0:00

You'll need those general questions at the end

0:03

and we'll move on to our next.

0:06

So our fifth case is another patient

0:09

to presented with chest pain in the

0:12

component elevation after covid. So after Stars

0:15

could we do infection? And again, they were

0:18

suspicious the clinicians versus suspicious for macarvis and

0:21

referred patients for cards. So start with

0:24

a similar pattern. I'm going to show you the four chamber sending us

0:27

with the on the left and hopefully even on here you

0:30

can see that the left ventricle function is imperative. It's not

0:33

normal the shotgun ventricle injection fraction with

0:36

impaired here moderately impaired with ejection

0:39

fraction of 40% Right ventricle also

0:42

has an impaired machine with the

0:45

injection fraction Quantified of 45%

0:48

And so even ours in the ssfps before

0:51

we've got to any of the tissue characterization sequences. This is

0:54

a young patient. This is a certainly not

0:57

normal. Let's look at our short access to try to

1:00

get a clue of whether they're maybe a regional wall motion remaldi

1:03

to kind of direct our attention on our tissue characterization sequences,

1:06

and hopefully at that in for

1:09

a lot of wall at the base you could see that it was thickened and hypokinetic.

1:12

So not only is their Global left ventricular dysfunction.

1:15

There's also a regional law motion of normality and

1:18

that's kind of helpful. I find when I'm reviewing

1:21

with my photos to when you see that on the short axis when you

1:24

see those original While most genre you want to look very carefully at

1:27

that area of my cardium on your tissue characterization. So

1:30

I'll just pause here.

1:33

That this area of ladderwall is thickened and

1:36

we can maybe see that there's some subtle higher

1:39

signal intensity. Again. This is required

1:42

those contrast. You can also see that there is a small effusion mostly

1:45

in Fairly and lateral.

1:48

Now we'll move on to our edema Imaging

1:51

teaching math on the right and I'll pull up our teaching with

1:54

the image on.

1:56

on the left

1:57

This patient was imaged again. Not in the very acute

2:00

phase when they presented. This was an outpatient.

2:04

Had a moderate covid-19 illness

2:07

and then came in with

2:10

chest pain, but with images and outpatient. So

2:13

the Imaging was done a few weeks after their chest pain started

2:16

and we can see though that despite this

2:19

there is some increased signal intensity.

2:22

At that influater wall, but unlike some of the more few

2:25

cases that we image. It's kind of more diffuse almost the whole

2:28

wall has in that area has higher signal intensity

2:31

and you might be able to see as well that the overlying

2:34

pericardium is also Abner and what's also

2:37

itemitous and has higher signal times.

2:40

On our teaching map again, you can see that that

2:43

area of myocardium thickened and values were

2:46

slightly elevated above our normal reference range.

2:49

Here's our lake at an intense Imaging

2:52

on the right and I'm going to show you where it's T1 map.

2:55

Again. This is a need of two and map on the right. I find

2:58

that the fusion kind of really pops here. So

3:01

if you missed it before this might be include it there is a small

3:04

pair of cartilage Fusion as well. And on the

3:07

LG images. I'm just gonna window them a bit and start

3:10

to see that it into a lot of wall. There's mid wall and some

3:13

epicardial energy and as we come down

3:16

we can see that it's also involving in nature wall here the

3:19

cardium as well as the answer or lateral wall in

3:22

the intra wall and there's also enhancement of overlying

3:25

pericardium at that infilateral wall. So we have a myoperative

3:28

in a patient to presented with

3:31

very classic symptoms of a cute concept of

3:34

chest pain and troponine elevation after Stars could be

3:37

to infection but again in a very similar pattern and

3:40

Station compared to the other myocards of

3:43

this cases that we saw before here. You

3:46

can see that this is a little bit more extensive though. It's extending actually all

3:49

the way here in the mid ventricular level up and

3:52

actually to the apical segments as well. So more extensive

3:55

involvement involving more segments and

3:58

more area of The myocardium. But again meeting

4:01

both T2, based criteria and a T1 based criteria here

4:04

with more extensive abnormalities and

4:07

more impaired left ventricular ejection

4:10

fraction in a regional motion abnormality.

