Imaging: Student/Resident Case Report Poster - Imaging |

Epicardial Fat Associated With a Type IV “Wrap-Around” Left Anterior Descending Artery (LAD) Mimicking Right Ventricular Apical Thrombus FREE TO VIEW

Hoyle Whiteside, BS; Amudhan Jyothidasan, MD; Preston Conger, MD; Jayanth Keshavamurthy, MD; Gyanendra Sharma, MD
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Medical College of Georgia, Augusta, GA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):668A. doi:10.1016/j.chest.2016.08.762
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SESSION TITLE: Student/Resident Case Report Poster - Imaging

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: A right ventricular (RV) apical mass on transthoracic echocardiogram (TTE) is generally considered to be a thrombus. We report a case, in which a RV apical mass was proven to be epicardial fat surrounding the distal LAD. By definition, a type III LAD occurs when the apex of the heart is completely supplied by the LAD and is present in 77% of patients.1 A type IV LAD, in which the LAD wraps around the apex to supply a portion of the RV, is the second most common type with a prevalence of 16.4%.1

CASE PRESENTATION: A 61 year old male presented to the emergency department with a three day history of orthopnea, shortness of breath, and lower extremity edema. His past medical history is significant for: RV failure secondary to arrythmogenic right ventricular cardiomyopathy (ARVC) status post implantable cardioverter defibrillator, heart failure with preserved systolic function, and persistent atrial fibrillation on apixaban. On presentation, he was tachypneic, hypoxic, and started on non-invasive positive pressure ventilation. Vital signs were: BP 120/86, HR 90, RR 35, O2 sat 93% on 60% FIO2. Physical exam revealed an irregularly irregular rhythm, bilateral inspiratory crackles, and 3+ pitting edema. Chest X-ray revealed a triple lead ICD (two RV leads) and perihilar interstitial and alveolar densities consistent with pulmonary edema. TTE was significant for severely reduced RV function and a hyperechoic immobile mass in the RV apex measuring 28mm x 21mm concerning for thrombus. The next day the patient underwent CT thorax for evaluation of acute respiratory failure. CT was consistent with severe pulmonary edema, but would also reveal a type IV LAD with significant pericoronary fat near the RV apex.

DISCUSSION: Right ventricular apical thrombus is a finding on TTE that cannot be ignored. Our patient had multiple risk factors including two pacing leads in the RV as well as RV failure secondary to ARVC. CT Thorax demonstrated a type IV LAD associated with a significant amount of pericoronary fat near the RV apex (Figure 1). The pericoronary fat measured the same dimensions as the RV mass identified on TTE (Figure 2A and 2B) and the density was measured at 85 Hounsfield units, which was consistent with epicardial fat in other locations. CT concluded that the hyperechoic mass identified on TTE was the result of the patient’s coronary anatomy and epicardial fat distribution. The epicardial fat distribution is independent of his cardiomyopathy.

CONCLUSIONS: In rare cases, pericoronary fat associated with a type IV LAD can mimic a right ventricular apical thrombus on TTE. This is a unique finding that has not been widely reported in the literature. Those reading CT or TTE should be aware of this possibility when evaluating a RV apical mass.

Reference #1: Abdelrahman, SF. Salem, MA. et al. Coronary arteries variants & congenital anomalies; using MDCT to assess their prevalence in 1000 of the Egyptian population. Egypt. J. Radio I. Nucl. Med., vol. 46, pp. 885-892, 2015

DISCLOSURE: The following authors have nothing to disclose: Hoyle Whiteside, Amudhan Jyothidasan, Preston Conger, Jayanth Keshavamurthy, Gyanendra Sharma

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