Presentation
Shortness of breath.
Patient Data
Frontal view of the chest shows cardiomegaly with increased vascular markings and small left pleural effusion.
Myocardial perfusion scan performed using 8 mCi of Tc99m sestamibi IV at rest and 24 mCi of Tc99m sestamibi IV at stress. Images presented in the short axis (top 3 rows), vertical long axis (middle 3 rows) and horizontal long axis (bottom 3 rows) with stress supine (top row of each set of images), stress upright (middle row of each set of images) and rest upright (bottom row of each set of images).
On splash view, there is a large-sized, severe-intensity, fixed perfusion defect of the apex, all distal segments, and mid anterior wall.
On vertical long axis (VLA) the apex is located to the right and horizontal long axis (HLA) the apex is located at the top. In both series, the walls of the left ventricle show abnormal divergence towards the apex (splaying outward). This has been termed the 'reverse apex' sign.
On wall motion analysis, there is again shown to be absent perfusion centered about the apex with dyskinetic motion of the apex.
Combination of findings is most typical for a chronic large infarct centered about the apex with apical aneurysm.
FDG PET-CT performed to assess for viability showed only minimal metabolic activity involving the large fixed perfusion defect, consistent with scar.
Case Discussion
Ventricular aneurysm is a complication that may be seen following a large transmural myocardial infarction. It almost always involves the left ventricle, with the apex and anterior wall most commonly affected following a left anterior descending artery infarct.
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