IMAGES THAT TEACH Multimodality cardiac imaging of a patient with syncope Dhaval Kolte, MD, PhD,a Kedar Sankholkar, MD, MS,b Sahil Khera, MD,a Amar B. Shah, MD,c Rocco J. Lafaro, MD,d and Diwakar Jain, MD, FACC, FRCP, FASNCb a
Department of Medicine, New York Medical College, Valhalla, NY Division of Cardiology, New York Medical College, Valhalla, NY c Department of Radiology, New York Medical College, Valhalla, NY d Department of Cardiothoracic Surgery, New York Medical College, Valhalla, NY b
Received Jan 8, 2014; accepted Feb 13, 2014 doi:10.1007/s12350-014-9880-x
A 60-year-old man was admitted to the hospital following an episode of syncope lasting for a few minutes while brushing his teeth. He denied chest pain, palpitation, or an aura prior to falling unconscious. He had history of hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, transient ischemic attacks, smoking, and heavy alcohol abuse. He suffered from a myocardial infarction several years ago, which was treated with percutaneous coronary intervention. His electrocardiogram showed precordial Q waves with 1-mm ST-segment elevation (Figure 1A). Chest x-ray revealed a faint curvilinear opacity in the cardiac apical region, suspicious for a calcified apical aneurysm (Figure 1B). Echocardiogram (Figure 2; Video 1) showed left ventricular ejection fraction (LVEF) of 35% and dyskinesia of the distal anteroseptal and apical myocardium. He ruled out for an acute myocardial infarction, but was noticed to have frequent episodes of non-sustained ventricular arrhythmias. Pharmacological stress-rest myocardial perfusion imaging revealed a large dense scar involving the apex and apical parts of the anterior wall and septum and dyskinesia of these segments (Figure 3; Videos 2-4). LVEF was severely impaired at 23%. In view of the presence of a large, but discrete apical aneurysm, with severely impaired LVEF
Electronic supplementary material The online version of this article (doi:10.1007/s12350-014-9880-x) contains supplementary material, which is available to authorized users. Funding None. Reprint requests: Dhaval Kolte, MD, PhD, Department of Medicine, New York Medical College, 100 Woods Road, Valhalla, NY 10595; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2014 American Society of Nuclear Cardiology.
and symptomatic ventricular arrhythmias the patient was evaluated for possible LV aneurysm resection, surgical ventricular reconstruction, and ICD placement. Echocardiography and stress-rest MPI provided adequate information for the ICD placement. However, we still lacked adequate information about the residual left ventricular shape, size, and volume after LV aneurysm resection. Therefore, an equilibrium radionuclide ventriculography (RNV) was also performed after blood pool labeling with Tc-99m-pertechnetate to better define the apical aneurysm and to get a better estimate of the LV residual volume and function prior to consideration for LV aneurysm resection (Figure 4). RNV showed a discrete, but large aneurysm involving the apex and distal part of the LV. The volume of the non-aneurysmal part of the LV was adequate, with relatively preserved wall motion. As a prelude to LV aneurysm resection, he underwent coronary angiography and left ventriculography (Figure 5A; Videos 5-7), which revealed chronic complete occlusion of the distal left anterior descending coronary artery (LAD), high grade narrowing of the first and second obtuse marginal (OM) branches of the left circumflex coronary artery, and a large calcified apical aneurysm. Cardiac CT was also performed for a detailed three-dimensional view of the LV aneurysm and for planning ventricular reconstruction during surgery (Figure 5B-D). Patient agreed to undergo ICD implantation, but remained reluctant for aneurysm resection. However, after successful and uneventful ICD placement, he agreed for aneurysm resection. He underwent aneurysm resection and bypass of the LAD and OM branches. A Dacron patch was needed to cover the large apical gap. The postoperative course was complicated by sternal wound infection, and leakage of the Dacron patch resulting in a pseudoaneurym requiring redo
Kolte et al Multimodality cardiac imaging of a patient with syncope
Journal of Nuclear CardiologyÒ
Figure 1. (A) ECG showing an age-indeterminate anterior wall myocardial infarction and persistent ST-segment elevation in V3 and V4 (arrows), suggestive of LV aneurysm. (B) Chest xray at admission showing slightly enlarged cardiac silhouette and a faint curvilinear shadow at apex (arrow), suspicious for a calcified apical aneurysm.
