A 71-year-old woman with acute chest pain and ST-segment elevation

Figures

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  FIGURE 1. a) Angiographic view of the right coronary artery, demonstrating a patent vessel without angiographically significant stenosis along its course. b, c) Angiographic views of the left coronary system. The left anterior descending artery demonstrates a mild to intermediate angiographic narrowing (red arrow), which was further evaluated with fractional flow reserve and found to be negative, indicating the absence of functionally significant coronary artery disease. The remaining segments and side branches appear patent without obstructive lesions.

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  FIGURE 2. ECG showing sinus rhythm with ST-segment elevation in leads I, II, III, aVF and V5–V6, and ST-segment depression in V1–V2.

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  FIGURE 3. a) Prior coronary angiography demonstrating a normal obtuse marginal (OM) coronary branch without angiographic abnormalities. b) Repeat coronary angiography demonstrating the same OM branch with diffuse moderate luminal stenosis (red arrows), representing a significant interval change compared with the prior study, possibly related to extrinsic encasement or infiltration by an adjacent myocardial mass.

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  FIGURE 4. Transthoracic echocardiography. a) Apical three-chamber view demonstrating focal thickening/mass involving the posterior left ventricular wall (red arrows). b) Apical two-chamber view demonstrating the same focal myocardial mass involving the inferior wall (red arrows). c) Parasternal short-axis view demonstrating the myocardial mass within the left ventricular wall (red arrows).

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  FIGURE 5. Contrast-enhanced transthoracic echocardiography. a) Parasternal short-axis view demonstrating a myocardial mass involving the inferior-posterior and posterior segments of the left ventricle (red arrows). b) Apical four-chamber view obtained using a contrast perfusion protocol, demonstrating involvement of the lateral left ventricular wall with absence of contrast uptake within the mass (red arrows). c) Parasternal short-axis view obtained using a contrast perfusion protocol, again demonstrating the inferior-posterior and posterior left ventricular segments, with lack of contrast enhancement of the myocardial mass (red arrows).

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  FIGURE 6. a) Posteroanterior and b) lateral chest radiographs demonstrate bilateral dependent basal atelectasis with associated basal interstitial crowding, more pronounced posteriorly on the lateral view. A solid opacity is noted paraaortically in the left upper lung zone (red arrows). The cardiomediastinal silhouette appears borderline enlarged, with mild age-related aortic unfolding. The costophrenic angles are mildly blunted bilaterally, right greater than left; small pleural effusions cannot be excluded.

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  FIGURE 7. Contrast-enhanced chest computed tomography (CT). a) Axial contrast-enhanced chest CT image displayed in the lung window, demonstrating a left upper lobe pulmonary mass (red arrows). b) Axial contrast-enhanced chest CT image displayed in the mediastinal (soft tissue) window, demonstrating a left ventricular mass involving the inferior-posterior myocardial wall (red arrows).

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  FIGURE 8. Cardiac magnetic resonance imaging. a) T2-weighted short tau inversion recovery (STIR) sequence, four-chamber (4CH) view, demonstrating increased T2 signal within the myocardial mass involving the lateral wall (red arrow), consistent with myocardial oedema and tissue infiltration. b) Cine balanced steady-state free precession short-axis view demonstrating marked myocardial thickening of the lateral-inferior wall with mass effect and signal intensity inhomogeneity (red arrow). c) T2-weighted STIR sequence, three-chamber view, demonstrating hyperintense signal within the myocardial mass (red arrow), consistent with oedema. d) Native T1 mapping (long-axis view) demonstrating focally elevated native T1 values within the myocardial mass (green arrow). e) T1-weighted black-blood sequence with fat suppression, 4CH, demonstrating the myocardial mass (red arrow) with signal intensity similar to adjacent myocardium and poorly defined margins, raising concern for infiltrative behaviour and possible involvement of surrounding myocardial tissue. f) Late gadolinium enhancement imaging, short-axis view, demonstrating peripheral enhancement with a large central hypoenhanced area, consistent with…