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Cases of the Week 2013

Number 13-04: Pericardial Agenesis 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.

Number 13-03: Complicated isolated RV infarction – a diagnostic dilemma 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.

Number 13-02: Pericystic fibrosis of a cardiac hydatid cyst History: A 60-year-old man, originally from Sardinia, with diabetes and hypertension presented with sporadic, nonspecific precordial discomfort of short duration.

Number 13-01: Calcified aneurysm of Left ventricular apex in Apical Cardiomyopathy 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

Number 12-12: ‘Looking outside the box’ History: 59 yo female two months post abdominal hysterectomy, bilateral salpingo-oophorectomy for a high grade endometrial leimyosarcoma.

Number 12-11: Post Pericardiectomy for Constriction – Late Complication 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.

Number 12-10: Complex Congenitally Corrected TGA 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.

Number 12-09: A Pseudo-“Alfieri” Aortic Valve Masquerading as Severe Aortic Stenosis 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.

Number 12-08: A severe ductal aneurysm in a neonate 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.

Number 12-07: The Study of Last Resort. 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.

Number 12-06: Long segment severe coarctation of the aorta in a 9 year old child 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.

Number 12-05: Angiosarcoma presenting as a large right atrial mass History: Patient presenting with constitutional symptoms and right atrial mass. Several differential diagnosis and CMR helped to point the correct diagnosis and plan treatment

Number 12-04: Heterotaxy and Tetralogy of Fallot History: 27 year-old male with the history of heterotaxy syndrome, Tetralogy of Fallot with pulmonary atresia, and right aortic arch.

Number 12-03: Branch pulmonary artery flow curves in repaired Tetralogy of Fallot History: A 51 year old man was referred for a CMR study. He had repair of Tetralogy of Fallot in childhood.

Number 12-02: Echo and CMR in Acromegalic Cardiomyopathy History: A 49 year-old male presented with a 10-day history of worsening shortness of breath, paroxysmal nocturnal dyspnea and orthopnea

Number 12-01: Ruptured Left Ventricular Aneurysm 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

Number 11-24: Myocardial fatty focus in a patient with tuberous sclerosis History: a 18 year old male with tuberous sclerosis presents for cardiac MR after an abnormal echogenic foci was identified on echocardiogram.

Number 11-23: Left Atrial Sarcoma History: 53yo male with dyspnea and left atrial prolapsing sarcoma

Number 11-22: Ebstein Anomaly in an Asymptomatic Air Force Professional 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.

Number 11-21: Utility of Cardiac MRI in Carcinoid Heart Disease 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.

Number 11-20: Not Just Another Apical HCM History: 63 year old male patient initially presented to the outpatient clinic with fatigue and progressive shortness of breath.

Number 11-19: Giant Left Ventricular Aneurysm 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.

Number 11-18: CMR advancing towards the new reference standard in cardiac sarcoidosis 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.

Number 11-17: Myocardial Contusion 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.

Number 11-16: An unexpected finding in a routine CMR study: the relevance of a skillful, attentive technician History: An 42 y/o asymptomatic male underwent CMR for screening

Number 11-15: Mitral valve prolapse-widening views onto the myocardium by cardiovascular magnetic resonance History: We decsribe two cases with known and previously documented mitral valve (MV)prolapse on transthoracic echocardiography.

Number 11-14: Anterior Mitral Valve Cleft in the Presence of a Primum ASD History: Anterior Mitral Valve Cleft in the Presence of a Primum ASD

Number 11-13: Fibro-fatty replacement and other abnormalities in suspected ARVC. 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.

Number 11-12: Oral Iron Supplementation: A Curious Contraindication to Cardiovascular Magnetic Resonance History: 72 yo female with susceptibility artifact from oral iron ingestion.

Number 11-11: Chest pain in a young patient History: An 18-year-old African American male was admitted to our Emergency Department after developing sudden and severe chest pain

Number 11-10: Complications After Surgical Repair of Tetralogy of Fallot History: A 24 year old man underwent surgical repair of tetralogy of Fallot (TOF) at the age of 10 months.

Number 11-09: The case of disappearing aortic mass 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

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

Number 11-07: Percutaneous tricuspid valve implantation History: Management of a 5-year old girl with tricuspid valve dysplasia.