surgery. Patient recovered well from surgeries for repair of the pseudoaneurysm and debridement of the sternal wound, and has remained free from overt heart failure and symptomatic ventricular arrhythmias one and a half year after surgery.
LV aneurysm is a sequela of transmural myocardial infarction in approximately 5% of patients.1 Calcified aneurysms are relatively uncommon and successful surgical repair has been described in case reports.2 Patients with LV aneurysms typically present with
Journal of Nuclear CardiologyÒ
Kolte et al Multimodality cardiac imaging of a patient with syncope
Figure 2. End-diastolic (ED) and end-systolic (ES) two-dimensional echocardiogram frames in two-chamber long-axis view. Echocardiogram showed left ventricular ejection fraction (LVEF) of 35% and dyskinesia of the distal anteroseptal and apical myocardium suggestive of LV apical aneurysm (arrows) (see Video 1).
Kolte et al Multimodality cardiac imaging of a patient with syncope
Journal of Nuclear CardiologyÒ
Figure 3. Representative frames from the raw rotating projection images of the stress and rest myocardial SPECT perfusion imaging studies (upper panel). There is an enlarged LV and a large dense scar involving the LV apex and apical segments of the anterior and septal walls (see Videos 2, 3). The apex and apical parts of the anterior and septal segments were dyskinetic and the LVEF was severely impaired at 23% (see Video 4). Lower panel shows the representative myocardial slices in the short axis, vertical (VL), and horizontal (HL) long axes of the LV myocardium. This shows a large dense scar involving the LV apex and contiguous anteroseptal walls. There is no reversibility of the perfusion abnormality on rest images.
Journal of Nuclear CardiologyÒ
Kolte et al Multimodality cardiac imaging of a patient with syncope
Figure 4. Equilibrium radionuclide angiocardiography in three standard views (Ant, anterior; LAO, left anterior oblique; LLat, left lateral), showing the representative end-diastolic (ED) and endsystolic (ES) frames. There is a large LV apical aneurysm (arrows). LVEF was calculated at 30%.
Kolte et al Multimodality cardiac imaging of a patient with syncope
Journal of Nuclear CardiologyÒ
Figure 5. (A) Still frame from left ventricular angiogram prior to the injection of the dye showing calcified LV apical aneurysm (arrows) (see Video 7). Coronary angiography was also performed which revealed heavily calcified coronary vessels, chronic total occlusion of the mid left anterior descending coronary artery, severe high-grade stenosis of the first and second obtuse marginal (OM1 and OM2) branches of the left circumflex coronary artery (see Videos 5, 6). (B-D) Selected images from CT angiography of the heart showing a 3.2 9 1.8 cm LV apical aneurysm involving the anterior, inferior, septal, and lateral walls at the apical level and the apex itself. There is dense calcification of the LV apical aneurysm (arrows).
symptoms of heart failure and approximately 15% have symptomatic ventricular arrhythmias. Surgery may be considered for treatment of heart failure, intractable ventricular arrhythmias, or recurrent thromboembolism.3 Multimodality imaging is often helpful for adequate definition of ventricular aneurysms, detection of myocardial viability, and for planning surgical repair. Conflict of interest The authors have indicated that they have no financial conflict of interest.
References 1. Napodano M, Tarantini G, Ramondo A, Cacciavillani L, Corbetti F, Marra MP, et al. Myocardial abnormalities underlying persistent
ST-segment elevation after anterior myocardial infarction. J Cardiovasc Med (Hagerstown) 2009;10:44-50. 2. Wang X, Wu H, Sun H. Massive calcified left ventricular aneurysm and ventricular septum: Successful surgical repair and reconstruction. J Thorac Cardiovasc Surg 2012;143:509-11. 3. O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78-140.
