Aneurysmal formation from silent myocardial infarction mimics increased 18 F-FDG uptake pattern
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Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
Received Oct 10, 2020; accepted Oct 12, 2020 doi:10.1007/s12350-020-02415-7
CASE A 50-year-old man was treated for diabetes mellitus and chronic kidney disease as an outpatient at our hospital. A screening electrocardiogram showed a sinus rhythm, negative T wave and abnormal Q waves in II, III, and aVF, respectively, and a completed right bundle branch block. He had no history of chest pain. Transthoracic echocardiography identified an aneurysm in the interventricular septum of the left ventricle (Figure 1). A laboratory analysis showed normal levels of angiotensin-converting enzyme activity (10.6 U/L) and soluble interleukin-2 receptor (276 U/mL), low estimated glomerular filtration rate levels (26 mL/min/1.73 m2),
Reprint requests: Yumiko Kanzaki, MD, Department of Cardiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 5698686, Japan; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2020 American Society of Nuclear Cardiology.
and elevated brain natriuretic peptide levels (390 ng/L). Cardiac magnetic resonance imaging also identified a mid-inferior myocardial aneurysm (Figure 2). We performed fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography to evaluate the possibility of cardiac sarcoidosis 15 min after administration of heparin and after 22 h fasting with a low carbohydrate diet. Focal uptake was identified in the peri-aneurysm border zone (Figure 3). Based on these images, we suspected isolated cardiac sarcoidosis. However, a coronary angiography identified total occlusion of right coronary artery (Figure 4). Finally, we diagnosed myocardial aneurysm from a silent previous myocardial infarction.
Kanzaki et al Aneurysmal Formation from Silent Myocardial Infarction Mimics
Journal of Nuclear CardiologyÒ
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F-FDG is a PET tracer and glucose analog that is widely used to assess cardiovascular inflammation. Focal increases in myocardial FDG uptake suggest active cardiac sarcoidosis,1 but results are not specific. Because the heart uses a mixture of free fatty acids and glucose for energy production under normal resting conditions, assessing myocardial inflammation on a background of physiologic myocardial 18F-FDG uptake can be challenging.2 Therefore, we used dietary preparation and intravenous heparin to suppress of physiological 18F-FDG uptake.3 Nevertheless, this case showed increased FDG uptake in the peri-myocardial infarct zone. Even when focal increases in myocardial FDG uptake are observed, coronary artery disease should be considered part of the differential diagnosis, in addition to cardiac sarcoidosis. Figure 1. Transthoracic echocardiography. The parasternal short axis view showing the aneurysm in the interventricular septum of the left mid-ventricle.
Figure 2. Three tesla cardiac magnetic resonance imaging. On cine MRI, a large aneurysm is observed on mid-inferior myocardial aneurysm. Fused images show an overlap of 18F-FDG uptake in the peri-
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