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.