High take off left main coronary artery accompanied by multicryptic left ventricle myocardium detected by cardiac computerized tomography in a young male: case report

Background Myocardial crypts are discrete, narrow, blood filled invaginations within the left ventricular myocardium and high-take-off coronary artery are rare manifestations where coronary arteries originate above the sinotubuler junction. Case presentation A 41-year-old man with multiple coronary artery disease risk factors admitted to our outpatient department with progressive dyspnea and atypical chest pain. Physical examination revealed no pathological findings. His blood examination revealed only mild to moderately high IgE and LDL levels. Transthoracic echocardiography (TTE) was normal. His treadmill test was normal, yet in the 3rd stage of the test he had an atypically located chest pain which was relieved in the resting period. As he had multiple cardiovascular risk factors, we performed a coronary CT angiography to exclude coronary artery disease. Coronary CT angiography(CCTA) demonstrated multiple myocardial crypts, a muscular VSD like defect which were not detectable with TTE and a high take off left main coronary artery (LMCA). After CCTA, we repeated the TTE to investigate the crypts and VSD-like defect which were clear on CCTA, yet a precise TTE hardly showed crypts and didn’t confirm a shunt between the left and right ventricle. We defined the defect as ‘spontaneously closed muscular VSD’. None of these pathologies were clinically relevant with the patient’s symptoms, thus pneumonology started a montelukast therapy for 1 year and we decided to follow up the patient, as multiple crypts may indicate an early phase hypertrophic cardiomyopathy. Conclusions Considering that a high take-off LMCA is a congenital anomaly, encountering multiple crypts which are also congenital pathologies, is plausible, as congenital anomalies may accompany eachother. Echocardiography is a very useful, practical imaging tool but regrettably may be suboptimal due to various patient and method related reasons. Target combination of different cardiovascular imaging tools like echocardiography, cardiac CT(CCT), may be utilized in order to ensure a comprehensive diagnosis particularly.

Diagnostic opportunities of magnetic resonant imagingmri of heart in differential diagnosis of phenotypical forms of hypertrophic cardiomyopathy

Introduction. Phenotype variants of left ventricular (LV) remodeling in patients with hypertrophic cardiomyopathy (HCM) are often associated with abnormalities of the mitral valve (MV), myocardiumstructure, contributing to the development of medium and/or subaortic obstruction. Itcauses the detail visualization of morphological obstruction substrates, tissue characteristics.Aim. To evaluate the possibilities of magnetic resonance imaging (MRI) in the diagnosis of various forms of HCM and combined abnormalities.Materials and methods. 75 patients with suspected HCM were examined. For verification, all patients underwentMRI using protocol: short-pulse T1w-TSE/ T2w-TSE (STIR), gradient echo in cine (CINE), T1-weighted post-contrast images (Inversion Recovery IR-MDE). Results. Patients classified into 4 types according to the anatomical principle (Wiggle E.D. et al., 1985). In addition to the most frequent forms affecting the interventricular septum (IVS) — 64 patients, unusual forms covering the apical zones and papillary muscles — 11 patients. The majority of patients were diagnosed with abnormalities of MV, divided into abnormalities of the number and position of papillary muscles, as well as the ratio of chords and muscles. Myocardial crypts were diagnosed in 12 patients, some combined with areas of non-compact myocardium. Post-contrast visualization using the delayed contrast technique allowed differentiating HCM with accumulation diseases, excluding cavity thrombosis, and evaluating the severity of myocardial fibrosis.Conclusions. MRI allows to estimate in details anatomic picture of LV remodeling, to diagnose features of the mitral valve, tissue characteristics that allows to stratify risk of sudden death, classify the HCM phenotype form and to determine the volume of surgical intervention.

