Magnetic Resonance Assessment of Cardiac Function, Infarct Scar Distribution, and Ventricular Remodeling in the Setting of Ischemic Cardiomyopathy
A 62-year-old man with known chronic myocardial infarction resulting from an ischemic event 11 years previously was referred to the cardiovascular magnetic resonance (MR) center for assessment of cardiac function, infarct scar distribution, and ventricular remodeling. Transthoracic echocardiography had not been diagnostic because of a suboptimal acoustic window. During the years immediately before the MR workup, the patient was able to walk up to 2 blocks, work in his garden, and climb 1 flight of stairs.
Cardiovascular MR imaging (MRI) was performed using a 1.5 T Magnetom Sonata (Siemens Medical Systems). Fast gradient echo cine and single shot imaging (TrueFISP) demonstrated an enlarged, non-hypertrophied ventricle (Figure 1) with severely impaired global function (left ventricular end diastolic diameter: 63 mm; end-diastolic volume: 660 mL; end-systolic volume: 600 mL; left ventricular ejection fraction 9%) and a large apical aneurysm (10 cm×8.6 cm). Only inferior and inferolateral myocardial segments localized at the base of the heart showed contractile function. The entire apex, as well as the anterior, anteroseptal, and anterolateral walls, were akinetic or dyskinetic (Movie I).
After injection of 0.1 mmol/kg gadolinium diethyltriaminepentaacetic acid (Magnevist, Schering AG), delayed enhancement imaging was performed using an inversion recovery technique. Late contrast enhancement, representing myocardial scar, is visible in all areas exhibiting wall motion abnormalities and is consistent with the perfusion area of a large left anterior descending artery (Figure 2). Contrast distribution within the apical aneurysm also reveals the mass filling approximately 50% of the aneurysm cavity to be a partially organized thrombus (Movie II).
This case demonstrates the use of in-vivo MRI in the setting of a massively enlarged left ventricle due to ischemic cardiomyopathy. MRI is independent from the acoustic window and is capable of assessing function, visualizing myocardial infarcts, and demonstrating ventricular thrombus. MRI worked effectively despite a ventricular aneurysm that was too large to be fully visualized by any available echocardiographic technique.
This work was supported by a grant from the Robert Bosch Foundation (Dr Mahrholdt).
Movies I and II are available as an online-only Data Supplement at http://www.circulationaha.org.