0:00

Okay, next case is again post vaccination.

0:03

This is another young adult meal. So

0:06

I'm sure seeing a theme here all three

0:09

vaccine cases that we're going to show today are getting adult

0:12

men in their early 20s. And again, we'll start

0:15

with a four chamber sunny and here

0:18

you can see that like the first case the left

0:21

ventricle function is impaired. So our left ventricular rejection fraction

0:24

was around 50% in this case and I'm

0:27

going to show you the short axis and eclip as

0:30

well. So as we come through again a reminder that this was

0:33

required after contrast so you can see that high signal intensity

0:36

at the even if

0:39

they're Walling in for a lot of wall again in a sub-up recover region, so

0:42

a clue to look there for a regional potential

0:45

Regional law motion our Melody.

0:47

And as I mentioned before this ventricle is

0:50

not the ejection fraction is mildly impaired

0:53

and actually The ventricle you can even see visually with near

0:56

the upper limits of normal first size. So this ventricle is

0:59

mildly dilated and can see

1:02

here again that sub epicardial High signal intensities and

1:05

good.

1:08

EBay ultimate in for a wall so here

1:11

in Sicily. You can actually see that quite nicely but even and

1:14

vastly on the more Basil's life we can

1:17

see that there's some high signal intensity here mostly in some

1:20

epicardial myocardium in that area of

1:23

myocardium also had a bad again wasn't Contracting normally had

1:26

a hypokinesis. So again, we have both Global

1:29

and Regional dysfunction and

1:32

slow motion. Let's move on

1:35

to our tissue characterization sequences. So next I typically

1:38

my search pattern is to look for a demon X.

1:41

So to look for our T2 based Governor Melody. So again, I'm gonna

1:44

pull up our block blood teaching on the left and I'm gonna

1:47

pull up our YouTube map on the right.

1:49

And here we're going to scroll through

1:52

and as we get to the base here, we

1:55

can see again at that inferior wall mostly in the

1:58

sub of a cardinal maccardium. We have high signal intensity telling us

2:01

that there is a Dima here and as they come

2:04

down to the next slice again, you can see actually in this case. It's more in

2:07

the basal to make in for a while also extending

2:10

into that in for a lot of wall, but it barely similar

2:13

pattern to the other cases who presented

2:16

with a human eye product vaccination and I

2:19

thank you forgot to mention the clinical history as patient also prevents

2:22

with it. You don't sort of chest pain and elevated component level.

2:25

So really classic presentation for my

2:28

credit is along with the concordant history of covid-19

2:31

vaccine. This was after the second

2:34

dose of the day prior.

2:36

And here just a

2:39

reminder actually this ties into that last question about if you didn't

2:42

see and how your Melody on our teaching map and I

2:45

wanted to show the case again are only midventricular teaching

2:48

map slices much more towards the midventricle

2:51

and it's not really not through this mean

2:54

area of abnormality. So you might have normal teaching mapping values

2:57

here. Don't let that this way. You can clearly

3:00

see on the black led to do with it and stack that

3:03

we have a son of the cardinality now,

3:06

we're gonna go to our Lake and

3:09

hands Imaging and love our

3:12

T1 map which is a matching place to the teach you so

3:15

again, it's much more towards the ventricle than the

3:18

main abnormality which is quite basil and again, you

3:21

can see here that there is SOB upocardial algae at

3:24

the end for a while and actually extending and in for

3:27

a lot or wall as well.

3:29

This is a very classic pattern as you've seen

3:32

on three cases of top of the Cardinal LGE most

3:35

commonly involving the basal to

3:38

knit infilateral wall as well as the in for a wall in enchilada

3:41

wall on to a lesser extent. So this is

3:44

another case where we have both T2 based criteria.

3:47

Our t1b is criteria and the patient has

3:50

supporting a supportive abnormalities of global

3:53

and Regional distractions.

3:57

And as I mentioned at the left ventricular rejection fraction was

4:00

also impaired and this is another patient to key back

4:03

for follow-up Imaging and so I'll show you again to show

4:06

you the corresponding images here.

4:12

We'll pull

4:16

up our leak and let my hands dimaging the patient is

4:19

much more extensive Imaging when they came back and here

4:22

we can see I'll just show you all highlight the link

4:25

hand.

4:27

Image and the left is our Vape Baseline Imaging and on our

4:30

right.

4:38

Is that left is our basement Imaging and

4:41

on the right is follow which is done about three month later and you

4:44

can see as we come down some more towards the mid ventricle.

4:47

Here almost all of the lake element

4:50

that we saw Baseline has resolved. And

4:53

so I think this the kind of key point that I think is really important and

4:56

I often shoulder fellows when we're reviewing is sometimes we

4:59

think or we kind of associate LGE is equaling

5:02

fibrosis. It does in many cases but not

5:05

always sometimes edema or they get in.

5:08

My husband father is just telling us that there is lots of

5:11

Edema intracellular extracellular and it doesn't necessarily mean

5:14

in fact it often doesn't mean that

5:17

there's fibrosis get in the acute phase. It can lead

5:20

to fibrosis and that's on what we're seeing here in that case

5:23

and we saw before where we had follow up and residual LG but

5:26

in the cute phase algae is telling us

5:29

that there is myocardial injury, there's injured tissue

5:32

holding on to contrast in this post contrast space, but often

5:35

we will see that the extent about she

5:38

decreases on follow-up in some cases resolves or

5:41

nearly results as we're seeing here. And so

5:44

when the follow-up really you're looking for residual edema, which we

5:47

did not see

5:47

The case and to look at the presence

5:50

and extent of the residual LGE which

5:53

in that case without edema would tell us that there is

5:56

fibrosis.

5:58

Happy to answer any questions about this case

6:01

before we move on to the next one. I think the last question that popped

6:04

up in the Q&A is relevant and it's if lake

6:07

Eden enhancement or LG persists in the first follow-up after

6:10

three to six months. Do you still do follow-up? I think

6:13

this is a really important question. There are

6:16

unfortunately new clear guidelines on this and so I've spoken

6:20

to many of my colleagues that other centers and and different centers

6:23

will do this differently.

6:25

I think the bottom line is clinical guidelines indicate that

6:28

these patients should have clinical follow-up so they should

6:31

see a cardiologist certainly be referred to a Cardiologist for

6:34

Fallout if they haven't already seen one.

6:37

This area of residual LG indicating fibrosis potentially

6:40

put them at risk of arrhythmias and development

6:43

of heart failure depends how

6:46

much elegy you have and so again issue of clinical follow-up that our

6:49

Center they would not have a subsequent like a further follow-up

6:52

MRI routinely, they might if

6:55

a cardiologist refer them if they were worried they had residual

6:58

or persistent impaired function that

7:01

hadn't normalized at their first follow-up. Those might be

7:04

reasons that they might have further follow MRI, but but not

7:07

reaching me at our Center. The bottom line is

7:10

though that there's no clear guidelines on how many follow-ups or

7:13

when they should be done. But that's a great question. Thank you for asking that.