In this case, catheter angiography was performed prior to the CT and illustrates the complementary role CT coronary angiography can have in the assessment of coronary artery disease.

The LAD anatomy is complex in this case. The 'LAD proper' is shortened and appears to terminate high in the interventricular groove. The first early branch of the 'LAD proper' in this case has been defined as a dual LAD type 1 ¹, but could also be described as a dominant D1 branch. The complete occlusion of its major branch was not visible on catheter angiography and has resulted in the mid to apical LAD infarct and subsequent left ventricular aneurysm.

Subsequent to the CCTA, a cardiac MRI was ordered to assess for viability. This confirmed the aneurysmal dilatation of the LAD territory infarct was non-viable.

Finally, an important point to remember when reporting chest radiographs: enlargement of the heart shadow is non-specific and can be due to chamber dilatation and/or pericardial effusion and this distinction is important. Acute pericardial effusion can be fatal if not recognized and treated. In this case, the presence of interstitial pulmonary edema indicates left ventricular failure while systemic venous distension can be due to congestive heart failure and/or cardiac tamponade. The oreo cookie sign is valuable as it establishes the presence of pericardial effusion.

Pericardial effusion can rarely occur as an early reperfusion phenomenon after myocardial infarction. Dressler syndrome occurs weeks after MI and is due to autoimmune pericarditis. Contained LV perforation is a differential diagnosis to consider.