Number 11-06: Bilateral Superior Vena Cavae 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.

Number 11-05: Cardiac Sarcoidosis: A Severe Presentation 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.

Number 11-04: One question with two answers. Cardiovascular magnetic resonance in dual pathology. History: A 79 year old man with a recent episode of non-sustained ventricular tachycardia.

Number 11-03: Post Traumatic Aortic Pseudoaneurysm History: Unsuspected post-traumatic aortic pseudoaneurysm in a patient presenting with acute coronary syndrome

Number 11-02: Another cause of mitral regurgitation 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. .

Number 11-01: Aberrant Left Upper Pulmonary Vein with drainage into the brachiocephalic vein. 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

This is our 100th Case! Number 10-26: Incidental Cardiac Mass 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.

Number 10-27: Giant Systemic Venous Collateral History: MRI evaluation of a double outlet right ventricle with a giant systemic venous collateral

Number 10-25: Constrictive Pericarditis Post Cardiac Transplant: Diagnostic Role of Cardiovascular MRI History: A 56-year old male underwent heart transplantation (HTX) 8 years ago.

Number 10-24: Acute Pericarditis 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.

Number 10-23: Cardiac Lipoma 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.

Number 10-22: Anomalous Right Coronary Artery Arising from the Main Pulmonary Artery History: Multimodality imaging of an anomalous right coronary artery arising from the pulmonary arterial trunk

Number 10-21: Role of CMR in the diagnosis of ARVC 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.

Number 10-20: Electrophysiologic and CMR features of ARVC History: A 19-year old caucasian female with documented ventricular tachycardia was referred to electrophysiology service.

Number 10-19: Clinical Utility of Stress CMR to Guide Management 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.

Number 10-18: Aortic Coarctation Repair with associated Bicuspid Aortic Valve History: 3D MRA demonstrating pre and post stenting of descending thoracic aorta coactation in addition to a bicuspid aortic valve with dilated aortic root.

Number 10-17: Clinical role of perfusion CMR *** CASE WINNER 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.

Number 10-16: Improvement in Image Quality in Atrial Fibrillation by using a Novel Prospective Reconstruction Method History: Presentation of alternative techniques for improving image quality in patients with arrhythmia.

Number 10-15: T2* CMR to tailor chelation therapies 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.

Number 10-14: Persistent Left SVC and AF Ablation History: Electrical Activation of Atrial Fibrillation via persistent left SVC

Number 10-13: Cardiac Metastasis of the Renal Cell Carcinoma Diagnosed by CMR History: A 59 year old male with history of pleuritic chest pain and pulmonary embolism presenting with painless hematuria

Number 10-12: Spiral Hypertrophic Cardiomyopathy History: This is a case of HCM with asymmetrical hypertrophy which is distributed in a spiral or helical way from base to apex.

Number 10-11: Cardiac Sarcoidosis 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.

Number 10-10: The Case of Three Ventricles History: Large left ventricular basilar aneurysm with thrombus secondary to infarct

Number 10-09: Acute Pulmonary Edema in an Active Duty Officer in Iraq History: A 27-year-old female active duty soldier with no significant past medical history was evacuated from Iraq for flash pulmonary edema.

Number 10-08: Perfusion Abnormalities in Cardiac Amyloidosis 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.

Number 10-07: Sludge infarcts due to homozygous sickle cell anemia History: 16 y/o male with homozygous sickle cell anemia presenting with a history of chest pain and normal coronary angiography.

Number 10-06: Common Trick, Uncommon Application History: An incorrect diagnosis of Gerbode defect by CMR clarifed by echocardiography with agitated saline.

Number 10-05: Dobutamine inducible ischaemia: Case 2 History: An 48 year old male was admitted to hospital with 6 hours of crushing central chest pain.

Number 10-04: Hemorrhagic myocardial infarction History: Case demonstrating CMR sequences which can aid in the effective diagnosis of hemorrhagic infarct

Number 10-03: Unicuspid aortic valve and associated anomalies 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.

Number 10-02: Dobutamine inducible ischaemia: Case 1 History: 62 year old asthmatic male presented to the cardiologists with worsening atypical chest pain and breathlessness on exertion.

