Lipomatous metaplasia in cardiac CT: when ‘normal’ extracellular volume does not indicate myocardial viability - a case report

LM can obscure chronic infarcted myocardium on CT-derived ECV maps by abolishing extracellular expansion and generating deceptively normal values. Reliable interpretation mandates correlation with tissue attenuation, mono-energetic reconstructions, or fat-sensitive CMR sequences. DE-CT affords single-acquisition, high-resolution characterization of both ECV and tissue composition, but its quantitative outputs must be contextualized to avoid misclassification of viability. Awareness of this pitfall is essential for accurate decision-making in chronic ischaemic heart disease and underscores the continuing need for integrated multimodality imaging.