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1/2. Myocardial scarring caused by left ventricular assist device (LVAD) insertion demonstrated by cardiovascular magnetic resonance.

    We report three cases of dilated cardiomyopathy treated with left ventricular assist devices (LVAD), subsequently explanted. These mechanical devices are being increasingly used to support left ventricular function in the short and long term. We used cine and gadolinium-enhanced cardiovascular magnetic resonance (CMR) to examine the consequences of previous LVAD implantation. In all cases, there was apical akinesis and tethering on cine imaging. Early (< 5 minutes) imaging after gadolinium demonstrated apical hypo-enhancement, an avascular area of scar or thrombus, while late (> 10 minutes) imaging demonstrated transmural apical infarction which in one case extended into the inferior wall. The findings suggest that LVAD insertion may cause permanent myocardial fibrosis at the site of ventricular insertion, and the cases demonstrate the use of contrast-enhanced CMR in this scenario of iatrogenic ventricular scarring.
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ranking = 1
keywords = cardiomyopathy
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2/2. Postero-lateral scar tissue resulting in non-response to cardiac resynchronization therapy.

    In large cardiac resynchronization therapy (CRT) trials, approximately 20-30% of patients did not respond to CRT. Recent studies indicated that left ventricular (LV) dyssynchrony is needed for response to CRT. However, the presence of LV dyssynchrony may not be the only determinant of response, because some patients with LV dyssynchrony do not benefit from CRT. In the current case report, we present a patient with ischemic cardiomyopathy, NYHA class III heart failure symptoms, and substantial LV dyssynchrony on tissue Doppler imaging who underwent CRT implantation but did not respond. Following CRT, LV dyssynchrony was not reduced and the patient did not improve in clinical symptoms or LV function. The lack of LV resynchronization was explained by the presence of extensive scar tissue in the region of the tip of the LV pacing lead resulting in ineffective LV pacing. In patients with ischemic cardiomyopathy and history of previous infarction, assessment of scar tissue should be considered before CRT implantation.
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ranking = 2
keywords = cardiomyopathy
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