0:00

case number H is

0:04

okay case number eight. I'm just going to keep this still image up for case

0:07

number eight case number eight. The history is

0:12

it's an older gentleman you presented with

0:15

believe which has been or with heart failure case

0:18

number eight the history.

0:21

The question is based on the images here on here we have

0:24

on the left. We have a three chamber image on the right. We have delayed enhancement.

0:28

What is the most likely diagnosed based on these images amyloid?

0:32

ischemy cardiomyopathy dilated cardiomy of

0:35

the hemochromatosis or sacritosis

0:37

amyloid and

0:40

punch. That's not the correct diagnose. The correct diagnosis is ischemic heart

0:43

disease notice that there is enhancement involving

0:46

the LED distribution also identify the

0:49

low signal intensive structure attached to

0:52

the LV Apex in the region of the enhancement. This is a thrombus thrombi

0:55

typically assign the left ventricular Apex

0:58

in patients who have apical infants.

1:01

Many players any image here. Maybe there's

1:04

any image will make the diagnosed a little bit more obvious.

1:08

Okay. Yeah notice the thin

1:11

apical segments and the apical septum.

1:15

Overall lbjection stability decreases

1:18

an area of thickening in the ape in the extreme Apex and

1:21

this is the area which is not enhancing.

1:25

thrombi do not enhance

1:27

drawn by do not take up contrast to gatheringium. So they don't have however in

1:30

facts enhance notice the impact or delay enhancement

1:33

in these sub-indocardial region in the LED distribution. This

1:36

is the patient has ischemic cardiomyopathy and thrombus in the

1:39

heart.

1:40

A very important indication for County Commander identify cardiac thrown

1:43

by particularly the apical portions of the left ventricle

1:46

attached the AP lb AP Apex difficult rejection on

1:49

Echo car geography and they can merge with the adjacent left

1:52

ventricular wall. So it should be

1:55

kind of your mind within apical thrombosis the answer to this question.

1:58

There's two more questions based on this case fairly quick

2:01

questions, which of the following sequences for

2:04

delay enhancement would preferable for infant detection in a

2:07

heart failure patient requiring.

2:09

Fairly rapid Imaging most of the

2:12

cardiac AMR sequences require breath hold senior sequences

2:15

are late Galvin enhancement. However, patients unable to

2:18

hold their breath that is in heart failure. There

2:21

are choices available.

2:23

And it's either these five choices and more

2:26

challenging question related to kinigmatic technique.

2:29

The correct answer is actually a single

2:32

shot inversion recovery action. Sorry. Yeah,

2:35

the correct answer is B. Yes, correct, single chart

2:38

inversion recovery and steady state repossession single shot

2:41

is when we do the acquire all

2:44

the images in one R interval. They do not require breath hold so the

2:47

patient cannot hold the breath

2:48

A single shot inversion recovery steady state repossession can

2:51

be used for delay enhancement the standard or

2:54

traditional delayed enhancement is a segmented sequence which requires several

2:57

heartbeats the case spaces collector with several

3:00

heartbeats. However, the based on able to hold the breath a

3:03

single shot sequence can be used in their fairly diagnostic for evaluation

3:06

infant.

3:07

And also for thrombi good last question,

3:10

I think we have one more one more.

3:14

Question and that's possible in for time.

3:17

It's 10:57 now and will wrap up the more

3:20

sensitive technique for cardiacromis detection is either echocardiography

3:23

standard steady-state free

3:26

procession cinemri question to be late

3:29

Gallery enhancement with a 252 to 300 inversion

3:32

time or late elements on 600 to

3:35

800 version time or contrast ventric geography where we actually

3:38

inject contrast Into The ventricle invasively.

3:41

Okay contrast when the graph is is not a sensor technique for

3:44

dictionary from this this was in the wrong answer called. The

3:47

correct answer here is is D late Calum

3:51

enhancement is 600 to 800 in version time millisecond version.

3:54

I'm typical inversion times for dictionary. In fact 25300 over

3:57

if thrombus is suspectedly longer in version

4:00

time is used because in that case the thrombus becomes dark

4:03

and the normal myocardium becomes gray. So it increases

4:06

the contrast between the thrombus and the infant.

4:10

So a thrombus sequence typically requires a

4:13

fixed longer inversion time somewhere between 600 to

4:16

800 milliseconds.

4:18

and that improves diagnosis of thrombus echocardiography is

4:22

not sensitive therefore detection of thrombi even using the

4:25

contrast agents because the thrombus can be

4:28

Can merge with the adjacent myocardium same

4:31

happens with any MRI the thrombus can be a indistinguishable

4:34

from hsmicon. For example, in this case. The thrombus

4:37

may be confused with adjacent. My Kanye

4:40

West late again delayed enhancement is the key technique and in

4:43

the late enhancement and and inversion time

4:46

increasing your Invasion time from the typical 300 to 5300 to

4:49

600 to 800 improve strongest detection. Okay, so

4:52

that's case number the case. I

4:55

believe it's case number

4:58

eight. We have about two minutes left two

5:01

to three minutes left. I think that that's just about enough we

5:04

can get through today. Actually. It's 10:59 by my

5:07

time.

5:08

Do we have any questions?

5:11

From the audience. Okay. Thank you very much.