Figure 1. Two-dimensional echo. A, Parasternal long axis view demonstrating markedly thickened ventricular septum and posterior wall and left atrial enlargement. B, Apical four chamber view demonstrating markedly thickened and hyper-refractile ventricular septum, left ventricle mildly enlarge and apical infarct with thinned wall and aneurysmal dilatation. C, Short-axis view mid ventricular level, thickened papillary muscles are seen. D, Global longitudinal strain demonstrating mild reduction in global strain—8.5% and regional heterogeneity with severely reduced strain in anteroseptal and lateral segments with comparatively better strain values for the inferior and septal in the basal level. E, Mitral inflow slightly increased E velocity (90 cm), reduced A velocity (30 cm) deceleration time is 165.5 ms. F, Septal e’ reduced to 30 cm. E/e’ = 26 meaning high LA pressure.
Figure 2. Cardiac magnetic resonance imaging. Steady-state free precession cine images in short axis (A) and 4 chamber (B) demonstrate increased left ventricle (LV) wall thickness up to 20 mm in the septum, as well as an area of wall thinning and akinesis at the apical lateral wall (arrows) extending to the apical anterior wall. T1 maps in short axis (C) and 4 chamber views (D) demonstrate diffuse elevation in T1 times, with a global average measuring 1201 ms and regions measuring up to 1400 ms. Late gadolinium enhancement (LGE) images obtained with phase sensitive inversion recovery sequences show severe, diffuse circumferential LGE throughout the basal to mid LV walls (E, F) as well as transmural LGE throughout the apex (arrows) corresponding to a chronic myocardial infarction.
Figure 3. Events timeline. HF, heart failure; MI, myocardial infarction; PCI, percutaneous coronary intervention; SPECT, single photon emission computed tomography; SOB, shortness of breath.
Figure 4. Clinical and imaging red flags that should prompt evaluation for cardiac amyloidosis in patients with known ischemic heart disease.
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