ArticleEuropean heart journal. Case reports2025
Lipomatous metaplasia in cardiac CT: when 'normal' extracellular volume does not indicate myocardial viability - a case report.
Article in European heart journal. Case reports, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Extracellular-volume (ECV) mapping derived from dual-energy cardiac computed tomography (DE-CT) demonstrates potential for informing myocardial-viability assessment. However, intramyocardial lipomatous metaplasia (LM)-a frequent sequel of chronic infarction-contains little or no interstitial space and may therefore normalize ECV values, falsely suggesting viable tissue. Case Summary: A 65-year-old man with chronic total occlusion of the left anterior descending (LAD) artery underwent multimodality imaging to guide revascularisation. Cardiac magnetic resonance (CMR) demonstrated a transmural, thinned scar in the antero-septal apex and sub-endocardial fibrosis in basal-mid anterior segments. DE-CT demonstrated low attenuation in the same territory, whereas ECV mapping revealed normal values in the scarred apex (comparable to non-infarcted myocardium) and mildly elevated ECV in the basal-mid anterior segments with non-transmural scar. The presence of chemical-shift artefacts on cine CMR, along with further attenuation reduction on DE-CT, confirmed intramyocardial fat, explaining the paradoxically low ECV in this region. Ultimately, the integrated assessment of limited viability, extensive scar remodelling, and high-risk procedural features led to the decision to defer revascularization. Discussion: LM can obscure chronic infarcted myocardium on CT-derived ECV maps by abolishing extracellular expansion and generating deceptively normal values. Reliable interpretation mandates correlation with tissue attenuation, mono-energetic reconstructions, or fat-sensitive CMR sequences. DE-CT affords single-acquisition, high-resolution characterization of both ECV and tissue composition, but its quantitative outputs must be contextualized to avoid misclassification of viability. Awareness of this pitfall is essential for accurate decision-making in chronic ischaemic heart disease and underscores the continuing need for integrated multimodality imaging.
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