0:01

So our next case is a 51 year old man

0:04

with no significant past medical history

0:07

who had a witnessed defi arrest in the field.

0:10

It was brought to the emergency department

0:11

where he was diagnosed with a STEMI

0:14

and then had a drug-eluting stent placed in his RCA.

0:18

So this again was done to evaluate for,

0:23

um, any kind of complication

0:26

and assess for viability a few days after the event.

0:29

So just starting with our long axis views.

0:32

Four chamber looks pretty normal.

0:35

Two chamber also looks pretty normal.

0:40

Not much that I would call on this one Three chamber,

0:44

a little gating artifact here,

0:46

but overall looks pretty unremarkable as well.

0:50

And getting into our short axis syn, a stack

0:54

moving from base to apex

0:58

and here maybe you would call

1:03

a little bit of hypokinesis in the

1:05

basal inferior lateral segment.

1:06

So if you focus kind of in this region,

1:09

this is an RCAA supplied territory.

1:12

And so knowing our history, we're gonna interrogate

1:14

that a little more closely and I think we would call some

1:17

mild hypokinesis in that region.

1:19

But overall, his cardiac function seems

1:22

to be fairly well preserved.

1:24

And as we work down a couple more sites of arrhythmia,

1:28

our gating artifact there, but really as we move mid

1:31

and apically, nothing else

1:33

that looks like significant regional wall motion

1:35

abnormalities in this patient.

1:38

So then we wanna look, uh, of course at our LG images next.

1:43

So if I window

1:44

and level this to kind of draw out the pathology a bit more,

1:48

what we see as we move from base to apex here is in that

1:52

basal inferior segment here we see kind of what

1:57

probably is appropriate to describe, you know,

1:59

definitely greater than 50%,

2:00

but near transmural LGE that we see kind

2:04

of becomes nearly transmural with maybe a little bit

2:07

of hypo attenuation there,

2:08

probably some microvascular obstruction in

2:10

this case as well.

2:12

And that LG pattern persist a few slices into

2:16

the mid region.

2:18

So kind of basal to mid infra lateral segment

2:21

with near transmural, late gadolinium enhancement.

2:24

The other long axis view that would be nice

2:27

to take a look at this and see if it, you know,

2:29

helps us discern kind of extent of it moment, you know,

2:32

is the two chamber, which is gonna slice the heart kind

2:34

of right down the middle here.

2:36

And so if I pull up the two chamber,

2:38

you can again see this finding pretty nicely in the basal

2:43

to mid inferior segment.

2:47

There's sub endocardial lake GA enhancement,

2:49

which looks basically transmural in this case.

2:53

Again, this is an acute injury,

2:55

so we wanna look at the T twos.

2:57

I'm gonna show you the T two

2:58

Maps in this patient.

3:00

So you know, we're kind of focused perhaps

3:03

here in this region.

3:04

I'm a little bit suspect in these cases where

3:07

I have all my slices on these T two maps

3:11

that have papillary muscles,

3:12

especially when we have a really basal pathology.

3:16

I'm worried this is a little bit too mid.

3:18

So we may have missed actually the area

3:21

of interest on this T two mapping,

3:23

the quantitative values in these regions.

3:25

So focusing here

3:26

where we thought we saw some leak enhancement,

3:28

not really elevated in this case.

3:30

So again, I'm, I'm curious if either we missed the pathology

3:33

or now this infarct has kind

3:34

of evolved from an acute infarct to more

3:37

of a subacute infarct depending on the time

3:39

course of imaging.

3:41

We did in this case,

3:43

have a reasonably good dark blood imaging

3:47

that maybe goes a little bit more towards the base.

3:50

And so on this T two way to dark blood imaging, you know,

3:54

I'm probably a little bit biased just by the fact

3:57

that I know there's an infarct there,

3:58

but could we convince ourselves

4:00

that maybe there's a little elevated T two in this region

4:03

and still call it sort of acute plus or minus on that.

4:06

But we definitely have a myocardial infarction in the RCA

4:09

territory with a small amount of microvascular obstruction.

4:12

Again, I'll show the short axis image here looks transmural

4:18

and there doesn't seem to be a ton of edema.

4:20

So this is probably moving more towards a subacute

4:24

infarct at this point in imaging.

4:26

And so the one thing that,

4:28

and we'll talk about this in a later case, you know,

4:30

when you're thinking about viability, it's important to know

4:32

where you're at in the acuity spectrum

4:35

because as we'll see, these infarcts can evolve over time.

4:39

And so in someone like this,

4:40

if they're really concerned about viability

4:43

or potential for reperfusion

4:45

after this acute injury, they may want

4:47

to get a follow up in a few months to see

4:49

what direction this has really gone in this case.