CASES PRESENTATION
In this case series we present three patients (pts) that underwent
myocardial contrast echocardiography (MCE) in the setting of recent
chest pain, as paradigmatic examples of the usefulness of
contrast-echocardiography with very-low mechanical index imaging in the
context of rest wall motion assessment.
The first patient was a 57 years old man with no cardiovascular risk
factors who presented to the emergency department (ED) due to chest pain
on effort and also at rest. The ECG showed mild abnormalities on the
anterior leads, and there was a mild increase of the troponin I levels.
At transthoracic echocardiography (TTE) left ventricular wall motion
(WM) was apparently normal with no regional abnormalities.
The second patient was a 40-year-old man with hypercholesterolemia who
had chest pain on effort and again also at rest. In this case the ECG
was unremarkable and the high sensitivity troponin I was between the
limit of detection (LOD) and upper reference limit (URL) with no
significant delta between two serial measurements. Again, at TTE there
was an apparently normal segmental WM of the left ventricle.
Last patient was a 58-year-old woman with obesity and hypertension who
was evaluated at the outpatients clinic for exertional chest pain with
few episodes at rest. The ECG was unremarkable and the troponin was not
measured at that time. TTE was apparently normal also in this case.
Since the symptoms were very typical in all the three cases and the
suspect of coronary artery disease (CAD) was high, we integrated the TTE
with contrast administration for better WM assessment. In all the cases,
the more accurate evaluation of endocardial border could reveal WM
abnormalities in the LAD territory: in particular, in case 1 they
involved the anterior mid-to-distal wall, the apex and the distal septum
(see figure 1 for details, and video 1 and 2), in case 2 the distal
anterior wall, the apex and the distal septum (see figure 2 and video 3
and 4), in case 3 the mid-to-distal septum, the apex and the
latero-apical wall (see figure 3 and video 5 and 6).
Moreover, even if the use of small boluses of contrast is not ideal for
the study of myocardial perfusion (MP), the assessment of WM using
real-time very low mechanical index (<0.2) provides collateral
information regarding MP, which was reduced in these cases and further
contributed to highlight the subtle WM abnormalities.
All the three-pts had severe left anterior descending coronary artery
(LAD) stenosis which turned out to be sub-occlusive in all of the three
pts. The first two pts underwent coronary angiography (figure 4 and 5),
whereas the last patient underwent computed tomography (figure 6 and
video 7) and will soon undergo coronary angiography as well.