0:00

So the next case is a 57 year old man who

0:03

comes in with chest pain and dysbian exertion. So we

0:06

have two steady state free procession sequences of four

0:09

chamber View and a two chamber of

0:12

view here on the left. And so

0:15

we're looking at a few different things here. So we're looking at contraction. We're

0:18

looking at valves many sort of abnormality.

0:22

And so what do you think of the contraction here? So globally most

0:25

of the left ventricles seems to be contracting normally everyone.

0:28

When you look at this kind of apical region

0:31

here kind of near the Apex and more apical

0:34

interventricular septum. It

0:37

doesn't seem to be pulling in quite as well as the other segments of

0:40

myocardium.

0:42

So we have a short axis sequence on the left. We have

0:45

a left ventricular track sequence on the right and again,

0:48

you can see this apical part doesn't really seem to

0:51

be contracting. So there's relative akinesis here. That's really

0:55

Regional akinesis.

0:57

On the short axis images as we kind of scroll from the

1:00

base here. You can see that most of the basal left ventricle

1:03

seems to be pulling your nicely Contracting normally.

1:06

However, as we start to get more towards the mid-ventricle as

1:10

well as the Apex you can see this area spend. It's also

1:13

not Contracting.

1:14

So right off the bat that's kind of where I'm kind of looking at

1:17

on these Lake edelenium dance images. So now we've

1:20

injected contrast.

1:21

We're doing Lake edelenium enhanced images. These are

1:24

short axis images. We want to pick the

1:27

inversion time. So normal. Myocardium is black we can

1:30

see quite a bit of Lake edelenium enhancement in that

1:33

same area that was demonstrating while motion abnormality. And

1:36

so questions are is there

1:39

enhancement? Yes, is it following a vascular territory?

1:42

Well, it seems to really be confined to

1:45

this led territory and then there's also

1:48

this kind of non-enhancing portion here more towards the

1:51

Apex.

1:53

So four chamber views again showing that Lake

1:56

Adeline even enhancement seems really transmiral because

1:59

this non-enhancing portion there the two

2:02

chamber views kind of confirming what we already saw on

2:05

the other sequences.

2:07

So the question here is we think that this is ischemic pattern

2:10

of linked. I don't even enhancement. What's the next best

2:13

step in management? So, how can we tell if we should revascularize this

2:16

patient or do something else?

2:23

And so the correct answer here is going to be medical management.

2:26

And so this would be

2:29

something that you wouldn't want to necessarily revascularize because

2:32

in this case this is showing transmiral enhancement.

2:35

And so remember that 50% cut off if

2:38

you have less than 50% enhancement by patient may benefit

2:41

those segments May recover function, but in

2:44

this case, you essentially have non-viable myocardium

2:48

And so this was an LED territory infarct here

2:51

in this non-enhancing portion similar to that other case. We

2:54

showed was a small amount of thrombus. And so you

2:57

often get thrombus next to non-viable infarctic.

3:00

Myocardium. So remember again that we

3:03

do these

3:04

Viability Imaging 10 to 15 minutes after

3:07

the injection of getting contrast. If you have more than 50%

3:10

wall thickness. This is going to be non-viable. It will

3:13

not benefit from revascularization.