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Vol. 72. Issue 7.
Pages 578 (July 2019)
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Vol. 72. Issue 7.
Pages 578 (July 2019)
Image in cardiology
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Subepicardial Ischemia Without Obstructive Coronary Disease
Onda de lesión subepicárdica sin lesión coronaria obstructiva
Zaira Gómez-Álvarez, Juan Carlos Gómez-Polo
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Corresponding author:
, José Alberto De Agustín
Instituto Cardiovascular, Servicio de Cardiología, Hospital Clínico Universitario San Carlos, Madrid, Spain
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A 71-year-old man presented to the emergency department with chest pain and developed cardiogenic shock at admission. He had history of chronic kidney disease under hemodialysis, coronary heart disease with an episode of unstable angina in 2002, which was treated with a drug-eluting stent in the left anterior descending artery, peripheral arteriopathy with a stent placed in the abdominal aorta in 2013 and a bioprosthetic aortic valve replacement in 2013 due to a severe aortic stenosis.

Physical examination revealed signs of lung congestion and peripheral hypoperfusion. In the emergency department, an electrocardiogram was performed (Figure A), showing ST-segment elevation in precordial leads. Urgent angiography was performed, showing nonobstructive coronary disease (Figure B). The patient developed severe hypotension and deep cardiogenic shock, with multiorgan failure.


Transthoracic and transesophageal echocardiography were performed, showing normal bioprosthetic function, with a huge left heterogeneous ventricular hypertrophy mainly in the posterior and lateral wall (30 mm of average thickness, Figure C, asterisk), suggesting the presence of myocardial infiltration by an oncologic disease, with mild pericardial effusion. The patient finally died and autopsy was performed, showing diffuse infiltration of the left ventricular wall (Figure D, arrow) by neoplastic small blue cells that replaced cardiomyocytes, with diagnosis of diffuse large B-cell lymphoma (Figure E, arrowhead).

The present image shows the myocardial infiltration produced by a high-grade lymphoma, mimicking an acute myocardial infarction due to a coronary occlusion. This is an exceptional manifestation of this systemic disease, with only 1 previous case reported in the scientific literature.

Copyright © 2018. Sociedad Española de Cardiología
Revista Española de Cardiología (English Edition)

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