Answer for BIR CoW 27 Oct 2024
Ischemic cardiomyopathy
Findings
Cine imaging using TRUFI sequences reveals global hypokinesia of the left ventricle, particularly with reduced systolic wall thickening in the anterior and antero-septal walls of the mid-cavity. Post-contrast imaging indicates significant areas of non-viable myocardium. Transmural late gadolinium enhancement (LGE) is observed in the anterior, antero-septal, and antero-lateral walls of the mid-cavity, as well as in the anterior septal, lateral, and inferior walls of the apical segment. Additionally, subendocardial LGE exceeding 50% of myocardial thickness appears in the anterior, antero-septal, inferior septal, and infero-lateral walls at the base. These findings suggest extensive non-viable myocardium predominantly within the territories of the left anterior descending (LAD) and left circumflex (LCX) coronary arteries, consistent with ischemic cardiomyopathy.
Discussion
Ischemic cardiomyopathy (ICM) is characterized by significant left ventricular systolic dysfunction, often with a reduced ejection fraction due to prior myocardial ischemia or infarction. Risk factors are generally similar to those for coronary artery disease, including genetic predisposition, age, smoking, diabetes, hypertension, hyperlipidemia, and obesity. Clinically, ICM patients frequently present with symptoms of heart failure, such as angina, dyspnea, fatigue, and in severe cases, edema or syncope. Echocardiography typically shows a reduced left ventricular ejection fraction (≤35-40%) with regional wall motion abnormalities, wall thinning, and reduced end-diastolic wall thickness (<6 mm), indicating limited contractile reserve.
Cardiac MRI is particularly useful in ICM evaluation, as it can delineate left ventricular dysfunction and myocardial scar patterns specific to coronary artery territories, indicating ischemic origins. Cine imaging often reveals regional wall motion abnormalities, while first-pass perfusion imaging can show delayed uptake in affected areas. Late gadolinium enhancement (LGE) patterns, particularly if transmural, predict poor functional recovery potential.
Treatment and Prognosis
The treatment approach for ICM includes optimal medical therapy, cardiac resynchronization therapy to prevent sudden cardiac death, and options such as transcatheter mitral valve intervention for secondary mitral regurgitation. Coronary revascularization, through percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), may improve survival. However, treatment strategies vary based on symptoms, coronary anatomy, myocardial viability, and patient comorbidities.
References
Schuster A, Morton G, Chiribiri A, Perera D, Vanoverschelde J, Nagel E. Imaging in the Management of Ischemic Cardiomyopathy: Special Focus on Magnetic Resonance. J Am Coll Cardiol. 2012;59(4):359-70. doi:10.1016/j.jacc.2011.08.076 - Pubmed Panza J, Ellis A, Al-Khalidi H et al. Myocardial Viability and Long-Term Outcomes in Ischemic Cardiomyopathy. N Engl J Med. 2019;381(8):739-48. doi:10.1056/NEJMoa1807365 - Pubmed Cabac-Pogorevici I, Muk B, Rustamova Y, Kalogeropoulos A, Tzeis S, Vardas P. Ischaemic Cardiomyopathy. Pathophysiological Insights, Diagnostic Management and the Roles of Revascularisation and Device Treatment. Gaps and Dilemmas in the Era of Advanced Technology. Eur J Heart Fail. 2020;22(5):789-99. doi:10.1002/ejhf.1747 - Pubmed
Findings
Cine imaging using TRUFI sequences reveals global hypokinesia of the left ventricle, particularly with reduced systolic wall thickening in the anterior and antero-septal walls of the mid-cavity. Post-contrast imaging indicates significant areas of non-viable myocardium. Transmural late gadolinium enhancement (LGE) is observed in the anterior, antero-septal, and antero-lateral walls of the mid-cavity, as well as in the anterior septal, lateral, and inferior walls of the apical segment. Additionally, subendocardial LGE exceeding 50% of myocardial thickness appears in the anterior, antero-septal, inferior septal, and infero-lateral walls at the base. These findings suggest extensive non-viable myocardium predominantly within the territories of the left anterior descending (LAD) and left circumflex (LCX) coronary arteries, consistent with ischemic cardiomyopathy.
Discussion
Ischemic cardiomyopathy (ICM) is characterized by significant left ventricular systolic dysfunction, often with a reduced ejection fraction due to prior myocardial ischemia or infarction. Risk factors are generally similar to those for coronary artery disease, including genetic predisposition, age, smoking, diabetes, hypertension, hyperlipidemia, and obesity. Clinically, ICM patients frequently present with symptoms of heart failure, such as angina, dyspnea, fatigue, and in severe cases, edema or syncope. Echocardiography typically shows a reduced left ventricular ejection fraction (≤35-40%) with regional wall motion abnormalities, wall thinning, and reduced end-diastolic wall thickness (<6 mm), indicating limited contractile reserve.
Cardiac MRI is particularly useful in ICM evaluation, as it can delineate left ventricular dysfunction and myocardial scar patterns specific to coronary artery territories, indicating ischemic origins. Cine imaging often reveals regional wall motion abnormalities, while first-pass perfusion imaging can show delayed uptake in affected areas. Late gadolinium enhancement (LGE) patterns, particularly if transmural, predict poor functional recovery potential.
Treatment and Prognosis
The treatment approach for ICM includes optimal medical therapy, cardiac resynchronization therapy to prevent sudden cardiac death, and options such as transcatheter mitral valve intervention for secondary mitral regurgitation. Coronary revascularization, through percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), may improve survival. However, treatment strategies vary based on symptoms, coronary anatomy, myocardial viability, and patient comorbidities.
References
Schuster A, Morton G, Chiribiri A, Perera D, Vanoverschelde J, Nagel E. Imaging in the Management of Ischemic Cardiomyopathy: Special Focus on Magnetic Resonance. J Am Coll Cardiol. 2012;59(4):359-70. doi:10.1016/j.jacc.2011.08.076 - Pubmed Panza J, Ellis A, Al-Khalidi H et al. Myocardial Viability and Long-Term Outcomes in Ischemic Cardiomyopathy. N Engl J Med. 2019;381(8):739-48. doi:10.1056/NEJMoa1807365 - Pubmed Cabac-Pogorevici I, Muk B, Rustamova Y, Kalogeropoulos A, Tzeis S, Vardas P. Ischaemic Cardiomyopathy. Pathophysiological Insights, Diagnostic Management and the Roles of Revascularisation and Device Treatment. Gaps and Dilemmas in the Era of Advanced Technology. Eur J Heart Fail. 2020;22(5):789-99. doi:10.1002/ejhf.1747 - Pubmed
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!