P570Extreme non-viability following late presentation myocardial infarction

Abstract

A 49 year old businessman was admitted with very late presenting anterior ST elevation myocardial infarction. He complained of slightly atypical chest pain for 12-16 hours. There was a smoking history of 40 pack years, untreated hypertension and a family history of premature coronary artery disease in his father aged 50. ECG confirmed established anterior wall infarction with Q waves. He was referred for emergency PCI and had successful stenting of the left anterior descending artery with 2 drug eluting stents and good angiographic result. There was a chronic occlusion of the circumflex, left untreated, and minor right coronary artery disease. Peak hs-Troponin T was 8936ng/L. Pre-discharge echocardiogram showed severe LV impairment with LVEF 20-25% and there was a plan for outpatient viability assessment of the circumflex territory. Over the next 9 weeks, he was admitted to a local district general hospital twice, for up to 9 days, and missed the first CMR appointment. Index outpatient CMR confirmed severe LV impairment with LV ejection fraction 17%. There was very extensive full-thickness myocardial infarction of the entire LAD territory, apical RV infarction and >50% transmural infarction of the inferolateral wall. Extensive non-viability totalling 13 out of 17 segments was the worst ever seen in our centre, with viability in the inferior wall and the partially infarcted basal inferolateral segment only. The scan also confirmed multiple LV thrombi and signs of decompensation with bilateral pleural effusions and small pericardial effusion. See figure (animated GIF) for representative short axis stack of late gadolinium imaging, showing the extent of irreversible scarring and multiple clots. He was admitted immediately after the MRI scan and commenced on appropriate heart failure therapies. Admission NT-pro BNP was 11407 ng/L. There was slow response and on day 20 he developed runs of non-sustained ventricular tachycardia, causing cardiogenic shock and peri-arrest status. Inotropic support and Amiodarone therapy were started and he was transferred to the nearest transplant centre for further management. He had successful implantation of durable left ventricular assist device (LVAD) 7 days later and improved promptly. He is currently well, back at home and active on the cardiac transplant list. Summary: A case of the most non-viable ventricle scanned in our centre but thankfully the outcome was positive following prompt and aggressive heart failure management, including early LVAD implantation.