LV Volume / Pressure Overload

Primary Dilated CMP and CAD

FINDINGS
IMPRESSION
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Note: ECHO, catheterization, and angiography data are provided below
Impression:
  • Fixed marked reduced uptake in the inferior wall with no late fill-in (white arrows) -- consistent with transmural injury (6/25 segments) (RCA territory).
  • No stress-induced ischemia detected.
  • Nonspecific reduced uptake in the high septum (green arrows) -- probably RV insertion (normal variant).
  • Moderate increased LV volume. Mild increased RV uptake (pink arrows with "RV").

  • Higher degree of LV dilatation than one would expect for the injury in the inferior wall raises the possibility of LV volume overload condition (CMP ?, valve disease ?).

    ECHO

  • Dilated LV with severe reduction in global systolic function (EF = about 25%)
  • Severe hypokinesis of the anterior, septal, and apical walls, and akinesis of the inferior wall.
  • Mild RV enlargement with reduced RV function
  • 2+ MR, 1+ TR

    Cardiac catheterization

  • RV ESP / EDP = 64/21 mm Hg
  • PAP = 62/36 mm Hg
  • PCW = 25 mm Hg
  • Resting hemodynamics consistent with biventricular failure

    Coronary angiography

  • LAD - diffuse 30% stenosis; 1st diagonal branch - 70-80% stenosis
  • LCX - 70-80% mid-stenosis; 1st marginal branch - 60% stenosis
  • RCA - totally occluded in the middle portion, filled by left-to-right and right-to-right bridging collaterals

    Comments:

  • The inferior wall MI was silent. There is no hemodynamic reason for other walls to be hypokinetic (consistent finding over time with ECHO). Primary CMP therefore the most likely etiology.
  • Mild or moderate subendocardial MIs are common findings at autopsy or after heart transplantation in patients with severe LV dilatation and failure, even with normal coronary arteries. The etiology apparently is compromised subendocardial perfusion pressure secondary to elevated LV EDP.
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    Atlas of Myocardial Perfusion SPECT
    © Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
    Comments and errors to atlasspect@yahoo.com
    Contributions and case related information through     Fmannting@bics.bwh.harvard.edu
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    Initiated: Nov 19, 1995. Last updated: April 26, 1999.