Incidental detection of myocardial clefts in a patient with acute inferior ST-segment elevation myocardial infarction: a very unusual and potentially ominous association—a case-report

Background The crescent availability of high-resolution cardiac imaging allows detection of myocardial structural variations. Differentiate these entities from others with different clinical significance can be challenging. Clinicians should be familiar with myocardial clefts to avoid erroneous diagnosis. Case summary A 63-year-old smoker man alerted the emergency medical system for sudden chest pain. The electrocardiogram showed Pardee wave in inferior leads. Coronary angiography evidenced a 100% occlusion of right coronary artery that was treated by angioplasty and drug-eluting stent implantation with optimal angiographic result. At ventriculography, two fissure-like protrusion were observed in the inferior wall. Urgent transthoracic echocardiogram (TTE) demonstrated two deep fissures on the mid-inferior wall, contained by a thin sub-epicardial layer, with sub-total obliteration during systole. A diagnosis of myocardial clefts was suspected and after Heart Team discussion, a conservative strategy was proposed. Early cardiac magnetic resonance (CMR) confirmed two myocardial crypts on the mid-inferior wall. Stability of myocardial fissures and absence of left ventricular remodelling was confirmed by TTE, in a 2 years of follow-up period. Discussion Myocardial cleft should always be considered in the differential diagnosis of myocardial wall defects. In a patient presenting with an acute myocardial infarction, the main differential diagnosis is pseudoaneurysm. In this setting modified TTE views and meticulous analysis of CMR sequences are recommended to confirm the diagnosis and estimate the risk of myocardial rupture.

Congenital diverticulum of the left ventricle – diagnosis with echocardiography, ventriculography and magnetic resonance imaging: clinical case

Myocardial diverticula are rare and incidental fi ndings. They are most probably congenital anomalies of the cardiac wall, mainly of the left ventricle (LV), which in the majority of the cases are associated with other anomalies – cardiac, vascular or thoraco-abdominal. The lack of specifi c clinical symptoms and electrocardiographic changes in the presence of cardiac diverticulum, make them most commonly an incidental fi nding during a diagnostic imaging examination. The diagnosis of LV diverticulum can be made with echocardiography, left ventriculography, computed tomography or magnetic-resonance imaging (MRI). Among all, MRI gives the best morphologic assessment of the ventricular wall, the location and the relation of the diverticulum to surrounding structures and its dynamic behaviour during systole and diastole. MRI can rule out infl ammatory, traumatic and ischemic cardiac pathology, and cardiomyopathy, and thus differentiate the diverticulum from another entity – myocardial crypts, pathologically formed focal aneurysm or pseudoaneurysm of the LV. Therefore, MRI is the preferred non-invasive method for evaluating the cardiac wall in detail and helps to differentiate and defi nitively diagnose congenital cardiac diverticulum, which in most cases does not require therapeutic intervention.

Left ventricular myocardial crypts: morphological patterns and prognostic implications

Aims Left ventricular (LV) myocardial crypts are considered a subtle marker of hypertrophic cardiomyopathy. However, crypts have also been observed in seemingly healthy individuals and it is unknown whether myocardial crypts are associated with adverse outcome. Methods and results Myocardial crypts were defined as invaginations traversing >50% of the myocardial wall and assessed using contrast-enhanced cardiac computed tomography in 10 097 individuals from the Copenhagen General Population Study. Number of crypts, location, shape, penetrance, and volume were assessed. The endpoint was a composite of major adverse cardiovascular events and defined as death, myocardial infarction, heart failure, or stroke. Cox regression models were adjusted for clinical variables, medical history, electrocardiographic parameters, and cardiac chamber sizes. A total of 1199 LV myocardial crypts were identified in 915 (9.1%) individuals. Seven hundred (6.9%) had one crypt and 215 (2.1%) had multiple crypts. During a median follow-up of 4.0 years (interquartile range 1.5–6.7), major adverse cardiovascular events occurred in 619 individuals. Individuals with one or multiple crypts had a hazard ratio for major adverse cardiovascular events of 1.00 [95% confidence interval (CI): 0.72–1.40; P = 0.98] and 0.90 (95% CI: 0.47–1.75; P = 0.76), respectively, compared with those with no crypts. No specific pattern of crypt location, shape, penetrance, or volume was associated to an increased hazard ratio for major adverse cardiovascular events. Conclusion LV myocardial crypts are frequent in the general population and are not associated with intermediate-term major adverse cardiovascular events.