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A 67 year old woman was admitted one week after an ambulatory inferior myocardial infarction. Cardiac magnetic resonance imaging (MRI) (1.5 T, Sonata, Maestro class; Siemens, Erlangen, Germany) was performed the next day to assess myocardial viability. Contrast enhanced dynamic myocardial perfusion imaging (TrueFISP-sequence) at rest demonstrated contrast flow from the cavity of the left ventricle into the myocardium near the basal septum (arrows). The contrast agent penetrated about three quarters of the myocardial thickness, thus showing impending myocardial rupture (panel A). Using late enhancement technique (TurboFLASH-sequence) 10 minutes after application of contrast agent, an extended transmural inferior infarction could be seen in the long axis view (panel B). Impending myocardial rupture is non-transmural and does not reach the subepicardial fatty tissue (†). Inside the myocardial infarction a zone with hypointense signal represented microvascular obstruction (*). Four hours after the MRI examination the patient developed cardiogenic shock with a loud systolic murmur. Left ventricular angiography in a left anterior oblique (LAO) 60° position demonstrated an inferiorly located ventricular septal defect (panel C).
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