PMC3700493_01
ECG October 2011: Normal.
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A 58-year-old amateur cyclist (MTB), who was considered fit for competitive sports after a specific medical and cardiologic assessment for sports carried out in October 2011 with ECG (Figure 1) consulted a local cardiology clinic in June 2012 because of an oppressive retrosternal thoracic pain felt the day before during his participation in a competitive race.
ECG June 2012: mild ST elevation and negative T wave on inferior - lateral leads.
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Serial electrocardiographs recorded on that occasion (Figure 2) showed a high ST segment with negative T waves in the inferolateral derivations with an enzymatic increase of CPKMB and T troponin.
Coronary angiography: Patent left anterior descending artery, left circumflex artery and right coronary artery.
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A further coronarography (Figure 3) was basically negative, without significative endoluminal stenosis, myocardial bridge, or congenital anomalies in the context of a coronarography for right-sided heart failure predominance.
CMR: a) Delayed contrast enhancement magnetic resonance images (a horizontal long-axis, and b short axis) in a patient with acute myopericarditis. White arrows indicate a hyper-intense signal in the subepicardial layer of anterolateral and inferolateral walls. b) Delayed Enhancement (LGE) in the sequences Inversion Recovery/IR 10 minutes after IV administration of Gadolinium (sequences for the evaluation of the micro-vascular permeability and necrosis) in the intra-myocardial and sub-epicardial Short-axis, (2) long-axis, and (3) four-chamber three-dimensional delayed-enhancement T1-weighted multishot gradient-echo IR Mr images of a diffuse form of myocarditis in 58-year-old man. Nodular centromyocardial high enhancement of the inferolateral wall associated with bandlike or nodular subepicardial high enhancement predominating in the inferolateral wall of the left ventricle is seen.
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A precocious and belated homozonal enhancement (LGR) extended to the adjacent pericardium is associated to this." In conclusion, the MR context gives initial evidence of myocarditis, with traces of activity and outcomes that are still visible (Figure 4).