Miscellaneous - Cases
Anna Perazzolo, MD
Radiology Resident
Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy and Institute of Radiology, Department of Diagnostic Imaging, University of Udine, Udine, Italy, Italy
Anna Perazzolo, MD
Radiology Resident
Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy and Institute of Radiology, Department of Diagnostic Imaging, University of Udine, Udine, Italy, Italy
Florinda Mastro, MD
PhD Student
University of Padua, Italy
Giulia Tufano, MD
Radiology Resident
University of Padua, Italy
Nicola Pradegan, MD
Heart Surgeon
University of Padua, Italy
Ambra Coccato, MD
Radiology Resident
University of Padua, Italy
Amalia Lupi, MD
Radiologist
University of Padua, Italy
Vincenzo Tarzia, MD
Heart Surgeon
University of Padua, Italy
Stefania Zinato
Radiology Technician
University of Padua, Italy
Emilio Quaia, MD, PhD
Professor/Radiologist
Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy, Italy
Gino Gerosa, MD
Professor/Heart Surgeon
University of Padua, Italy
Alesisa Pepe, MD, PhD
Professor/Cardiologist/Radiologist
Institute of Radiology, Department of Medicine, University of Padua
Padova, Veneto, Italy
A 62-year-old woman underwent heart transplant for Dilated Cardiomyopathy (DCM). At first post-operative Endomyocardial Biopsy (EMB) an early moderate focal rejection was detected and treated with immunosuppressive drugs. The patient was asymptomatic with a negative Trans-Esophageal Echocardiography (TEE). One year later, she underwent a routine Cardiovascular Magnetic Resonance (CMR). Concomitant to the first CMR, the EMB showed no signs compatible for rejection and the presence of mature adipose tissue (10%). A second follow-up CMR was performed five months later due to a decompensate state.
Diagnostic Techniques and Their Most Important Findings:
CMR was performed using Siemens Magnetom Avanto fit 1.5 T scanner.
At first CMR examination, cine SSFP sequences showed normal ventricular volumes with preserved biventricular systolic function, multiple areas of India Ink artifacts compatible with fat infiltration/ metaplasia (Figure 1), as confirmed by T1w Black Blood images (Figure 2). Acute/subacute pericardial inflammation was found at the lateral wall (Figure 2. A, C). No signs compatible with myocardial inflammation were found by using parametric (T2 mapping) and non-parametric TIRM T2w sequences.
In both examinations but more extensive in the second CMR, delayed-enhanced images showed areas of intramural/sub-epicardial myocardial late gadolinium enhancement (Figure 2). In the second CMR, we found diffuse signs of myocardial inflammation: areas of hyperintensive signal in the mio-pericardium on TIRM T2-w images, elevated global (57 ms) and segmental T2 values and elevated global (1165 ms) and segmental T1 values. Moreover, a significant pericardial effusion with partial signs of organization was detected (Figure 1-3). Both ventricles showed reduced volume with a reduction of the global systolic function, mild at left and severe at right. Concomitant to the second CMR, the EMB showed signs compatible for focal moderate rejection (3A).
Due to a persistent decompensate state despite the therapy the patient was placed in the list for re-transplant.
Learning Points from this Case:
At best of our knowledge, no data are available in literature reporting fat infiltration/metaplasia in a transplanted heart. These findings could be compatible with a cardiomyopathy in the donor heart. Despite the transthoracic echocardiography, CMR is a non-invasive imaging test with a clinical relevance in assessing not only early signs of acute rejection in heart transplant patients, but preexistent cardiomyopathy in the donor heart. The multiparameter CMR evaluation seems to tell us both the future and recalling the past in transplant patients and could significantly influence the clinical management in this setting.