The perfect Infarct disguise: Acute Myocardial Infarction with Microvascular Obstruction and Absence of Late Gadolinium Enhancement on Cardiac Magnetic Resonance

Presenting Author(s)

• 

  LUIZ FLAVIO GALVAO GONCALVES

  MD – Cardiologist, CMR & Cardiac CT Specialist, Chief of Cardiovascular Imaging, Hospital São Lucas Rede Dor
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil

Co-Author(s)

• EJ

  ERYCA V S JESUS

  MD – Cardiologist, specialist in CMR and Cardiac CT,MD – Cardiologist, specialist in CMR and Cardiac
  Hospital São Lucas
  Aracaju, Sergipe, Brazil

Primary Author(s)

• 

  LUIZ FLAVIO GALVAO GONCALVES

  MD – Cardiologist, CMR & Cardiac CT Specialist, Chief of Cardiovascular Imaging, Hospital São Lucas Rede Dor
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil

Co-Author(s)

• IS

  Ibelize Santiago

  Cardiovascular Imaging Fellow
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil
• 

  Carlos Rochitte, MD, PhD, FSCMR

  Associate Professor of Cardiology, Academic Coordinator of Cardiovascular Magnetic Resonance and Computed Tomography sector, and Medical Director of the Research Center at Heart Institute, InCor, University of São Paulo Medical School Cardiovascular Magnetic Resonance and Computed Tomography Director at HCOR Senior Medical Leader at Alta Excelência Diagnóstica, DASA, São Paulo
  InCor - Univ. of São Paulo / HCOR - Heart Hospital
  InCor - Univ. of São Paulo
  São Paulo, Sao Paulo, Brazil
• AS

  Antônio Carlos Sousa

  Cardiologist and Doctor of Medicine (PhD) in Cardiology,
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil
• MB

  Milena Barros

  MD – Cardiologist
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil
• RA

  Roberto Cintra de Azevedo Aragão

  MD – Cardiologist
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil
• JB

  José Augusto Soares Barreto

  Cardiologist and Doctor of Medicine (PhD) in Cardiology,
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil
• MS

  Maria Souto

  MD – Cardiologist, specialist in CMR and Cardiac CT, Hospital São Lucas
  Hospital São Lucas, Sergipe, Brazil
• KS

  Karina Sousa

  Cardiovascular Fellow
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil
• LB

  Leonardo Baumworcel

  MD – Cardiologist
  Hospital Sao Lucas, Sergipe, Brazil
• AF

  Andrielle Ferreira

  Cardiovascular Fellow
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil
• DP

  David Ptak

  MD – Cardiologist, specialist in CMR and Cardiac CT, Hospital São Lucas
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil
• GB

  Gabriela Barros, MD

  Fellow in Cardiovascular Imaging
  Heart Institute, University of São Paulo, Brazil
• JO

  Joselina Oliveira

  Cardiologist and Doctor of Medicine (PhD) in Cardiology,
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil
• cC

  caroline Costa

  MD – Cardiologist
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil
• VV

  Vitor Vahle

  MD – Cardiologist
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil
• aP

  andre Paixao

  MD – Cardiologist
  Hospital Sao Lucas
  Aracaju, Sergipe, Brazil

Description of Clinical Presentation: A 46-year-old previously healthy man was admitted with chest pain of 24 hours’ duration, showing partial relief. The electrocardiogram revealed no significant abnormalities, but high-sensitivity troponin was highly elevated. CMR demonstrated basal inferolateral akinesia, resting perfusion deficit, but no late gadolinium enhancement (LGE), but a hypointense area consistent with microvascular obstruction (MVO). Parametric mapping revealed reduced native T1 values in the affected region (971 vs. 990 ms in remote myocardium) and normal T2 (49 ms), findings consistent with MVO associated with intramyocardial hemorrhage. Coronary angiography confirmed an obstruction in a large obtuse marginal branch, successfully treated with percutaneous coronary intervention. At 30-day follow-up, repeat CMR demonstrated transmural LGE in the affected region, confirming scar from myocardial infarction.

Diagnostic Techniques and Their Most Important Findings: To the best of our knowledge, this is the first reported case in the literature of myocardial infarction associated with microvascular obstruction, documented by additional CMR sequences (rest perfusion and parametric mapping), in which no late gadolinium enhancement was initially observed, becoming evident only on follow-up imaging.

Learning Points from this Case: The unusual and unprecedented presentation of this case underscores the relevance of comprehensive CMR multimodality assessment in cases of suspected acute myocardial injury, as well as the importance of follow-up imaging.

Acute phase: Short-axis view after gadolinium administration demonstrating absence of late gadolinium enhancement.
T1 mapping in the hypoperfused region demonstrating reduced native T1 values.
First-pass gadolinium imaging demonstrating a perfusion defect in the inferolateral wall.