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JAMA Cardiology Clinical Challenge
October 2016

Diffuse Epicardial Involvement on Cardiac Magnetic Resonance Imaging

Author Affiliations
  • 1Department of Cardiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
  • 2Department of Radiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China

Copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Cardiol. 2016;1(7):845-846. doi:10.1001/jamacardio.2016.2557

A woman in her 50s was referred for evaluation of progressive shortness of breath over several months. No history of clinically significant fever was noted. The electrocardiogram showed ST-segment elevation in leads I, aVL, II, III, aVF, and V3-6 (Figure 1A), which was accompanied by fluctuating elevation of troponin-T levels (1.2-12.0 ng/mL). Angiography showed no evidence of coronary artery disease. Transthoracic echocardiography demonstrated restricted diastolic filling with a low left ventricular ejection fraction (40%). Treatment for heart failure was initiated. Cardiac magnetic resonance (CMR) imaging was then scheduled. Late delayed enhancement images showed a striking sawtooth pattern of hyperenhancement in the left ventricular epicardium (Figure 1B) and right-sided enhancement of the anteroseptum. Extensive myocardial edema was noted in the left ventricle via T2-weighted short tau inversion recovery imaging (Figure 1C). Chest and abdominal computed tomography (CT) showed no inflammatory changes or lymphadenopathy. Serum angiotensin-converting enzyme (ACE) levels were not elevated. The brain natriuretic peptide level was elevated (1550 pg/mL).