Advanced Cardiac Imaging and Women’s Chest Pain: A Question of Gender

Figures

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  Figure 1. Case 1. ACS: A 37-year-old woman underwent a CCTA due to chest pain, ECG abnormalities, and elevated troponin levels. Imaging results, including axial two-dimensional imaging (a), 3D imaging (b), and CPR (curved planar reconstruction) (c), revealed the presence of a significant subocclusive stenosis (>90%) in the proximal LAD. This stenosis was caused by a non-calcified plaque (black and red arrows). A subsequent ICA (d) confirmed a significant stenosis with a subsequent vessel stenting.

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  Figure 2. Case 2. Coronary computed tomography angiography (CCTA) was performed on a 73 years old woman who experienced acute chest pain. CT study revealed the presence of a diffuse, partly calcified atherosclerosis in LAD and a main stenosis in the proximal segment of the vessel, causing an intermediate morphological reduction of the patent lumen, accounting for 50–70% (stenosis area), highlighted in the red square.

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  Figure 3. Case 2. To establish the real hemodynamic impact of the stenosis, a stress CT perfusion scan (A) was subsequently performed. The scan was composed by rest (B) and stress (C) dynamic acquisitions, using vasodilator coronary selective medication. A relative perfusion defect was seen in the stress bull eye (C) regarding interventricular septum, from the base to apex. The finding was clearly appreciable in comparison to the rest of the dynamic acquisition (B) and baseline angiographic reconstruction of the ventricle (D).

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  Figure 4. Case 3. MINOCA: A 55-year-old woman was admitted to the emergency department with chest pain, ECG changes, and mildly elevated necrosis enzymes. The patient underwent ICA, which did not show significant stenosis in the left (C) and right (D) coronary arteries. Given the persistence of symptoms, she was subjected to a CMR study, which showed acute myocardial injury at edema-sensitive sequences in the lateral wall of the left ventricle (red arrow (A)) and the presence of LGE (red arrow) on the same side (B), thus confirming MINOCA diagnosis.

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  Figure 5. Case 4. SCAD: An invasive coronary angiography was conducted on a 56-year-old woman experiencing chest pain, elevated troponin levels, and ECG alterations. The figure depicts the presence of a segmental luminal interruption (red arrow) in the distal left anterior descending (LAD) artery with slow flow progression distally, representative of spontaneous LAD intimal dissection (Type 2).

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  Figure 6. Case 4. SCAD: A CCTA follow-up was performed after 14 days. Curved planar reconstruction images (a,c), as well as a 3D reconstruction image (b), demonstrated a partial vessel reperfusion with moderate expansion of the luminal caliber.

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  Figure 7. Case 4. SCAD: Another CCTA follow-up was performed 6 months later. Curved planar reconstruction images (a,c), as well as a 3D image (b), revealed the complete resolution of the dissection following conservative treatment.

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  Figure 8. Case 5. Takotsubo Syndrome: Cardiac magnetic resonance (CMR) findings in a 56-year-old woman presented with chest pain and absence of coronary stenosis at ICA. In the end-systolic (b) phase, compared to end-diastolic (a) 2-chamber frames, there is noticeable mid-ventricular ballooning of the left ventricle (red arrow). This abnormality is accompanied by transmural wall edema (red arrow), demonstrated by the STIR sequence (d) in the absence of late gadolinium enhancement (LGE) (c).

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  Figure 9. Case 6. Myocarditis: Coronary computed tomography angiography (CCTA) was performed on a 25-year-old woman who experienced a cardiac arrest, followed by cardiac reanimation, at the beach. The patient arrived at the hospital showing nonspecific ECG changes and a slight elevation in troponin levels. CT scan revealed normal patency and anatomy of the coronary tree.

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  Figure 10. Case 6. Myocarditis: Coronary evaluation at CCTA was followed by a late iodine enhancement (LIE) acquisition (a), showing the presence of a myocardial scar (red arrow) in the inferolateral wall of the basal left ventricle. The same findings (red arrow) was confirmed upon the subsequent CMRI on the LGE acquisition (b). CMRI was able to demonstrate the presence of acute damage (edema) on STIR sequences (red arrow) (c) and acute hyperemia (red arrow) on early gadolinium enhancement (EGE) acquisition (d).

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  Figure 11. Case 7. Myocarditis: A 35-year-old woman underwent CCTA, using the dual-energy technique (DECT), for thoracic discomfort in the presence of fever. Patient was classified as a low ACS risk. CCTA excluded significant coronary stenosis (upper row of figure). A delayed acquisition dual-energy phase was performed after an 8 min contrast injection, using iodine maps to quantify ECV (lower row of figure). The ECV calculated was higher than normal, and several areas of late iodine enhancement were seen.

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  Figure 12. Case 7. Myocarditis: In the upper row, four chambers iodine maps showing hyperenhancement foci in the subepicardial layer along the left ventricle lateral wall (red arrow). In the lower row, same patient underwent a subsequent CE-CMR study showing, in late gadolinium enhancement phase, a perfect overlap of findings compared to DECT.