Number 10-01: Myofibroblastic tumor of the right atrium in a 2-year old boy 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

Number 09-19: Pulmonary embolism by CMR 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

Number 09-18: Traumatic interventricular septal dissection 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.

Number 09-17: Characterization of a left atrial anomaly with CMR History: A 67-year-old female with hypertension presented with a 5-month history of exertional chest pain and dyspnea.

Number 09-16: A large and mysterious mass in the LV History: A 59 y/o female with history of breast CA s/p right lumpectomy and ovarian CA was referred for CMR

Number 09-15: Peripartum Cardiomyopathy? History: CMR in possible Peripartum Cardiomyopathy demonstrates Duchenne muscular dystrophy in a carrier - scar burden reinforces decision for ICD implantation

Number 09-14: CMR in Systemic Sclerosis History: A 28 years old female with Scleroderma (SSc) for 11 years and acute angina and elevated creatine kinase (CK).

Number 09-13: Severe AI in a bicuspid AV assessed with CMR History: A nice example of how CMR can be used to evaluate the severity of AI using cine and phase contrast CMR imaging.

Number 09-12: Role of CMR in acute myocardial infarction, primary angioplasty, and autologous stem cell therapy History: 50 y/o male with a 3 week history of accelerated angina...

Number 09-11: Gerbode Ventricular Septal Defect after Ross Procedure History: A 26-year-old male patient with past medical history of aortic coarctation repair...

Number 09-10: An unusual complication of the Ross procedure and the role of CMR in its assessment History: A 26 year old male had previously undergone a Ross procedure for a stenosed bicuspid aortic valve when aged 17yrs.

Number 09-09: Left Atrial Appendage Clot and Atrial Fibrillation History: Atrial appendage thrombus post thoracoscopic atrial appendage amputation imaged with CMR.

Number 09-08: Syncopal Event in a Case of Kawasaki's History: Kawasaki's Disease and Atrial Septal Aneurysm. Single imaging modality for complete assessment.

Number 09-07: All That Elevates Is Not Plaque Rupture History: A 75-year-old woman with atrial fibrillation

Number 09-06: Heterogeneous etiologies affecting a patient with cardiac amyloidosis History: 81 year-old male with history of atrial fibrillation

Number 09-05: Locating the leaks History: 61 year old female with endocardial cushion referred for CMR to measure shunt flow.

Number 09-04: Diagnosing RV dilatation by CMR (2) History: A 52 year old male with a dilated right ventricle and elevated pulmonary artery pressures on echocardiography.

Number 09-03: Coincident Hypertrophic Cardiomyopathy and Left Ventricular Non-Compaction History: Woman, 44 y/o, diagnosed by echocardiography of Non-Obstructive Hypertrophic Cardiomyopathy (HCM)

Number 09-02: Giant LV Pseudoaneurysm by CMR History: A 79 year old male with late-presentation lateral STEMI 3days earlier..

Number 09-01: Is it or isn't it coronary artery disease? History: A 46-year-old man presents with breathlessness, heart failure and chest pain. Troponin borderline

Cases of the Week 2008

Number 08-23: A tricky diagnostic challenge History: A man in his 40s presenting to respiratory medicine with 6 months breathlessness and hemoptysis.

Number 08-22: A Segmented thoracic mass 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.

Number 08-21: Myocardial scarring from 2 distinct pathologies History: Asymptomatic 62 yr ?. Diagnosed with HCM more than 20 with an abnormal ECG. Recent echo demonstrated concentric LVH. CMR to further assess this.

Number 08-20: Imaging Restrictive cardiomyopathy by CMR History: A 23 year old male presented with increasing dyspnea, abdominal distension, pedal edema and orthopnea over 18 months.

Number 08-19 Diagnosing RV dilatation by CMR History: ** Case of the year winner, 2008

Number 08-18 'Bystander' ST elevation MI in DCM 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.

Number 08-17: Isolated Left Ventricular Apical Hypoplasia History: 35yr male. Known previous DCM diagnosed via echocardiography. Currently stable, NYHA Class I, and well controlled. No significant arrhythmias noted. Referred for CMR.

