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Number 08-05 Acute MI, normal coronaries

Case from: Rory O’ Hanlon, Sanjay Prasad, Royal Brompton Hospital, London. UK

Clinical 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.

Angiography: Normal coronaries, normal LVgram, normal transthoracic echo

Cine CMR: Preserved LV function but subtle focal infero-lateral hypokinesis without thinning.
Contrast CMR: Matching transmural MI with central dark microvascular obstruction*

Based on CMR, it was recommended to investigate for a potential source of paradoxical embolism and thrombophilia. The thrombophilia screen was normal.

Contrast Echo: (agitated saline): A large PFO was visualized with complete opacification of the LV cavity within one cycle on Valsalva.

Result:
1. Percutaneous closure of PFO was performed based on clinical presentation and presumed diagnosis of MI secondary to paradoxical embolism
2. CMR in this case made a significant contribution to establishing a diagnosis and directing relevant subsequent investigations.
3. Imaging modalities are complementary: LV angiography and echo may miss subtle RWMA, CMR would not easily detect a PFO.

*MVO, The often found dark core of an acute MI caused by capillary occlusion – the tissue equivalent of ‘no-reflow’

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