Proximally Amputated LAD with Subsequent Severe Anterior Myocardial Infarction

This 44 year old smoker suffered from dyspnea and recently from orthopnea. The ECG at rest showed a probably old anterior myocardial infarction with ST segment elevation and sinus rhythm. Ejection fraction was 24% with echocardiography, where a large anteroseptal myocardial infarction and significant mitral regurgitation was seen. On coronary angiography, a proximal amputation of the LAD was noted, furthermore a 75% stenosis of the first diagonal branch. Monoplane ejection fraction was 14%. The R-Test revealed a polymorphic self limited ventricular tachycardia with a fusion beat 54 hours after the initiation of the test. 

On CMR, the EF was 18%, stroke volume 72 ml, enddiastolic volume 401 ml, transmitral regurgitation volume 30 ml (regurgitation fraction 39% derived from substraction of quantitative aortic flow and left ventricular stroke volume using Cine CMR).

The CMR coronarography using navigator technique in a quiet breathing fashion in the supine position with image resolution of 1.5x1.5 mm and 20 slices showed the abrupt closure of the proximal LAD and - more distally - a clearly visible thinning of the anterior left ventrcular wall. The figure is a reconstruction using a path tracking technique.