Number 08-16: Advanced late gadolinium enhancement optimisation History: 48 Y/O male from Kuwait presented with dyspnea and palpitations. Holter shows 2:1 heart block episodes. PMH: severe asthma.

Number 08-15: Danon Disease - A rare cause of LV hypertrophy History: 20 years old male, history of RF ablation for WPW syndrome, without prior history of heart failure.

Number 08-14: Erdheim-Chester Disease by CMR 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.

Number 08-13: Viral Myocarditis by CMR 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.

Number 08-12: Congenital Bicuspid Aortic Valve with Ascending Aortic Dilatation 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.

Number 08-11: CMR for RA Mass characterization History: A 37 yr female had an echocardiogram for chest pain showing a possible mass in the right atrium. CMR was performed to further characterise this.

Number 08-10: Interrupted Aortic Arch History: 2 day old female, mild respiratory distress

Number 08-09: Lipomatous Hypertrophy of the Interatrial Septum (LHIAS) History: 73 year male. 1 year hx of myalgia and weight loss. RA mass on echo.

Number 08-08: Incidental chest findings - is CT needed? 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).

Number 08-07: Left Ventricular Trabeculae, Non-Compaction and DCM History: 18 Y/O male presented with dyspnea and palpitations. His father had died suddenly at age 32.

Number 08-06: Coarctation & aortic stenosis? History: A 46 year old male with 6 months breathlessness. Previous patch repair of “adult type” CoA.

Number 08-05: Acute MI, normal coronaries 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.

Number 08-04: Where is the murmur from? 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.

Number 08-03: Primary Pericardial Echinococcosis 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.

Number 08-02: Apical HCM, fibrosis and sustained VT History: An 82 yr man admitted with palpitations, presyncope and sustained monomorphic VT. Family history, his brother died age 6 of unknown cause.

Number 08-01: Measuring Dyssynchrony in Pulmonary Hypertension History: A stable, idiopathic pulmonary artery hypertensive (IPAH) 38 year old female (PAP 110 mmHg, WHO functional class III) underwent CMR.

Cases of the Week 2007

Number 07-22: LV Thrombus History: A 59 year old man with previous anterior MI presented with a 6 hour history of acute dyspnoea without chest pain

Number 07-21: An unexpected cause of ascites History: A 31 year old male with a 2 year History of recurrent ascites, peripheral oedema and deranged LFTs. Budd-Chiari syndrome suspected. Proteinuria noted so Renal MRA requested to exclude renal vein thrombosis

Number 07-20: ASD First pass contrast bolus tracking History: A 28 year old white male with incidental CXR abnormalities: cardiomegally, right heart enlargement and R pleural effusion ECG: RVH

Number 07-19: CMR guided revascularisation History: 72 yr old man with a 3 week history of chest pain and shortness of breath presented in cardiogenic shock with pulmonary edema, acute renal failure and VT

Number 07-18: Right Atrial Tumour - or not? History: An incidental mass was identified in the right atrium of a middle aged female on pre-operative trans thoracic echocardiography (top left). CMR requested for further characterization.

Number 07-17: ARVC mimic - congenital partial absence of the pericardium History: Family screening implemented for ARVC after a 1st degree relative died of cardiomyopathy with ventricular dilatation. In this individual, and abnormal ECG with right pre-cordial T wave inversion and a shift of the transition zone to V5 was found suggesting possible ARVC. Echo normal but with poor windows.

Number 07-16: Late Mediastinal malignancy treatment complications History: Increasing Breathlessness. Past medical history included a thymoma removal with subsequent mediastinal radiotherapy. Previous successful PCI to the LAD for radiation induced coronary artery disease.

Number 07-15: Sarcoidosis Masquerading as ARVD/C History: A 46 year old African American presenting with VT of LBBB morphology.

Number 07-14: ARVC with LV involvement History: A 59 year old with an 8 year history of asymptomatic ARVC diagnosed through family screening. A disease causing mutation in plakophilin was found. Type 1 diabetes since childhood. Recent echo showed a possible new LV apical aneurysm. Coronary angiography normal.

Number 07-13: Cine Artefact History: A 55 y.o. male admitted with new heart failure. No acute coronary syndrome. Past medical history includes type I Diabetes, hypertension, chronic renal insufficiency and anaemia of chronic disease. After stabilization, transthoracic echo showed an EF of 40%, no significant valvular disease. CMR was requested.