4:15

little pots there

4:17

Okay, and I will answer questions the more

4:20

general questions about treatment and stuff afterwards. But again,

4:23

hopefully you're starting to see the pattern kind of

4:26

how I go through cases and some of the similarities in

4:29

these cases despite the fact that they actually

4:32

trigger for the acute myocarditis.

4:35

Okay, now our next case I need to pull up is our tax

4:38

did not let me load all of the cases in advance.

4:46

fun

4:47

So we're gonna move on to our sixth case.

4:50

This is also a patient to presented with chest

4:53

pain after SARS copy to infection this patient with

4:56

hospitalized during their covid infection, and I'm

4:59

going to pull up the four chamber view on the left and

5:03

You can see here that the left ventricle has impaired

5:06

objection directions with this lap ventricle is not Contracting

5:09

normally actually are left. Atria is

5:12

dilated here. This is the patient you presented several

5:15

weeks before kind of had a more indolent course

5:18

and had again. Oh patient Imaging they have been very

5:21

more sick the moderate infection during their

5:24

acute SARS Kobe 2 infectious phase

5:27

and then came in with persistent and

5:30

worsening chest pain and I'm just

5:33

going to skip I'm going to show you the tutu map on

5:36

the right and I'll show you the

5:40

resource images

5:42

My teaching black way to do it teaching mapping

5:45

images and we can see here that the pericardium is

5:49

kind of quite hyper intense. There's some

5:52

patchy areas of high signal intensity in The myocardium, but

5:55

nothing vocal like we saw before our teaching mapping

5:58

values, we're also wildly elevated but more diffusely and

6:01

on our Lake and our enhanced image all

6:04

the short axle Stack Up on the right. You can see here as a

6:07

school through that. There's actually quite extends about normalities mostly

6:10

stop that the cardio here at the basil in for

6:13

a wall in for a lateral Angel Walling pericardium

6:16

is enhancing and Molly thick

6:19

and we also have an abnormality that extends to

6:22

involve the right particular side. So and I

6:25

will come down towards the midventricle we can see that this is much more

6:28

extensive like and enhancement. But again,

6:31

mostly step up a card you'll also involve me to stop

6:34

them in this patient to presented with just

6:37

pain and elevated Japan and level here after a

6:40

more severe.

6:42

Kobe 2 infection again would meet both teach you

6:45

and T1 based criteria in this case in this

6:48

patient who had

6:50

a carditis after

6:52

their covid itself very quickly. I'm going to show you

6:55

a companion case and then we'll move on to the slides.

6:59

A patient who is referred for MRI for suspected

7:02

myocarditis after covid and

7:05

I'm good quickly. I'm just gonna skip to

7:08

the key findings in the interest of time unlike the

7:11

last cases where the predominant abnormality

7:14

on LG Imaging with epicardial or

7:18

midwall in this patient. We did see that there

7:21

was abnormal LG and pointing it out here. It's actually any some

7:24

endocardial pattern here at the

7:27

intro wall extending into the involateral wall. There was

7:30

some corresponding and demo which I'll show you

7:33

but it was quite subtle.

7:36

And I wanted to show this with the companion

7:39

case because this patient did have so there is some edema

7:42

in that area of myocardium, but perhaps not

7:45

as striking in some of the other cases this patient

7:48

presented very similarly acute onset of

7:51

chest pain and elevated drone levels after Cyrus Kobe

7:54

to infection this pattern of abnormality,

7:57

which is currently stubborn to Cardinal has been

8:00

described in myocarditis. There was actually a paper

8:03

in Radiology last year that described this subunit cardial

8:06

pattern as a infrequent pattern of acute myocarditis,

8:09

but of course the other thing you want

8:12

to think about when you see this pattern particularly corresponding to

8:15

Corner artery distribution is a cute monocardial infarction.

8:18

And so that's what we suggested here at patient

8:21

had a calf and did actually have a cute RCA occlusion

8:24

proximately and underwent PCI and

8:27

we'll talk a little bit about why that was potentially precipitated

8:30

by the Stars Kobe to

8:33

infection as patient, but I wanted to show it at the companion case.

8:36

Just a reminder that other etiologies and other

8:39

disease processes can present clinically quite similarly and

8:42

just to have the differential in the back of your mind.