PMC2697369_01
ECG at admission suggestive for an acute anterior wall infarction: sinus-rhythm with 58 beats per minute, 1st degree AV block, ST segment elevation in leads V1-V4, and pathological Q waves in V2 and V3
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Fig1
The electrocardiography (ECG) showed an acute anterior wall infarction (Figure 1).
Left ventricular (LV) angiography showing severe mitral regurgitation and apical ballooning
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Fig2
Left ventricular (LV) angiography showed severe mitral regurgitation and apical ballooning (Figure 2).
123I-MIBG scintigraphy: images on the left were made 15 min postinjection (p.i.) of 123I-MIBG (early) and the images on the right were made 4 h p.i. (late). Upper left panel shows the regions of interest over the myocardium and mediastinum for the calculation of the semiquantitative parameters of 123I-MIBG myocardial uptake and washout. 123I-MIBG images 4 days after hospital admission, show severely reduced myocardial uptake (A). Semiquantitative analysis of the myocardial uptake confirmed the visual interpretation (early heart/mediastinal (H/M) ratio: 1.54, late H/M: 1.26 and myocardial washout of 123I-MIBG: 18%). Three (B) and seven months (C) after hospital admission 123I-MIBG myocardial uptake and washout remained abnormal. The semiquantitative parameters remained abnormal after 3 months (early H/M: 1.78, late H/M: 1.33, and myocardial washout of 123I-MIBG: 25%) and after 7 months (early H/M: 1.66, late H/M: 1.13, and myocardial washout of 123I-MIBG: 32%). Due to the diffuse reduced myocardial 123I-MIBG uptake SPECT images could not reliably be reconstructed
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Fig3
MRI did not show late contrast enhancement which excludes myocardial fibrosis and myocardial infarction as the cause of the hemodynamic instability. Myocardial 123I-metaiodobenzylguanidine (123I-MIBG, a radiolabelled noradrenalin analog) scintigraphy, performed 4 days after admission, showed diffuse reduced myocardial uptake and increased washout of 123I-MIBG which reflects impaired sympathetic neuronal function and increased sympathetic activity, respectively (Figure 3A). However, cardiac sympathetic neuronal function and activity remained abnormal as was shown by 123I-MIBG scintigraphy at 3 and 7 months (Figure 3B and C, respectively).