0:00

Okay, great. So we'll move on to our next

0:03

case. This is also a patient to presented with

0:06

chest pain and an elevated component after vaccination. So

0:09

again, we're again looking at post-covid-19 vaccine

0:12

cases. And again, this was a

0:15

young adult male patient and this patient

0:18

was actually acutely unwell and was admitted to hospital. So

0:21

this Imaging was done in immediate days

0:24

after symptom.

0:28

Again, I'm going to show you the four chamber Sydney SSD here. This

0:31

is I find a really good overview to look at the function of the ventricles

0:34

and get a sense of what's going on. So unlike the

0:37

last case the ventricles are Contracting normally here.

0:40

We have normal Global stock function and the least

0:43

on this view. I know obvious regionality. So

0:46

both ventricles normal injection.

0:49

And now we'll look at our short axis View.

0:52

Short access in ussrp stack rather and one

0:55

thing I haven't mentioned to you. Is that our at our

0:58

Center are short axis ssfps are required after

1:01

contrast. And so you start to get a clue

1:04

that there may be an abnormality again at that basal to Mid

1:07

in for lateral and infra-wall because we're actually

1:10

seeing some enhancement even on the sequence because it was acquire.

1:13

D after so let's go through it and just a reminder kind of a clue to

1:16

look at that same area of The myocardium and I'll pause

1:19

it as we go through so you can see what I'm talking about. So even

1:22

here on this very basal slice, you can

1:25

see that there's increased signal intensity here at that in

1:28

for a wall and again not all centers of are

1:31

there short access facts after contrast, but we do it's on

1:34

time saving measure while you're waiting for to

1:37

acquire like getting the hands images. And again, you

1:40

can start to see here even on the short acts of Stack that there is

1:43

increasingly long time City. The other thing is that there's

1:46

actually reasonable thickening and that's a common finding when

1:49

you have a Dima you can have vocal Regional law

1:53

beginning related to indominus my cardium and although

1:56

the ejection was normal There is mild hypokinesis

1:59

in that area. So that area of my heart is

2:02

not Contracting as well as other areas.

2:04

So now let's go through and see if we need those T1 based

2:07

and T2 based criteria. So we'll start with our

2:10

teaching-based criteria and we'll pull up our teaching map

2:13

and unfortunately on a scanner this patient with scanned on

2:16

it doesn't display the color map but that's fine. Even the gray

2:19

scale you can start to see that there is an abnormality and our

2:22

black blood teaching Imaging which was kind of our traditional sequence

2:25

that we use qualitatively to assess

2:28

The myocardium and here even without much when doing you can

2:31

start to see that there is a marked abnormality again in the

2:34

sub epicardial myocardium at the

2:37

infer wall and in for a lot of wall actually expanding also into

2:40

the antilateral wall, you're running a

2:43

basil spice and as we come more towards the mid ventricle, you

2:46

can see that there's some artifacts as patients as they said was a cute

2:49

and well I was having difficulty holding their breath and had

2:52

some Rhythm disturbance as well. But despite that you can see

2:55

that this subject of cardinal High signal intensity

2:58

extends both

2:59

Basal level into the midterm treatment level.

3:02

And this patient had only a short act with

3:05

midventricular TT map and Visually I

3:08

even know this is a grayscale again areas of high T2,

3:11

which tell us that there is more free water and

3:14

the demon in this case visually we can see that that solved

3:17

epicardial. Myocardium has higher symptom. I'm just

3:20

gonna die very quick Roi just to show you how those

3:23

numbers compare so here in this again very

3:26

quick Roi at that set up a

3:29

cardilateral wall. The teach you value is 61. This was

3:32

a card at one point five. She as you can see well above our

3:35

normal reference range for one point five T teaching mapping

3:38

and just to compare that more normal spectrum of

3:41

the teaching value that's within our normal reference range

3:44

of 43 milliseconds. So again, we have clearly met

3:47

the teaching base criteria in this patients. And now

3:50

I'm gonna pull up our lake under your hands short axis stock

3:53

on the left and we'll show you our team one map again

3:56

native to your map on the right and Visually again,

3:59

even though this is a great scale we can see that there's

4:02

It would mapping values colocalizing again

4:05

with a edema that we saw in The sub-epocardial myocardium and

4:08

has become down on our Lincoln hands damage. We can see that

4:11

there's some artifact here patient again is having difficulty holding

4:14

their breath. Of course, they'll get an enhanced sequences one

4:17

of the last to be acquired at the post contrast sequence.

4:20

And so if patients are struggling in the scanner,

4:23

sometimes you'll see more marked part of facts later in later

4:26

Acquisitions, but again, you can see here that there's solve epicardial

4:29

algae as well as enhancement of that over one

4:32

pericardium. So again, this is another key of the myopericartidus.

