Differential diagnosis, investigations, and treatment:
An initial cardiac evaluation revealed elevated troponin and pro-BNP
levels. Echocardiogram showed severe global hypokinesis with left
ventricular ejection fraction (LVEF) of 20%. Coronary angiography
revealed multivessel coronary artery disease including chronic total
occlusion of the right coronary artery with collaterals from the left
coronary system (Figure 1). To fully characterize the territories
needing revascularization, MRI viability study was obtained, cardiac
magnetic resonance (CMR) showed viable myocardium at RCA, circumflex,
and predominantly viable LAD, except for distal apical septal segment.
(Figure 2). Due to the severity of CAD, the patient was referred for
coronary artery bypass grafting (CABG), however, was deemed not a good
candidate by the heart team.