P240 Thebesian veins draining to the left ventricle mimicking left ventricular non-compaction

Abstract

Abstract Description We report about a 59-year old asymptomatic woman initially presented with lateral T-wave inversions in a routine ECG. Echocardiography suggested isolated left ventricular non-compaction (LVNC). An additional cardiac magnetic resonance imaging (cMRI) showed positive diagnostic criteria for LVNC. Six years later a diagnostic coronary angiogram revealed by a coincidence extensive shunting from the left coronary arteries to the left ventricle through Thebesian veins (sinusoids). Finally color Doppler flow confirmed that the irregular anatomy of the LV was not a result of incomplete LV compaction but due to the coronary anomaly. Initial work up A 59-year old asymptomatic woman presented with lateral T-wave inversions in a routine ECG. Echocardiography suggested isolated left ventricular non-compaction (LVNC) with deep recesses and a systolic non-compacted to compacted ratio in short axis of >2. To confirm the diagnosis cardiac magnetic resonance imaging (cMRI) was performed. Quality was not optimal due to premature contractions and insufficient breath-hold, but positive diagnostic criteria for LVNC (as described by Petersen, Left ventricular non-compaction: insights from cardiovascular magnetic resonance imaging. JACC, 2005 July 5;46(1):101-5) were reported (Figure 1A). Diagnosis and Management Six years later, the patient was referred to our institution for catheter ablation of a suspected paroxysmal supraventricular tachycardia causing palpitations. Since the patient also complained about recurrent chest pain, a coronary angiogram was performed in the same session and revealed a chronic total occlusion of the right coronary artery. However, also extensive shunting from the left coronary arteries to the left ventricle through Thebesian veins (sinusoids) was observed (Figure 1B, arrows). Follow-up In light of this new finding, echocardiography was repeated and color Doppler flow revealed diastolic filling of the recesses not from the LV cavity but from the coronary system, confirming that the irregular anatomy of the LV was not a result of incomplete LV compaction but due to the coronary anomaly (Figure 1C, apical short axis view, upper panel color Doppler in diastole, lower panel color M-mode). To exclude concurrent LVNC a cardiac CT was performed, confirming that the recesses, which initially led to the diagnosis of LVNC, exhibited diastolic flow from the coronary system (Figure 1D). Conclusion This case exemplifies that for the diagnosis of LVNC all echocardiographic criteria as defined by Oechslin and Jenni (Left ventricular non-compaction revisited: a distinct phenotype with genetic heterogeneity. EHJ, 2011 June;Volume 32, Issue 12, Pages 1446–1456) need to be fulfilled – including color Doppler assessment of flow in the recesses. Consequently, it illustrates that cMRI alone is not sufficient for the diagnosis of LVNC but both echocardiographic and cMRI criteria need to be applied. Abstract P240 Figure.