Chef de Jour

Jérôme had learned from the best cooks in France. At only 45 years of age, he was now offered a position in one of the most prestigious restaurants in Vienna as Chef de Jour. Of course he wanted to be at his best. Jérôme knew exactly when to take the roast out of the oven and his entrecote was always cooked to perfection. His credo was “never wait too long”. Unfortunately, he dealt differently when it came to his own health.

Perfectly cooked entrecote, the meat should be “pink” inside. When the meat is cooked, remove it from the oven, transfer it to a board and allow it to stand in a warm place for up to an hour, loosely covered with foil, before carving.

 
“Over cooking” the beef

The restaurant was aiming for an additional Gault Millau “hat” and Jérôme knew that all eyes were on him. The first episode of chest pain occurred when he was shopping for the ingredients but they subsided after 30 min. What ever it was, it did not bother him much. But the pain reoccurred the same day while cooking for very important guests. This time the pain was stronger, causing him to pause and take short rests. The pain was followed by perfuse sweating and dyspnea. Jérôme ignored his symptoms thinking that they were caused by a simple flu. The pain subsided but the shortness of breath became more prominent especially when lying flat on his back. It took Jérôme two weeks until he finally decided it was time to go to the hospital.

Out of the oven

Jérôme had several risk factors for atherosclerosis. He was moderately obese and hypertensive. His lab values showed hyperlipidemia (Total cholesterol = 320mg/dl, LDL 175mg/dl, HDL = 43mg/dl) and elevated liver enzymes His CPK/MB values were mildly elevated. Here is his ECG:

ECG on arrival: QS complexes are seen in the anterior leads, ST is elevated from V1 to V6.

 

Based on the findings it was quite clear that Jérôme had coronary artery disease. But look at his echocardiogram to see the full extent of the problem:

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Four chamber view showing a severely dilated left ventricle with severely reduced left ventricular dysfunction and an apical aneurysm. Note that a pleural effusion (lateral to the left ventricle) is also present.

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Two chamber view displaying the extent of the large anterior infarct.

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Apical long axis (three chamber view): The anterior septum is akinetic.

Certainly, Jérôme had a large anterior infarct. However, what you see is not the echocardiogram of an acute infarct but rather that of a significantly remodeled ventricle with a large anteroseptal aneurysm. Remodeling is typically a feature of large infarcts that is seen more commonly in anterior myocardial infarction. The ventricle has to compensate and dilates progressively causing damage also to the residual myocardium. Remodeling occurs more frequently in patients with additional hypertension and mitral regurgitation. In these situations the ventricle has to cope with an additional load (volume overload, increased after load). In general the prognosis in patients with remodeled ventricles is rather poor.

The beef on the plate

Next it was time to take a look at his coronaries. After all Jérôme is young and we wanted to know if we could help him with an invasive procedure, despite the fact that the infarct occurred at least a week ago.

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Coronary angiogram showing complete occlusion of the proximal LAD.

 
Ventriculography of the left ventricle: confirming the echocardiographic finding of a large aneurysm.

What a terrible angiogram. The right coronary artery was fine but the left anterior descending artery was completely occluded. The occlusion was very proximal even before the first septal branch. Such patients usually experience very large infarcts that involve much of the septum, the apex and the anterior wall. Based on the echocardiogram most of the anteroseptal myocardium was scarred. So there is not much myocardium that could be saved even if the vessel was reopened. Jérôme simply waited too long.
 

No dessert

It was not easy to treat his heart failure. But with diuretics, ACE inhibitors and beta blocker therapy we were able to more or less stabilize his condition. Still, Jérôme remained in NYHA heart failure class III-IV and we decided to list him for heart transplantation. Jérôme was not very happy to stay in the hospital. Not only because he was eager to cook again but also because he disliked the meals he was served in the hospital.
 

“Mon dieu, send me the chef I will teach him how to cook”
 
At least he kept his humor.
 
We hope that you will not wait too long to visit our site 123sonography.com. More teaching material on echocardiography is waiting for you there…
 

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