Department of Medicine, New York Medical College, Valhalla, NY Division of Cardiology, New York Medical College, Valhalla, NY c Department of Radiology, New York Medical College, Valhalla, NY d Department of Cardiothoracic Surgery, New York Medical College, Valhalla, NY b
Received Jan 8, 2014; accepted Feb 13, 2014 doi:10.1007/s12350-014-9880-x
A 60-year-old man was admitted to the hospital following an episode of syncope lasting for a few minutes while brushing his teeth. He denied chest pain, palpitation, or an aura prior to falling unconscious. He had history of hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, transient ischemic attacks, smoking, and heavy alcohol abuse. He suffered from a myocardial infarction several years ago, which was treated with percutaneous coronary intervention. His electrocardiogram showed precordial Q waves with 1-mm ST-segment elevation (Figure 1A). Chest x-ray revealed a faint curvilinear opacity in the cardiac apical region, suspicious for a calcified apical aneurysm (Figure 1B). Echocardiogram (Figure 2; Video 1) showed left ventricular ejection fraction (LVEF) of 35% and dyskinesia of the distal anteroseptal and apical myocardium. He ruled out for an acute myocardial infarction, but was noticed to have frequent episodes of non-sustained ventricular arrhythmias. Pharmacological stress-rest myocardial perfusion imaging revealed a large dense scar involving the apex and apical parts of the anterior wall and septum and dyskinesia of these segments (Figure 3; Videos 2-4). LVEF was severely impaired at 23%. In view of the presence of a large, but discrete apical aneurysm, with severely impaired LVEF
Electronic supplementary material The online version of this article (doi:10.1007/s12350-014-9880-x) contains supplementary material, which is available to authorized users. Funding None. Reprint requests: Dhaval Kolte, MD, PhD, Department of Medicine, New York Medical College, 100 Woods Road, Valhalla, NY 10595; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2014 American Society of Nuclear Cardiology.
and symptomatic ventricular arrhythmias the patient was evaluated for possible LV aneurysm resection, surgical ventricular reconstruction, and ICD placement. Echocardiography and stress-rest MPI provided adequate information for the ICD placement. However, we still lacked adequate information about the residual left ventricular shape, size, and volume after LV aneurysm resection. Therefore, an equilibrium radionuclide ventriculography (RNV) was also performed after blood pool labeling with Tc-99m-pertechnetate to better define the apical aneurysm and to get a better estimate of the LV residual volume and function prior to consideration for LV aneurysm resection (Figure 4). RNV showed a discrete, but large aneurysm involving the apex and distal part of the LV. The volume of the non-aneurysmal part of the LV was adequate, with relatively preserved wall motion. As a prelude to LV aneurysm resection, he underwent coronary angiography and left ventriculography (Figure 5A; Videos 5-7), which revealed chronic complete occlusion of the distal left anterior descending coronary artery (LAD), high grade narrowing of the first and second obtuse marginal (OM) branches of the left circumflex coronary artery, and a large calcified apical aneurysm. Cardiac CT was also performed for a detailed three-dimensional view of the LV aneurysm and for planning ventricular reconstruction during surgery (Figure 5B-D). Patient agreed to undergo ICD implantation, but remained reluctant for aneurysm resection. However, after successful and uneventful ICD placement, he agreed for aneurysm resection. He underwent aneurysm resection and bypass of the LAD and OM branches. A Dacron patch was needed to cover the large apical gap. The postoperative course was complicated by sternal wound infection, and leakage of the Dacron patch resulting in a pseudoaneurym requiring redo
Kolte et al Multimodality cardiac imaging of a patient with syncope
Journal of Nuclear CardiologyÒ
Figure 1. (A) ECG showing an age-indeterminate anterior wall myocardial infarction and persistent ST-segment elevation in V3 and V4 (arrows), suggestive of LV aneurysm. (B) Chest xray at admission showing slightly enlarged cardiac silhouette and a faint curvilinear shadow at apex (arrow), suspicious for a calcified apical aneurysm.
surgery. Patient recovered well from surgeries for repair of the pseudoaneurysm and debridement of the sternal wound, and has remained free from overt heart failure and symptomatic ventricular arrhythmias one and a half year after surgery.
