A Double MINOCA: When CMR Enlightens Angiography (QF_FR_083)

Friday, January 31, 2025

8:40 AM – 8:50 AM East Coast USA Time

Location: Blue Room PreFunction

Primary Author(s)

DG

Daniela Grassano, MD

Cardiology Fellow
University Hospital of Perugia, Italy

Co-Author(s)

FG

Francesca Garinei, MD

Chief Radiology Division
Hospital of Todi, Umbria, Italy, Italy
AB

Andrea Broccatelli, MD

Consultant Cardiologist
University Hospital of Perugia, Italy
RS

Rocco Sclafani, MD

Consultant Cardiologist, Chief
University Hospital of Perugia, Italy
GC

Giuseppe Ciliberti, MD, PhD

Consultant Cardiologist
University Hospital of Ancona, Italy
VP

Valter Papa, MD

Chief Radiology Division
Regional Healthcare Unit, Umbria, Italy, Italy

Presenting Author(s)

Andrea Cardona, MD, PhD, FACC, FSCMR

Chief Advanced Cardiovascular Diagnostics – Regional Healthcare Unit, Umbria
Regional Healthcare Unit, USL Umbria, Italy, Italy

Co-Author(s)

Andrea Cardona, MD, PhD, FACC, FSCMR

Chief Advanced Cardiovascular Diagnostics – Regional Healthcare Unit, Umbria
Regional Healthcare Unit, USL Umbria, Italy, Italy

Description of Clinical Presentation: We present the case of a 51-year-old man with a past medical history significant for typical chest pain with normal coronary angiography diagnosed as myocardial infarction with non-obstructive coronary arteries (MINOCA). Additionally, he had dyslipidemia, paroxysmal AF (atrial fibrillation) not on anticoagulant therapy (CHA₂DS₂-VASC< 1), and a history of smoking. A few months later, he experienced recurrent chest pain, elevated cardiac troponin (3510 ng/L), and AF. Coronary angiography, including an ACh-provocation test and microcirculation study via hyperemia induction, was normal. He was referred to our center for early CMR during the admission.

Diagnostic Techniques and Their Most Important Findings: CMR cine revealed normal geometry and systolic function (LVEDVI = 101 ml/m², LVEF = 54%), however a mild hypokinesis was observed in the mid inferolateral wall. STIR-T2W imaging showed a hyperintense area in the same region, consistent with focal myocardial edema, which was corroborated by an increased T2 map value compared to remote myocardium (60 ms vs. 49 ms) (Fig. 1, panels A-B). On LGE, the same region showed subendocardial to transmural enhancement. These findings were indicative of a recent MINOCA. A closer review of the coronary angiography revealed that, compared to the angiogram performed in occasion of the first chest pain event, a small obtuse marginal branch was occluded, likely responsible for the new MINOCA (Fig. 2, panels A-B).

Learning Points from this Case:

Both the European and American cardiology guidelines endorse CMR as the gold standard non-invasive imaging modality for the diagnostic work-up of MINOCA. In this case, CMR not only provided a definitive diagnosis, but also helped refining the angiogram description by identifying the culprit lesion. Recurrent MINOCA, though rare, is a possible entity. In this case, embolic etiology appears the most likely explanation given patient’s multiple risk factors despite his relatively young age.