Number 07-12: Troponin +ve Chest pain, normal coronaries History: 6 months ago, a 48 year old body builder had troponin positive chest pain with inferior T wave inversion on ECG and normal coronary angiography. Echo had suggested possible inferior hypokinesia. Ongoing clinical uncertainty

Number 07-11: Valvular disease by CMR History: A 74 year old female with increasing breathlessness. Known rheumatic heart disease and LVH.

Number 07-10: Tumor or Thrombus? History: 61 year old male, known renal cell carcinoma with renal venous thrombosis.

Number 07-09: Tako-tsubo or Infarction History: ***Winner, case of the Year, 2007.

Number 07-08: Acquired VSD by CMR History: An 80 year old man with STEMI and cardiogenic shock.

Number 07-07: HCM with LVOT obstruction by CMR History: 62 year old man with HCM with obstruction referred for alcohol septal ablation (ASA) refractory symptoms of angina and dyspnea. This was a baseline study done prior to ASA.,

Number 07-06: Microvascular Obstruction by CMR History: A 41 year-old man admitted with 3 hours of chest pain with initial thrombolysis (tenecteplase) and salvage angioplasty one hour later.

Number 07-05: Double chambered Right Ventricle History: 34-yr-old male, recurrent syncope and dyspnea

Number 07-04: Delayed enhancement-targeted biopsy History: A 53-yr-old male with 2 types of symptomatic VT. One VT with LBBB and superior axis suggested origin from RV inflow, likely from IVS. Rest ECG shows inverted T waves inferiorly and no epsilon wave.

Number 07-03: HCM with multi-level obstruction History: A 69 yr-old female, increasing breathlessness.

Number 07-02. Coarctation, MS and bicuspid AoV History: A 17-yr-old female, referred with hypertension.

Number 07-01: `Ringing bell' sinus of valsalva aneurysm History: A 42-yr-old male, recent onset breathlessness.

Cases of the Week 2006

Number 06-10: Myocarditis History: A 42 year-old male admitted with 3 days of chest pain and diarrhoea

Number 06-09: Isolated RV infarction History: A 61-year-old male, 24 hours of chest pain, CK raised, normal ECG.

Number 06-08: Great vessel pathology History: A 16 year old male, known coarctation + dysplastic aortic valve.

Number 06-07: Infective cardiomyopathy History: A 55 year old male presented with breathlessness and palpitations

Number 06-06: What course the RCA? History: A 56 year old female, atypical chest pain and collapse.

Number 06-05: Apical HCM by CMR and echo History: A 64 year old women presented with chest pain and palpitations. The ECG showed Extensive T wave inversion. Echocardiography (L) was reported as showing diastolic dysfunction and an akinetic apex. Cine CMR confirmed the clinical suspicion of apical hypertrophic cardiomyopathy (aHCM).

Number 06-04: Thrombus or tumor? History: An 84 year old women presented breathless. Earlier in the year, she had undergone coronary artery bypass from which she had made a full recovery. Echocardiography demonstrated a left atrial mass, of uncertain aetiology.

Number 06-03: Pericardial constriction History: A 59 year old presented with paroxysmal atrial fibrillation, breathlessness, ankle oedema and disturbed liver function tests.

Number 06-02: High Risk HCM History: A 33 year old man with HCM with a family history of sudden death. Seven years previously, a single Holter had shown 3 beats of NSVT. Cine CMR shows HCM with ASH, no SAM, no LVOTO (left or right), and normal systolic function. After gadolinium, there was very extensive late enhancement, (44% of LV myocardium, arrowed). The scan triggered re-evaluation of cardiac risk, and the patient was offered an ICD.

Number 06-01: Left Atrial Myxoma History: An 80 year old men presented with dyspnea. Echo showed a LA mass. Cine CMR (left) showed a large (7x7x4cm) tumor attached to the fossa ovalis, prolapsing through the mitral valve. Signal intensities: low T1 and high T2 (middle, top and bottom) were also compatible with myxoma, subsequently confirmed at surgery (right). The patient was discharged 6 days after surgery.