Multimodality imaging to clarify an atypical presentation of branch vessel coronary occlusion Harshna Vadvala, MD; Andy Chan, MD; Udo Hoffmann, MD, MPH; Sanjeev Francis, MD; Sammy Elmariah, MD; Brian Ghoshhajra, MD, MBA Clinical History A 45-year-old female with a history of hypertension, dyslipidemia and morbid obesity managed with gastric bypass resulting in 120 pound weight loss, presented to an outside hospital with chest pain and anterolateral ST-segment elevations on electrocardiogram. She was in her usual state of health until the day prior to presentation when she woke up with left chest, shoulder, and jaw pain associated with diaphoresis. Her chest pain spontaneously resolved in 30 minutes but recurred the next day. Emergent invasive coronary angiography (ICA) revealed a dual-left anterior descending (LAD) system with sluggish low in the smaller, septal LAD, but no culprit vessel was apparent. The patient was presumed to have focal myocarditis involving the anterolateral wall. Subsequent outpatient cardiac magnetic resonance imaging (MRI) demonstrated mild left ventricular dysfunction and anterolateral akinesis with transmural abnormal late gadolinium enhancement in the anterolateral wall. Stress and rest nuclear myocardial perfusion imaging (SPECT-MPI) revealed a medium sized, severe, partially ixed perfusion defect in the mid to distal anterior wall. Upon referral from the outside hospital, conlicting information was present. The patient’s presentation included stuttering chest pain and territorial, transmural myocardial involvement by cardiac MRI and SPECT-MPI, each of which was suggestive of myocardial infarction. However, the lack of a culprit vessel on diagnostic coronary angiography led SEPTEMBER 2014 ISSUE 63 Figure 1 Figure 2 Figure 3 Figure 4 to a conlicting diagnosis of focal myocarditis. Coronary CT Angiography (CCTA) was consequently performed to assess for the possibility of a missed coronary occlusion. Findings CCTA conirmed “double LAD” coniguration, with a smaller, septal LAD shallow bridged segment. The LAD did not contain plaque or stenosis. A small D1 branch was well opaciied for approximately 15mm beyond its origin,