Disparity between Echocardiogram and Cardiac MRI Findings in a Patient with AMI. Who is Right, Echo Cardiologist or MRI Radiologist?
- Operator: Young-Guk Ko, MD
Clinical Information

- Relevant clinical history and physical exam:
A 73-year-old man with a history of diabetes and hypertension was admitted to persistent chest pain after about 13 hr from symptom onset.

- Relevant test results prior to catheterization:
The initial ECG showed ST elevation without a Q wave in the precordial leads and reciprocal change of ST depression in the inferior leads (Fig. 1).

- Relevant catheterization findings:
Coronary angiogram revealed total occlusion of left main artery and well developed collaterals from RCA to LAD territory. (Fig 2, Fig 3)

Interventional Management

Procedural step:
PCI was performed with sirolimus eluting stent resulting in restoration of TIMI III flow. (Fig 4, Fig 5)

Clinical Course after intervention

After procedure, immediate echocardiography showed the severely reduced LV function with an estimated ejection fraction of 13% and the LCA territory was akinetic without thinning suggesting mostly stunning feature of anterior LV wall.( Movie 1) Cardiac MR revealed extensive transmural delayed hyperenhancement with massive "no reflow" zone along the LCA territory indicating nonviable myocardium in the entire LCA territory.(Fig 6) However, LV systolic function and the wall motion of LCA territory gradually improved over the period of 4 months in follow-up. LV ejection fraction on his last echocardiogram was 38%.( Movie 2)

Discussion

1. Which imaging modality was right?
2. Was there extensive myocardial damage or more stunning in the anterior wall?
3. Is Cardiac MRI really accurate to assess myocardial viability and infarct size in the acute stage of myocardial infarction?

Comments

  • yuichi noguchi 2009-02-08
  • Guanghui Chen 2009-02-08 I think both modality of Echocardiography and heart MRI are right. however, they have their own advantages and limitations. Echocardiography is good at observing the thickness, motion and heart walls and assessing the function, MRI is preferred to test the viability of cells and the cell density in addition to knowing the structure and function. I am for the conclusion that at the acute stage, the myocardial stunning plays the major role in reducing the LV function, that is why the EF is so low, in the late phase, the stunning cells recovers, then the EF improves obviously. this is a very interesting case and it is very useful in making clear of some easily confused conceptions such as cardiac stunning, and deth.

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