The Enhancement Pattern That Rings the Bell

A 61-year-old man with a medical history of dilated cardiomyopathy (DCM) was referred for cardiac magnetic resonance imaging (cMRI) to evaluate for potential etiologies of his underlying cardiomyopathy. He has a recent history of stroke and is found to have severe biventricular (BiV) systolic function (Videos 1, 2).

Electrocardiographic findings include normal sinus rhythm, left axis with Q waves in the inferior leads, poor R-wave progression in the precordial leads, and nonspecific T-wave changes in the lateral leads (Figure 1).

Video 1: Parasternal Long-Axis View

Video 1

Video 2: Parasternal Short-Axis View

Video 2

Figure 1

Figure 1

As part of the evaluation of the underlying cardiomyopathy, he undergoes a coronary computed tomography angiography, with findings including no significant coronary artery disease. He has not taken any illicit drugs and has no other systemic diseases. His family history is negative for inherited cardiomyopathies and sudden cardiac death.

A cMRI is performed to further assess his BiV function. Four-chamber cine (Video 3), three-chamber cine (Video 4), and short-axis cine images (Video 5) are obtained. Late gadolinium enhancement (LGE) imaging is obtained 10 min after gadolinium administration (Figure 2).

Video 3: Cine Imaging, Four-Chamber View

Video 3

Video 4: Cine Imaging, Three-Chamber View

Video 4

Video 5: Short-Axis Cine Imaging at the Basal Ventricular Level

Video 5

Figure 2: Phase Sensitive Inversion Recovery Late Gadolinium Enhancement Imaging at the Base of the Heart (Short-Axis View)

Figure 2

Which one of the following is the most likely etiology of the underlying cardiomyopathy?

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