LV aneurysm is a sequela of transmural myocardial infarction in approximately 5% of patients.1 Calcified aneurysms are relatively uncommon and successful surgical repair has been described in case reports.2 Patients with LV aneurysms typically present with
Journal of Nuclear CardiologyÒ
Kolte et al Multimodality cardiac imaging of a patient with syncope
Figure 2. End-diastolic (ED) and end-systolic (ES) two-dimensional echocardiogram frames in two-chamber long-axis view. Echocardiogram showed left ventricular ejection fraction (LVEF) of 35% and dyskinesia of the distal anteroseptal and apical myocardium suggestive of LV apical aneurysm (arrows) (see Video 1).
Kolte et al Multimodality cardiac imaging of a patient with syncope
Journal of Nuclear CardiologyÒ
Figure 3. Representative frames from the raw rotating projection images of the stress and rest myocardial SPECT perfusion imaging studies (upper panel). There is an enlarged LV and a large dense scar involving the LV apex and apical segments of the anterior and septal walls (see Videos 2, 3). The apex and apical parts of the anterior and septal segments were dyskinetic and the LVEF was severely impaired at 23% (see Video 4). Lower panel shows the representative myocardial slices in the short axis, vertical (VL), and horizontal (HL) long axes of the LV myocardium. This shows a large dense scar involving the LV apex and contiguous anteroseptal walls. There is no reversibility of the perfusion abnormality on rest images.
Journal of Nuclear CardiologyÒ
Kolte et al Multimodality cardiac imaging of a patient with syncope
Figure 4. Equilibrium radionuclide angiocardiography in three standard views (Ant, anterior; LAO, left anterior oblique; LLat, left lateral), showing the representative end-diastolic (ED) and endsystolic (ES) frames. There is a large LV apical aneurysm (arrows). LVEF was calculated at 30%.
Kolte et al Multimodality cardiac imaging of a patient with syncope
Journal of Nuclear CardiologyÒ
Figure 5. (A) Still frame from left ventricular angiogram prior to the injection of the dye showing calcified LV apical aneurysm (arrows) (see Video 7). Coronary angiography was also performed which revealed heavily calcified coronary vessels, chronic total occlusion of the mid left anterior descending coronary artery, severe high-grade stenosis of the first and second obtuse marginal (OM1 and OM2) branches of the left circumflex coronary artery (see Videos 5, 6). (B-D) Selected images from CT angiography of the heart showing a 3.2 9 1.8 cm LV apical aneurysm involving the anterior, inferior, septal, and lateral walls at the apical level and the apex itself. There is dense calcification of the LV apical aneurysm (arrows).
symptoms of heart failure and approximately 15% have symptomatic ventricular arrhythmias. Surgery may be considered for treatment of heart failure, intractable ventricular arrhythmias, or recurrent thromboembolism.3 Multimodality imaging is often helpful for adequate definition of ventricular aneurysms, detection of myocardial viability, and for planning surgical repair. Conflict of interest The authors have indicated that they have no financial conflict of interest.
References 1. Napodano M, Tarantini G, Ramondo A, Cacciavillani L, Corbetti F, Marra MP, et al. Myocardial abnormalities underlying persistent
ST-segment elevation after anterior myocardial infarction. J Cardiovasc Med (Hagerstown) 2009;10:44-50. 2. Wang X, Wu H, Sun H. Massive calcified left ventricular aneurysm and ventricular septum: Successful surgical repair and reconstruction. J Thorac Cardiovasc Surg 2012;143:509-11. 3. O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78-140.
