Pulmonary arteriovenous malformations and embolic myocardial infarction identified with cardiovascular magnetic resonance.
Pulmonary arteriovenous malformations and embolic myocardial infarction identified with cardiovascular magnetic resonance.
复制标题
心血管磁共振识别肺动静脉畸形和栓塞性心肌梗死。
DOI：
10.1093/ehjci/jez169
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发表时间：
2019
期刊：
影响因子：
--
通讯作者：
Nazir MS
中科院分区：
文献类型：
--
作者：
Nazir MS
一名42岁女性出现向左肩放射的中心性胸痛。12导联心电图显示无缺血，血清肌钙蛋白升高至28（正常值< 13 ng/L），峰值为140，随后降至67。开始阿司匹林和氯吡格雷双重抗血小板治疗假定的急性冠状动脉综合征。经胸超声心动图显示保留的双心室功能和轻度二尖瓣返流（在线补充数据，电影S1和S2）。有创冠状动脉造影显示冠状动脉通畅，无冠状动脉粥样硬化（在线补充数据，电影S3、S4和S5）。安排了心血管磁共振（CMR）扫描，以调查临床表现的病因。初始低分辨率CMR图像显示右肺中两个高信号圆形胸膜下实性结节（图A）。二腔、三腔和四腔电影成像证实双心室功能良好（在线补充数据，Movie S6）。短轴电影成像显示中间隔壁存在细微的局部运动室壁异常（RMWA）（在线补充数据，Movie S7），经胸超声心动图显示不明显，与晚期钆增强（LGE）成像显示的局灶性透壁心肌增强区域相对应（图B）。为了进一步研究临床表现和右肺肿块，在静脉内给予0.1 mmol/kg钆布醇（Gadovist，Bayer，德国）期间采集4D血管造影（在线补充数据，Movie S8）。发现多发性肺动静脉畸形（AVM），传入（供血）和传出（引流）血管几乎同时增强（图C）。在冠状动脉通畅、中间隔RMWA、相应LGE和肺AVM的背景下，这些结果与反常栓塞性心肌梗死一致。停止抗血小板治疗，开始华法林抗凝治疗。临床随访证实超声心动图显示双心室功能保留。（图A）初始定位图像显示右肺胸膜下高信号圆形实性结节（红色箭头）。（图B）晚期钆增强成像显示透壁心肌增强的局灶性区域，表明心肌梗死（箭头）。（图C）动态4D血管造影图像的最大强度投影图像。多发结节和匍匐性肿块提示肺动静脉畸形（红色箭头）。
A 42-year-old female developed central chest pain radiating to the left shoulder. Twelve lead electrocardiogram demonstrated no ischaemia and the serum troponin was raised at 28 (normal< 13 ng/L), which peaked to 140 and fell to 67. Dual antiplatelet therapy with aspirin and clopidogrel was commenced for a presumed acute coronary syndrome. Transthoracic echocardiography demonstrated preserved biventricular function and mild mitral regurgitation (Supplementary data online, Movies S1 and S2). Invasive coronary angiography demonstrated unobstructed coronary arteries and no coronary atheroma (Supplementary data online, Movies S3, S4 and S5). A cardiovascular magnetic resonance (CMR) scan was arranged to investigate aetiology of the clinical presentation. Initial low resolution CMR images demonstrated two hyper-intense rounded sub-pleural solid nodules in the right lung (Panel A). Two, three, and four chamber cine imaging confirmed good biventricular function (Supplementary data online, Movie S6). Short axis cine imaging demonstrated a subtle regional motion wall abnormality (RMWA) in the mid septal wall (Supplementary data online, Movie S7), which was not clearly evident on transthoracic echocardiography, and corresponded to an area of focal transmural myocardial enhancement on late gadolinium enhancement (LGE) imaging (Panel B). To further investigate the clinical presentation and right lung mass, 4D angiography (Supplementary data online, Movie S8) was acquired during intravenous administration of 0.1 mmol/kg of gadobutrol (Gadovist, Bayer, Germany). Multiple pulmonary arteriovenous malformations (AVM) were identified, with afferent (feeding) and efferent (draining) vessels which enhanced almost simultaneously (Panel C). In the context of unobstructed coronary arteries, mid septal RMWA, corresponding LGE and pulmonary AVMs, these findings were in keeping with a paradoxical embolic myocardial infarction. Antiplatelet therapy was stopped, and anticoagulation with warfarin was commenced. Clinical followup confirmed preserved biventricular function on echocardiography.(Panel A) Initial scout images demonstrates a sub-pleural hyper-intense rounded solid nodule in the right lung (red arrow).(Panel B) Late gadolinium enhancement imaging demonstrated a focal area of transmural myocardial enhancement indicating myocardial infarction (arrowed).(Panel C) Maximum intensity projections images of the dynamic 4D angiography images. Multiple nodules and serpiginous masses are present which indicate pulmonary arteriovenous malformations (red arrows).