4:36

After covid-19 vaccination and I'll

4:39

just draw your attention on the T1 mapping slice. You

4:42

can see that there is also a small pericardial effusion mostly initially

4:45

as well as

4:48

and just I see that there are the question how

4:51

soon does myocarditis appear after vaccination? That's

4:54

a really great question. We'll cover that as well in the

4:57

slide at the end. But this is a great question typically

5:00

within a couple days some patients. We have

5:03

a fairly large case series which we published

5:06

on and continue to follow and most of the patients in

5:09

our case series presented within three days some patient

5:12

even later on the same day after vaccination, but typically

5:15

within a week and that's consistent with other

5:18

reports as well.

5:20

This patient I'm going to show you the follow-up Imaging so gives this

5:23

patient was accumulian. Well was an inpatient

5:26

we recommended follow-up to see what happens. And so

5:29

the dates here are just gonna anonymize them.

5:32

They're not reflective of the actual Imaging. Of course, everything is anonymized. What

5:35

I'm going to do is try to show you the corresponding images top

5:38

and bottom. So we have our Baseline Imaging

5:41

on the top and what I'll do is I'll show you our LGE and

5:44

we can show you that.

5:48

edema Imaging on the

5:51

So again top row here is our Baseline Imaging and I'm going to

5:54

show you the follow-up which was on about three months later on the

5:57

bottom. So you can see kind of the typical trajectory in typical

6:00

change that we would expect.

6:02

So let's start with our T2. So again bottom right that I'm

6:05

highlighting now is our edema Imaging and there is

6:08

no longer a demon. So three months later the patient symptoms

6:11

had resolved proponent had a normalized and there

6:14

was no longer any detectable edema,

6:17

either on black blood T2 with imaging event showing you here or on

6:20

our teaching map. The values were normal and on

6:23

our Lake I'm enhance damage. You can see that there is some residual

6:26

algae. So I'm just gonna get a little bit larger, so

6:29

please

6:29

Sure to see and then pointing to

6:32

hear there's some residual sub epicardial algae at

6:35

that infer wall. And this is important at our

6:38

Center. We typically do follow patients back who have acute macroditis

6:41

in three to six months.

6:44

What you're looking for is to see that the edema has resolved

6:47

which is happens in the vast majority of patients typically

6:50

within weeks and you want to look for

6:53

residual algae. So the extent of LG has decreased essentially

6:56

compared to Baseline. So all of this LG that

6:59

we saw on the initial a study in

7:02

acute and phase most of that at

7:05

the lateral wall has resolved in no longer detecting but

7:08

there is some residual stuff at the Cardinal LG an

7:11

inferol and when you have algae without edema in this

7:14

clinical setting that tells us that there's like the fibrosis there

7:18

and that's important, you know from other causes of

7:21

my heart that is large key series as well as cardiopathies that

7:24

fibrosis and algae specifically indicating

7:27

fibrosis is a marker or can pay

7:30

plays patients at risk of arrhythmia. So important to just

7:34

I see a couple other questions that popped

7:37

up. Do you encounter mismatch between

7:42

Teaching images and teaching mapping for example hyperintensity on

7:45

trm or teaching Imaging

7:48

and normal values on teaching math. And how do

7:51

you approach that? I think this is a great question. Certainly we

7:54

have seen cases where there can be mismatched it

7:57

our Center as they said our routine

8:00

protocol is only a single midventricular short access teaching

8:03

map. And so one of the reasons that you might not detect an

8:06

elevated teaching mapping value in that case is because

8:09

you haven't gone through the area of normality or the area of

8:12

the worst normality. So just to keep in mind, you

8:15

know, if you haven't imaged with a particular sequence at the

8:18

specific area Melody, you might miss it.

8:22

and

8:23

the other thing I think is important to keep in mind is that if you're using

8:26

the revive like Louise criteria, which most Centers do

8:29

you only need to meet one of them. So if you

8:32

have a clear focal of

8:35

a cardinal hyperintensity on your black blood take the weighted

8:38

Imaging whatever it is at your scanner based on

8:41

the vendor you have that would meet criteria for your teaching-based

8:44

criteria wouldn't need to have an abnormality on

8:47

your teaching map. I have to say generally of

8:50

course they do go together. So hopefully that answers your

8:53

question that if you've met your teacher-based criteria on

8:56

one or either sequence that's sufficient and

8:59

call myocardial edema.

9:03

Okay, are there risk factors to get myocarditis at

9:06

post-covid-19 vaccination where we

9:09

will talk about a little bit about the demographics and the slides. I'm just going to leave that

9:12

one. I'll try to just answer any case specific questions now,

9:15

we'll leave the more general questions to the end

9:18

and any cases which

9:21

had edema on T2. But no LG that's a

9:24

great question. You can see that very

9:27

we have very few cases at least in our case

9:30

series if you have very mild edema.

9:33

That has not resulted in sufficient or extensive

9:36

enough damage to you know

9:39

have such a large area of myocardial injury

9:42

that it's holding on to contrast that you can see visually it is certainly

9:45

possible. So that is when possibility not just

9:48

close vaccination but in any cause of myocarditis that's

9:51

quite mild you could have edema particularly if edema

9:54

is intracellular and don't yet have cellular

9:57

destruction or extracellular edema.

10:00

It is possible.